Ache and tingling in arms and hands
Keywords: CERVICAL RIBS, tingling in arms and hands, Thoracic Outlet Syndrome, Inter Scalene Triangle
Normally speaking, only the twelve thoracic vertebrae have a pair of ribs, beginning at the spine, and attached to the sternum or other lower rib cartilage, and a couple of "floating ribs", forming the ribcage.
This vital structure serves to protect the vital organs, particularly the heart, but is moveable to allow breathing.
Cervical rib syndrome
At the upper end of the thoracic spine, at the junction with the neck, normally T1, the first thoracic vertebra has the first rib. But in 2 per 1000 people, there is a rib above the first rib. A cervical rib.
If there is a cervical rib then it penetrates through a very restricted passage called inter scalene triangle bounded by the first rib below, and two muscles, the scalenes on the sides of the triangle.
Why all the hype? Because at the cervico thoracic junction is the critical area where the large artery, the subclavian artery, and a large group of nerves, called the brachial plexus, emerge from the chest cavity to supply the arm.
The significance is that this syndrome may produce a crazy mixture of both arterial and neurological deficiency in the arm.
These ribs are usually rudimentary and of little or no clinical significance, but occasionally a very large space occupying cervical rib, originating from the transverse process of the lowermost cervical vertebra, passing through the inter scalene triangle and joining onto the normal first rib, may cause severe symptoms in the arm.
Remember, normally the cervical vertebrae have no ribs. Ribs pertain to the thoracic vertebrae.
A vascular and or neurological restriction in the inter scalene triangle is known as a thoracic outlet syndrome producing classically pain and tingling in the arm, particularly when lifting the arms as in hanging washing.
Notice how the cervical rib can affect both the subclavian artery above, and the lowermost cord of the brachial plexus both.
So, both artery and nerve symptoms and signs are possible, though not necessarily so.
The classical test to confirm a thoracic outlet syndrome is the test of Adson. Your chiropractor will locate your radial pulse in the wrist, and then ask you to turn your head and breathe in. Does the pulse die away, and return when you return your head to neutral and breathe out?
It's a difficult test, very subjective, and I like to do it with the arm on the lap to eliminate false positives. Done in the normal way with the arm abducted and externally rotated many quite normal people have a positive Adson's test.
The key sign that will alert your chiropractor to the fact that all is not well in the state of Denmark, is that she simply can't find a radial artery pulse in the wrist. The first time it happened to me, I was bowled over: how could there be no pulse in the arm? Had my palpation skills suddenly diminished? Nope, a very large cervical rib.
There's just enough blood getting through to the arm when it's at rest, but start to use the muscles in your arm, or raise your arm so the inter scalene triangle is further diminished in size, and bingo, pain and tingling in the arm.
It's known as intermittent claudication, not dissimilar to angina. When the body is at rest, there's enough blood to supply the muscles. But as soon as you start to exercise, the muscles require more oxygen, and there's not enough. Pain.
So, of course, it's quite impossible to do Adson's test if you can't locate the radial pulse. An xray is mandatory.
What is hard to explain is that the C7 rib lies silently in the inter scalene triangle for years minding its own business, its owner none the wiser. Then suddenly, one day, for no obvious rhyme or reason, the arm starts to ache and tingle.
It may have a carpal tunnel syndrome appearance, or a frozen shoulder, or tennis arm; the signs and symptoms are very variable.
In the case below, I believe it was taking a job where the patient took a job and started holding the phone between her neck and shoulder, a real no-no that could have been the trigger that provoked the incipient rib to start giving her pain and tingling in the arms and hands.
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Why didn't it cause pain years ago? If there's a big lump of bone in the way, how on earth can chiropractic help.
The medical treatment for the offending rib is not nice. The surgeon enters the inter scalene triangle via the arm pit, and surgically removes the offending rib. Frankly, I have no idea how successful the operation is, or what the morbidity is, but it's very close to extremely sensitive structures, the brachial plexus, the subclavian artery and the apex of the lung.
I have had numerous letter from patients at chiropractic help complaining that the operation either didn't help, or the condition was worsened because of injury to the brachial plexus.
Talking of lungs, in you have tingling in the arms and hands, and are a smoker and have a bad cough, your chiropractor should consider a nasty tumour in the apex of the lung that can mimic a C7 Rib.
You do know, don't you, that smoking will knock ten years off your life, and the end will most likely be very S-H-one-T?
It's not well understood why the Cervical Rib suddenly starts to misbehave. In fact, we think that often the symptoms are not caused by the rib at all - otherwise, if the Cervical Rib was there ten years ago, why was there no pain and tingling in the arms and hands back then?
But it is an aggravating factor, the space in the Inter Scalene Trianle is even more limited than normal.
The thinking is that there is either a fixation of the first Thoracic Rib, or the Scalene muscles go into spasm because of a Cervical Facet Syndrome or perhaps a whiplash, poor posture at the computer (do you have support under your elbow?), sleeping on your tum, or anyone of a host of other facts. Long journey, sleeping in an aeroplane...
Can Chiropractic help?
A guarded yes, the hesitation because there aren't enough cases for us to do reliable research, which would tell you that in 80% (or 50%, or 10%) of cases chiropractic management of the Scalene muscles, the cervical vertebrae, the first rib can help you. Here you can follow a casefile currently under treatment. Very successfully, I might say, but a "cure" is unlikely, like many medical conditions and chiropractic conditions too. Cervical Rib CaseFile ...
CERVICAL RIB vs THORACIC OUTLET syndromes
Cervical ribs are but one cause of the so-called Thoracic Outlet syndrome. Any invasive process, be it a cervical rib or a Pancoast tumour, or an old fracture of the first rib or clavicle can irritate and impinge on the Subclavian artery and the Brachial plexus.
But so can a Scalene spasm, be it due to a whiplash, cervical facet syndrome, sleeping in the upright position, long journeys... or an imbalance between the Trapezius msucles and the the smaller Scalenes and SCMs for example.
From a chiropractic standpoint, a fixated first rib is another very common cause of the Thoracic Outlet Syndrome, causing scalene muscle spasm, but with no invasion of the inter scalene triangle.
CLOT Very occasionally a clot may form in the subclavian vein causing swelling of the whole arm. This is a very serious condition requiring immediate medical attention. Intial treatment would probably be blood thinners and perhaps a stent.
Further resection of the first rib, and if present a cervical rib, may be necessary, but it's a difficult operation, not without attendant dangers:
"1st rib resection of my left shoulder (2 months ago) has squared up my shoulders but has increased the strain on my neck, mid and lower back. Nerve damage sustained due to the operation has serverely effected the first three fingers with hyper sensitivity, signs of muscle wasteage around the base of the thumb and forearm is apparent. Overall I have ailments from the finger tips through the wrist up my arm, within my elbow and shoulder down the spine,at the base of my back through my left hip joint and in the back of the knee."
Letter received at Chiropractic Help.
First lumbar rib
At the lower end of the thoracic spine, quite often the first lumbar vertebra may have a rib, and it may be very significant in the patient who has four (known as a sacralisation) or six (known as a lumbarisation) lumbar vertebrae, instead of the usual five.
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Interesting challenges of the day
1. Mr B has the trophy for the most acute neck in February. He has quite advanced lower neck arthritis for a forty year old, thanks to a severe fall on the head from a trampoline. But this is upper cervical pain. Right rotation is simply impossible. Luckily he is improving rapidly, eighty percent better he says after three treatments. See cervical facet syndrome.
2. Mrs C is a new patient with a long history of lower back pain, hip pain and pain in both feet. We'll see how we get on, Rome wasn't built in a day.
3. Miss U sprained her ankle two months ago, wearing high heels. She still has severe mid foot pain. Xrays and perhaps a CT scan.
4. Mr V is 86 years old and hurt his back helping his wife into the car. Just one treatment of the sacroiliac joint and he's eighty percent better. It's not always like that.
5. Mr W lay on his back knocking down a pillar. Turning his head causes severe vertigo. He needs the Epley exercises, not pills, research shows. Update, he's fine.
6. Mrs X, a young mother has severe lower back pain, with numbness down the posterior thigh, calf and side of foot. It started after a long drive in the car. Update, she's forty percent less painful after four treatments, but the leg is still numb. Update two; she 60% better, but it's slow and is going to take the full 6 weeks to heal. Further update; a setback, after lifting her child she now has leg pain. It's going to the be difficult.
7. Mrs Y, a 70 year old woman is on maintenance care fo a nasty lumbar stenosis despite having to do everything at home. Her husband has a hospital acquired infection in the shoulder. After 4 operations he is incapacitated and going rapidly down hill.
8. Mrs Z, an 78 year old woman is doing remarkably well with a bad sciatica. But at over 200 lbs she is not losing weight, in fact gaining despite my suggestions. She's high risk for a stroke. Referral to a dietician to crack the whip.
9. Mr A, a 73 year old engineer, still working, is doing fine after a long episode of lower back pain. Some pain on the side of the hip remains after five treatments. Reassured him it's not hip arthritis.
10. Mrs B, a 64 year old woman has had Scheuermanns disease; it's left with a spinal kyphosis and chronic middorsal pain. She responds well to chiropractic treatment, provides she come every six weeks or so for treatment.
11. Mr C, a young engineer fell off his mountain bike injuring his cervical spine and pelvis. Luckily both responded very quickly to a few chiropractic adjustments. Update: his neck is sore again. It all goes back to a whiplash injury ten years ago when he was rammed by a fully laden truck carrying a load of stone. Time for Xrays.
12. Mrs D, a middle aged woman with hip pain of one year duration, despite other treatment. Xrays reveal an impingement syndrome and early hip arthritis. There's much to be done.
13. Both Mrs E and I can't believe how much better her lower back and leg pain are. Surgery for a scoliosis and spondylolysthesis three years ago helped greatly for one year. But then her leg went lame and weak. He was responded extremely well despite all expectations.
And so the day goes. Chiropractors shouldn't be treating the elderly? Bunkum.
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