Following our previous articles on hand numbness and tingling, another condition can be added to this list with similar symptoms. A condition known as thoracic outlet syndrome. A fairly common condition in overhead workers, thoracic outlet syndrome (TOS) will be discussed in detail, in particular, the symptoms, diagnosis and treatment options.
The thoracic outlet is a term used to describe the narrow space between the collarbone (clavicle) and the first rib, through which major nerves and blood vessels pass from the neck to the arm. This passageway contains the brachial plexus (the nerves to your arm and hand), the subclavian artery and vein. Compression to the thoracic outlet structures can lead to TOS.
Compression may occur from several sources.
- Clavicular fractures can cause swelling or bony malformations
- First rib fractures or pathology
- Swelling from another injury
- Tight scalene muscles may pinch on the brachial plexus as it enters the thoracic outlet
- Tight pec minor tendon
- Vascular abnormalities of the subclavian artery or vein
- Bony abnormalities like an extra rib or elongated transverse process
- Pathological lesions (tumors, infection)
Often, TOS occurs as a result of an overuse injury. In overhead workers, the arms are held in a position for a long period of time while they are moving and contracting. The tension in the muscles to hold the arm in this position builds up over time. When these muscles are now stretched when the arms come down, the tight neck or shoulder muscles compress the nerves of the arm causing numbness or tingling in the hand. Individuals that use their neck and shoulder muscles on a repetitive basis can be more prone to TOS. This includes electricians, plumbers, musicians, gymnasts, throwing athletes and many more.
Symptoms of TOS are dependent on where the compression takes place and what structure is compressed. The majority of cases, around 95%, are classified as neurogenic, meaning the symptoms result from compression of nervous tissue. The other 5% of cases involve vascular compression. The symptoms can include:
Neurogenic:
- Neck, shoulder or arm pain
- Numbness or tingling in the arm or hand (predominantly the pink and ring fingers)
- Arm fatigue with movement or overhead use
- Weakness in the arm or hand
Vascular:
- Swelling for unknown reasons in the arm, hand or fingers
- Discolouration, pale or bluish in colour
- Coldness in the arm, hand or fingers
- Prominent veins in the neck, shoulder, arm or hand
- Delayed healing in lesions of the arm, hand or fingers
- Throbbing lump in the area of the clavicle
- Diminished pulses in the arm or wrist
A diagnosis can be made by a healthcare professional that is knowledgeable in this condition. Family physicians, chiropractors, physiotherapists are often the first individuals to see these patients. There are a number of tests that can be performed to isolate the source of the symptoms. If symptoms of discolouration or swelling are prominent, an urgent evaluation should be made as these are symptoms indicating a vascular blockage and need more emergency care. When there are symptoms of numbness and tingling, a differentiation must be made to distinguish from other neurological problems including but not limited to cervical disc injuries and peripheral nerve entrapments like carpal tunnel syndrome or tunnel of Guyon syndrome. When a diagnosis is still unclear after conservative treatment, nerve conduction testing or blood flow studies can be utilized to obtain a more accurate diagnosis.
Treatment for TOS includes taking the pressure off of the thoracic outlet. This can be achieved by various providers but ultimately includes a combination of cervical, thoracic and sometimes rib manipulation, soft tissue stretching to relieve tension and exercise to strengthen and allow proper movement. Many patients also benefit from Hamilton massage therapy to help reduce muscular tension contributing to TOS symptoms. Ninety percent of the neurogenic cases respond well to conservative care as described above. Surgery is generally used only for the vascular cases or those with structural abnormalities causing neurogenic symptoms.
If you are suffering from numbness or tingling in the hand, I invite you to review some of our past posts (Carpal tunnel syndrome, cervical disc injuries, burners or stingers). If you are interested in further evaluation of your current symptoms, please use our online booking system to book an appointment or contact your preferred healthcare provider.