Thoracic Outlet Syndrome: a Real Pain in the Neck!

Do you have thoracic outlet syndrome or a neck condition?
Oftentimes pain, numbness, tingling, and/or weakness radiating into the arm is associated with a neck problem. Neck problems can often cause the same symptoms as a condition known as thoracic outlet syndrome, a type of peripheral nerve compression syndrome that adversely affects the neurovascular structures as they exit the lower cervical spine.
There are three types of the syndrome: neurogenic, arterial and venous classifications. The most common type is neurogenic, which can affect patients who participate in repetitive activities. It can affect a worker in a warehouse who repeats upper extremity tasks, or an office worker, extensively typing or manually filing. This type is also associated with the athletic population; anyone who does a great deal of overhead activities, such as pitchers, swimmers, tennis and squash players, to name a few.

In addition to repetitive strain, oftentimes this injury can come from a direct blow or trauma that results in injury to the thoracic outlet region and surrounding neural vascular structures. There are structures, both bony and soft tissue, that can cause compression to the nerves and muscles that exit the lower cervical spine. Some of these are based on the patient’s anatomy, but others are based on muscular imbalances and/or joint displacement.
When addressing thoracic outlet syndrome, the three main nerve compression areas that physical therapists address are at the anterior and medial scalenes, pec minor muscle and elevated first rib. Often, the first two can be adjusted with self-stretches and treatment, but often the elevated first rib has to be addressed by a physical therapist that specializes in thoracic outlet syndrome and cervical pain syndromes.
In some cases, there is thought to be a double crush or compression at two sites, causing various nerves and vessels to be compromised into regions. This results in the diagnosis of thoracic outlet syndrome being harder to be determined and therefore there is less of a consensus on both the diagnosis and treatment of thoracic outlet syndrome. Since there is not a clear consensus on the incidence of thoracic outlet syndrome, it becomes more difficult for physical therapists and physicians to track.
As I stated before, the most common thoracic outlet syndrome is neurogenic, which comprises greater than 90% of the cases of thoracic outlet syndrome. When patients are evaluated in the clinic, we check to see if the cervical spine is contributing to the symptoms of numbness, tingling, and/or weakness in the upper extremities, and in some cases, muscle wasting. Once we are sure that the cervical spine is not the source the problems, in some cases, the patient has complaints of chest pain. If there is a history of heart disease, we often direct them to their primary physician if the results of their evaluation are inconclusive. Also, we want to make sure that the symptoms that they are currently complaining of are not progressing rapidly over a short period of time, which may be an indication of a more serious pathology, requiring immediate referral to a physician or emergency room consult. If these symptoms include severe unrelenting night pain, progressive weakness, difficulty walking, and/or fever, we then make a referral to the appropriate physician.
We then look at several tests to identify possible thoracic outlet syndrome. The symptoms of a true neurogenic type of thoracic outlet syndrome are pain, numbness and tingling, oftentimes in the C8, T-1 distribution in addition to unilateral neck pain. The patient may experience numbness intermittently throughout the day, but also throughout the night in cases of neurogenic thoracic outlet syndrome. Other more rare symptoms are poor tolerance for the cold and general clumsiness in the upper extremities.
After we’ve established a diagnosis of thoracic outlet syndrome, the compression sites are found at the pec minor, first rib, or scalenes. To ensure we don’t miss this case of thoracic outlet syndrome that is worsening, we also conduct a thorough neurological examination that includes testing the deep tendon reflexes in the upper extremities, myotomes, dermatomes, temperature baselines and pulses, in addition to baseline color of the upper extremities.
The main approaches that we provide patients to do at home are scalene stretches, thoracic stretches and doorway stretches that address some of the most common nerve compression sites when addressing thoracic outlet syndrome. At Apex Orthopedic Rehabilitation, we specialize in addressing pinched nerves in the cervical and lumbar spine and in treating those affected with a diagnosis of thoracic outlet syndrome.
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