Condition
Thoracic Outlet Syndrome
Thoracic outlet syndrome is compression of the nerves or blood vessels in the narrow space between the collarbone and the first rib.
- Seen at
- All three offices
- Typical wait
- Within the same week
- Treated with
- 3 procedures
In short
What thoracic outlet actually is.
Thoracic Outlet Syndrome
Thoracic outlet syndrome is compression of the nerves or blood vessels in the narrow space between the collarbone and the first rib. The great majority of cases are neurogenic, meaning the brachial plexus nerves are what is being squeezed, and they produce arm pain, numbness and hand weakness. The far less common vascular forms compress the artery or the vein and belong to vascular surgery rather than to pain management. It is frequently misdiagnosed as carpal tunnel syndrome, because both of them make the hand numb.
Symptoms
How it shows up.
If several of these sound like your week, it is worth having the source looked at properly.
- Aching along the side of the neck, over the shoulder and down the inner arm
- Numbness and tingling in the ring and little fingers, which is the opposite pattern from carpal tunnel
- The arm going heavy and dead when you hold it up, drying your hair or reaching a high shelf
- Weakness and clumsiness in the hand that builds through the day
- Symptoms that flare after carrying a bag on that shoulder or after a long drive
- A cold, pale or bluish hand, or sudden swelling of the whole arm, which points to the vascular forms
- Waking with a numb arm that takes several minutes to come back
What causes it
- An extra cervical rib, or a long transverse process at the seventh cervical vertebra, narrowing the space from birth
- A healed collarbone or first rib fracture that changed the shape of the outlet
- Whiplash or a seatbelt injury in a car accident, which is a common trigger
- Tight scalene muscles in the neck from posture, heavy lifting or repetitive overhead work
- Repetitive overhead activity in swimmers, throwers, painters and electricians
- Carrying heavy bags, tool belts or body armor on the shoulder over long periods
When to act
Stop waiting when this happens.
Do not sit on these
Any one of the following is a reason to be seen rather than to wait it out.
- Arm numbness keeps returning whenever you work with your hands above shoulder height
- Carpal tunnel was diagnosed or released and the hand is still numb
- The hand is weak, or the muscle between the thumb and index finger looks hollowed out
- The arm turns cold, pale or blue, or the whole arm swells suddenly, which needs urgent vascular assessment for a clot
- Symptoms started after a car accident or a broken collarbone and have not settled
Diagnosis
Finding the actual source.
A diagnosis is not a guess from an image. It comes from the exam, the history and, where nerves are involved, electrodiagnostic testing.
- Mapping the numbness, since involvement of the ring and little fingers and the inner forearm points to the lower brachial plexus rather than to the wrist
- Positional testing with the arms raised and the head turned, watching for reproduction of your symptoms and for a pulse that fades
- Examining the scalene muscles and the hollow above the collarbone for tenderness that reproduces the arm symptoms
- Nerve conduction studies and EMG, primarily to identify or exclude carpal tunnel, cubital tunnel and a cervical nerve root problem, which are far more common and are directly treatable
- X-ray of the neck and chest looking for a cervical rib or an old fracture, with MRI of the brachial plexus when the picture warrants it
- Vascular studies, ultrasound or angiography, when the colour, temperature or swelling of the arm suggests an artery or vein is involved, which is referred to vascular surgery
Nerve testing happens here, not elsewhere
EMG and nerve conduction studies are done in the office and read by Dr. Sheikh the same day, rather than sent out and waited on.
Treatment
How thoracic outlet is treated.
Ordered from the most common first step to the options reserved for pain that has not responded.
15–45 minNerve BlockA nerve block is an injection of local anesthetic, often with a steroid, placed next to a specific nerve or c…Read more →
Trigger Point InjectionA trigger point injection treats a knot in a muscle, a tight band that will not release and that often refers…Read more →
15–30 minEpidural Steroid InjectionAn epidural steroid injection puts anti-inflammatory medication into the epidural space, the area just outsid…Read more →Questions
Thoracic Outlet Syndrome, answered.
How is this different from carpal tunnel syndrome?
The finger pattern is the main clue. Carpal tunnel numbs the thumb, index and middle fingers and spares the little finger. Neurogenic thoracic outlet syndrome usually affects the ring and little fingers and the inner forearm, and it is provoked by holding the arm overhead rather than by wrist position. Nerve testing settles it.
Can an EMG diagnose thoracic outlet syndrome?
Not usually on its own. Nerve testing is frequently normal in the neurogenic form, so a normal study does not rule it out. What the test does reliably is confirm or exclude carpal tunnel, cubital tunnel and a pinched nerve root in the neck. Those need to be off the table before thoracic outlet syndrome is the working answer.
Do I need surgery for it?
Most neurogenic cases are managed without surgery, using targeted physical therapy for the scalene and shoulder girdle muscles, posture and activity changes, and injections when a muscle or nerve is clearly involved. Surgery to remove a rib or release the scalene muscles is reserved for cases that fail that, or for a confirmed vascular form. It is worth giving a well directed therapy program a few months before that conversation comes up.
Why do my symptoms only happen with my arms up?
Raising the arm narrows the space between the collarbone and the first rib and tightens the scalene muscles over the nerves. That is also why the position is used during the exam. Symptoms that reliably appear with the arms overhead and resolve when you lower them are one of the more useful findings.
My hand turns white and cold. Is that the same condition?
That is the vascular form, and it is handled differently. Compression of the artery or vein at the outlet can lead to a clot or reduced blood supply to the hand, which is a surgical problem, not a pain management one. Sudden swelling, colour change or coldness in the whole arm should be assessed urgently.
Get a real diagnosis for thoracic outlet.
Three New Jersey offices, most insurance accepted, and a real opening on the calendar.