Thoracic Outlet Syndrome
Are you experiencing pain as well as numbness, tingling, and weakness in the hand and fingers? Do your fingers or hands feel like they’re “falling asleep” while you type at a keyboard, grip a steering wheel, work out at the gym, or pick up groceries or even your child?
There are several conditions of the head, neck, shoulder, elbow, and wrist that cause sensations of tingling, numbness, pain, and weakness with grip strength. More common conditions include carpal tunnel syndrome1, tennis elbow (lateral epicondylitis)2, compression of the nerves exiting the neck spine (cervical radiculopathy)3, and pinched nerve (impingement syndromes) of the shoulder. Less common injuries involve brachial plexus injuries, such as Thoracic Outlet Syndrome, or TOS for short.
What is Thoracic Outlet Syndrome?
The thoracic outlet is a space in the body that sits between the lower part of the neck and the collar bone (cervicothoracobrachial region), close to the first rib of our ribcage. This region stretches to the upper part of the arm and contains a network of nerves and blood vessels supplying the arm.
Thoracic Outlet Syndrome describes a series of conditions that cause compression of the major nerves and/or blood vessels that run through that thoracic outlet space. However, the term “TOS” does not specify the structure being compressed.
There are three different types of thoracic outlet syndrome4, and all of these are named after the type of vessel or structure being compressed. Categories include:
Neurogenic
- Compression of the brachial nerve plexus
- Slower onset of symptoms
- Decreased sensation along the arm
- Possible weakness with grip strength and hand muscles
- About 90% of all TOS cases
Venous
- Compression of the axillary or subclavian vein
- Symptoms are more abrupt in onset
- Includes venous distention in the neck
- Pain ranges from the arm to the forearm
- Less than 10% of all TOS cases
Arterial
- Compression of the axillary or subclavian artery
- Symptoms are also more abrupt in onset
- May cause color changes in the fingers
- May cause diminished pulses in the upper extremity
- Less than 10% of all TOS cases
What structures can compress the neurovascular bundle in the thoracic outlet?
The compression of the neurovascular bundle in TOS can have multiple causes, ranging from anatomic anomalies to poor posture.
Cervical ribs and the fibromuscular bands connected to them are identified as the most common cause of neurovascular compression in TOS. Cervical ribs are not like the first rib of our ribcage, which is the uppermost rib and projects off the first thoracic vertebrae. Instead, cervical ribs are an anatomic anomaly where an extra rib branches off the lowest cervical vertebrae. It is known that about 1 in 500 people present with a cervical rib, making it a common genetic occurrence. Not everyone with a cervical rib will develop TOS; it is simply a contributing factor.
Another major cause of TOS is muscle tightness in the thoracic outlet. Affected muscles include pectoralis minor and scalene muscles.
Alterations in posture can be another cause of TOS. Slouched posture with forward rounding of the shoulder narrows down the thoracic outlet, which can compress any neurovascular structures. This can occur with prolonged poor posture or in individuals with additional breast tissue.
Finally, TOS can be seen in athletes who engage in repetitive extreme shoulder motions such as competitive swimming or baseball pitchers identified to narrow the thoracic outlet.
How do we treat thoracic outlet syndrome?
In our Lexington family Chiropractic practice, we perform a detailed history of your injury, followed by a functional movement assessment and examination.
Mechanical causes of TOS such as poor posture or tightness of certain muscles respond well to conservative chiropractic treatment. Often, TOS will be caused due to a combination of tight muscles and poor posture. Tight muscles would be treated with a muscle release technique called Active Release Technique. Poor posture will be addressed with sports rehabilitation exercises to strengthen the mid-back and deep neck flexor muscles.
Frequently Asked Questions (FAQ)
How do I know if a chiropractor is right for me? Do I need surgery?
At our chiropractic office, we take ample time to perform a detailed history and physical examination to find the cause of your pain. Once we have found the cause of your pain, we will develop a specific treatment plan that will suit your care.
In abrupt vascular symptoms such as diminished pulses, severe discoloration of the fingers, and cold hands, the patient will be sent out for an orthopedic consult to discuss surgical treatment.
With the absence of vascular symptoms, we would consider a conservative trial of care that includes releasing tight muscles, strengthening weak muscles to improve posture, and adjusting any restricted joints.
If a patient does not respond to a conservative management plan, the patient will also be sent out for an orthopedic consult to discuss possible surgical treatment.
A conservative treatment approach has fewer side effects than surgery and a faster return to normalcy than the extensive rehabilitation required after surgery.
How long will it take to recover from Thoracic Outlet Syndrome?
Unfortunately, this depends. According to the most recent research, an average conservative trial of care will take about eight visits, after which the symptoms will be re-assessed.
Recovery can be dependent on many things, including the body’s response to healing, lifestyle, ergonomics, and compliance to rehabilitation exercises. Depending on the severity of your symptoms, you may also need collaboration with other healthcare providers.
When should I see a chiropractor for my pain?
If you are dealing with any of the above-mentioned symptoms, we are here for you. If you want a same-day examination and treatment for your injury, call our Lexington Chiropractic office at 859-309-1996 or contact us at info@wellchiropractic.com.
References
- Wainner, R., Fritz, J., et al. (2005). Development of a clinical prediction rule for the diagnosis of carpal tunnel syndrome. Arch Phys Med; 86: 609-618.
- Walz, D.M., Newman, J.S., Konin, G.P., and Ross, G. (2010). Epicondylitis: pathogenesis, imaging, and treatment. RadioGraphics; 30(1): 167-184.
- Eubanks, J.D. (2010). Cervical radiculopathy: Nonoperative management of neck pain and radicular symptoms. American Family Physician; 81: 33-40.
- Laulan, J., Fouquet, B., et al. (2011). Thoracic outlet syndrome: definition, aetiological factors, diagnosis, management and occupational impact. Journal of Occupational Rehabilitation; Sep 1;21(3):366-73.