THORACIC OUTLET SYNDROME

SYMPTOMS.

The symptoms of Thoracic Outlet Syndrome (TOS) are varied and complex depending on whether nerves or blood vessels or both, in the neck are involved. Generally only one arm is affected, commonly with pain, tingling, or just a dull ache.

The hallmark of TOS is that much of the arm of the arm is affected, as distinct from a �dermatomal� pattern, where only parts of the arm are affected. Why? Because the arm is supplied by FIVE nerve roots (called C5, C6,

C7, C8 and T1) so, if you have a pinched nerve in the neck, you are likely only to have pain mainly in the thumb and forefinger and lower arm, say (the sixth nerve root from the neck, shown above).

In TOS however, not the nerve root per se, but a large group of nerves called the brachial plexus is affected, so the pain will be in broader parts of the arm most likely and also perhaps over the chest and parts of the shoulder and back. It is caused primarily from a subluxation of the first rib. This syndrome, because it affects several nerves, also makes you vulnerable to tennis elbow and other syndromes of the shoulder and wrist.

The blood vessels to and from the arm may also be affected, in which case the arm feels cool, and may occasionally (actually rarely) swell.

The arm tends to tire quickly whether from lack of blood, or nerve supply, or both. Working above your head, as in using a drill to put in a curtain rail, becomes very difficult. More later about why. Mouse arm is also partly result of this condition, if the arm is unsupported.

Heart Attack

Commonly, at the coalface, we see patients who have thought they were having a heart attack if the pain was in the left arm, and also the chest. Sometimes their doctors thought so too! Not infrequently they have been through a whole gamut of heart tests, some of them quite invasive and dangerous in themselves.

Obviously, because of the seriousness of a heart condition, this needs to be ruled out first, but our counsel is that, before expensive and invasive tests are considered, it is wise to consult a chiropractor to consider whether the pain in the chest and left arm could be coming from a Thoracic Outlet Syndrome, rather than a MI.

For an interesting case of Thoracic Outlet Syndrome, a man who went through a year of misery, and extensive (and very costly) medical tests for a heart condition, click here for Coalface stories. Look for the name, Mr Boersma. Right now it's case number 6, but this will change as I add more cases from the Coalface.

I'll be waiting for you, whilst you go down this country website lane, but remember to come back! Sigh, it's so easy to get sidetracked on the web, so many inviting little cul-de-sacs. Use the back arrow to return to this page. Meantime, I'll get a few pictures ready that will show you visually how a first rib subluxation can cause so much pain and tingling in the arm and chest.

If you enjoy reading, chiropractor Bernard Preston tells delightful inspiring chiropractic stories that will entertain and educate you. Watch out - expect to be stretched. His hobbies, like soaring with the eagles, are enthralling - but all the stories are in a chiropractic context. For an exerpt chapter, click here.

WHAT IS THE THORACIC OUTLET?

The blood vessels (Subclavian a. and v.) to and from the arm, and a large bundle of nerves (the Brachial Plexus), travel through a narrow passageway that runs in the deep valley just behind and below your collar bone. Run your fingers forward from the large shoulder/ neck muscle forming the nape of the neck. Just before you reach the collar bone you will discover this gully. Deep in it you can feel something hard (the first rib) and bundles of muscles (the Scalenes).

This passageway is made of a triangular gap between the collarbone, the first rib and two large neck muscles (the Scalenes). Spasm of the muscles (after a car accident, for example, or even after prolonged computer use if the arm is unsupported), subluxation of the first rib or a hard fall on the arm, which may jam the clavicle up against the rib. If there is pressure on the nerves, or the blood vessels, or both the arm will be affected, usually with an ache, and sometimes tingling, and very rarely with wasting of the muscles.

See how the plexus of nerves lie on the first rib?

There are other causes of pressure on these nerves and blood vessels. A Pancoast tumour at top of the lung (yes, caused by smoking!) or an anomaly that you were born with and others things, but these are rare causes of Thoracic Outlet Syndrome.

TOS may also be a factor in the so-called double crush syndrome, and be the underlying cause of a tennis elbow, for example, or carpal tunnel syndrome.

Cervical Rib

Normally only the thoracic vertebrae in the midback have ribs. Twelve pairs. However, at the transition areas to the low back and neck, sometimes ribs form.

These have been implicated in the thoracic outlet syndrome. Surgeons like to remove them, but I fairly regularly treat people who have had the surgery, and still have the tingling and numbness in the arm.

It's quite a gruesome operation - through the armpit (axilla). Certainly I would suggest you consult your chiropractor for an assessment before having this operation.

How is TOS diagnosed?

The classical orthopaedic test for Thoracic Outlet Syndrome was designed by a Dr Adson. Your chiropractor will turn your head towards the side of pain, ask you to look up, and take in a deep breath, whilst extending the arm and testing the pulse in your wrist.

You can try it for yourself. Does taking up this position cause tingling or an ache in your arm? Testing the pulse is more subtle, and I think it unlikely you could be objective enough.

Treatment

Chiropractic excels in the management of Thoracic Outlet Syndrome, except in its extremest forms which are very rare. Adjustment of the first rib opens the space in the tunnel, and cross friction of the two muscles that form the sides of the triangle helps too.

Sometimes the joints on either side of the collar bone, may be involved too.

Exercises for the neck and shoulder are important.

This is a complex syndrome, but generally patients respond well to chiropractic management.

Tip: Rest the elbow on a small table placed at your side whilst using the mouse. This takes the stretch off the muscles in the neck, and the nerves. Various commercial supports which attach to the computer station may also help.

Tip: Carrying heavy parcels in that hand is likely to aggravate the pain in the arm.

Go from Thoracic Outlet Syndrome to other causes of ARM PAIN.

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