Dr. Andrew Arnold discusses Thoracic Outlet Syndrome and how physical therapies may help.

You wake up and can’t ‘feel’ your arm or hand?  Or you have persistent tingling down your arm and into your fingers. You have shoulder and neck pain. Your hand feels hot or cold. You may even have a weakness.

Does any of this sound familiar?

You may have a condition called ‘Thoracic outlet syndrome’ or TOS.

Let’s start by defining what this is.

Firstly, this is more common in females and between 20 and 40 years old.

TOS refers to a group of disorders which happens when either the blood or nerve flow or both are interrupted by compression.

This could relate to trauma like a car accident, a repetitive work injury, a sports injury, a congenital issue like an extra rib, and pregnancy.

This is a relatively common condition we encounter a lot of and is not a cause for alarm.

So, let’s now focus on the various types of TOS:

  • Neurogenic (neurological) TOS relating to compression of nerves usually at the neck, chest and armpit region.
  • Vascular TOS referring to blood vessel compression usually by the collarbone and associated muscles.
  • Nonspecific-type TOS where the exact cause is unknown, but the patient presents with all the symptoms in particular pain.

What you need to know?

According to one research article, there is ‘currently no rehabilitation scheme, either osteopathic or chiropractic, considered a valid tool for a precise localisation of the pathologic condition, probably due to the lack of a manual assessment process to evaluate bones and muscular components of the thoracic outlet.’ [1]

TOS symptoms can vary depending on what’s compressed and where.

What can happen:

Nerve involvement:

  • Muscle wasting affecting the thumb pad muscles in the palm.
  • Numbness or tingling affecting the arm or fingers
  • Shoulder, neck or hand pain.
  • Weakness in a particularly affecting grip.

Blood vessel involvement:

  • Blue hands.
  • Arm pain and swelling.
  • Blood clots.
  • Weak or no pulse.
  • Coldness
  • Fatigue worsened with activity.
  • Numbness or tingling, in particular, effecting the fingers.
  • Weakness affecting arm and neck muscles.
  • A throbbing sensation in relation to the collarbone

Differential diagnosis: [4]

Thoracic Outlet Syndrome often presents in a vague, non-descriptive fashion. As such there are a variety of other conditions which need to be ruled out by the practitioner.

A common condition which is often mis-diagnosed is pectoralis minor syndrome which presents with chest, upper back and shoulder blade pain and discomfort. This may then cause pain in the hand or even tingling and numbness. Nerve compression causes this condition by the pectoralis minor muscle and is unrelated to the thoracic outlet.

Other differentials to consider are:

  • Brachial plexus injuries
  • Cervical spine injuries
  • Cervical radiculopathy
  • Shoulder impingement syndrome
  • Elbow or forearm overuse injuries
  • Acromioclavicular joint injury

Common causes

  • Anatomical g. extra ribs at the neck region.
  • Poor posture g. slouching shoulders and forward head posture leading to compression. This could also relate to stroke or emaciated patients who have lost a lot of weight from serious medical treatments such as chemotherapy.
  • Trauma g. car accident, work injury, sports injury…
  • Repetitive activity causing wear and tear, e.g. computer or factory work.
  • Pressure on your joints g. overweight causing excessive stress on joints and muscles around the neck; school kids using over-sized backpacks.
  • Pregnancy due to excessively loose joints.

When to consult a Chiropractor?

With regard to treatment, Thoracic Outlet Syndrome is categorised into two main groups:

  • Conservative management.
  • Surgical intervention.

The goal of the practitioner is offering conservative treatment as a first line of treatment unless the patient’s symptoms are debilitating.[4]

Conservative approach:

This may include lifestyle modifications, physical therapy, and rehabilitation; postural correction, sleeping positional training and addressing workplace ergonomics and repetitive activities. Various preventative splints and pads may be recommended to help provide relieving pressure.

Physical therapy (Chiropractic, Physiotherapy, Myotherapy, Osteopathy) is the preferred conservative treatment for many TOS patients. The goal is to strengthen muscles around the thoracic outlet to relieve pressure. Research has shown positive outcomes for patients choosing physical therapy.[3] One case report describes a positive response to chiropractic care related to a thoracic outlet presentation. ‘After a short course of care, the patient reported reduced pain, alleviated symptoms, and improved physical function.’ [2]

We manage TOS weekly with excellent results. Chiropractic treatment is safe and effective.

Chiropractic treatment:

The goal is to address the compression. This means mobilising the collarbone, releasing muscles and getting the neck and shoulder to work better.’

We do this using high tech spinal and joint manipulation devices which are highly accurate, effective and safe.

We also address posture by training our patients with posture aids and exercise.

Complications:

Complications with TOS are rare. It is possible to sustain circulatory problems, is the compression is severe enough and of long enough duration, but this is only in severe cases.

Most complications relate to surgical intervention, thus the reason for recommending a conservative approach first. Surgical iatrogenesis includes nerve injury, pneumothorax can result from first rib resection and bleeding. [4]

References:

[1] Bruno B, Fabiola M, Bruno M, Beatrice B, New Proposal of Evaluation of the Thoracic Outlet, Open Journal of Therapy and Rehabilitation, Vol.6, No.2, May 2018, DOI: 10.4236/ojtr.2018.62003.

[2] DiMond, M E, Rehabilitative Principles in the Management of Thoracolumbar Syndrome: A Case Report, Journal of Chiropractic Medicine, Volume 16, Issue 4, December 2017, Pages 331-339, https://doi.org/10.1016/j.jcm.2017.10.003

[3] Freischlag J, Orion K. Understanding thoracic outlet syndrome. Scientifica (Cairo). 2014;2014:248163. [PMC free article] [PubMed]

[4] Jason Kaplan; Arjun Kanwal, Book: Thoracic Outlet Syndrome, Last Update: May 4, 2020, Bookshelf ID: NBK557450PMID: 32491382, Copyright © 2020, StatPearls Publishing LLC.

About the Author:

Dr. Andrew Arnold is a Chiropractor at Cranbourne Family Chiropractic and Wellness Center.

 

Category: Chiropractor

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