Thoracic Outlet Syndrome (TOS)

The condition is common among athletes who participate in sports that require repetitive motions of the arm and shoulder, such as baseball, swimming, volleyball, and other sports. Neurogenic TOS is the most common form of the disorder 95 percent of people with TOS have this form of the disorder and generally affects middle-aged women.

Recent studies have shown that, in general, TOS is more common in women than men, particularly among those with poor muscular development, poor posture or both. The signs and symptoms of TOS include neck, shoulder, and arm pain, numbness or impaired circulation to the affected areas.

The pain of TOS is sometimes confused with the pain of angina chest pain due to an inadequate supply of oxygen to the heart muscle , but the two conditions can be distinguished because the pain of thoracic outlet syndrome does not occur or increase when walking, while the pain of angina usually does.

Thoracic outlet syndrome - Symptoms and causes - Mayo Clinic

Additionally, the pain of TOS typically increases when raising the affected arm, which does not occur with angina. Signs and symptoms of TOS help determine the type of disorder a patient has. Thoracic outlet syndrome disorders differ, depending on the part s of the body they affect. Thoracic outlet syndrome most commonly affects the nerves, but the condition can also affect the veins and arteries least common type.

In all types of TOS, the thoracic outlet space is narrowed, and there is scar formation around the structures. The disorders caused by TOS are not well understood. Thoracic outlet syndrome can be a result of an extra first rib cervical rib or an old fracture of the clavicle collarbone that reduces the space for the vessels and nerves.

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TOS can involve only part of the hand as in the pinky and adjacent half of the ring finger , all of the hand, or the inner aspect of the forearm and upper arm. Discoloration of the hands, one hand colder than the other hand, weakness of the hand and arm muscles, and tingling are commonly present.

TOS is often the underlying cause of refractory upper limb conditions like frozen shoulder and carpal tunnel syndrome that frequently defy standard treatment protocols [ citation needed ]. TOS can be related to Forward head posture [ citation needed ]. A painful, swollen and blue arm, particularly when occurring after strenuous physical activity, could be the first sign of a subclavian vein compression related with an unknown TOS and complicated by thrombosis blood clots , the so-called Paget—Schroetter syndrome or effort-induced thrombosis.

TOS can be related to cerebrovascular arterial insufficiency when affecting the subclavian artery. TOS can also lead to eye problems and vision loss as a circumstance of vertebral artery compression. Although very rare, if compression of the brain stem is also involved in an individual presentation of TOS, transient blindness may occur while the head is held in certain positions.

TOS can be attributed to one or more of the following factors: Adson's sign and the costoclavicular maneuver lack specificity and sensitivity and should comprise only a small part of the mandatory comprehensive history and physical examination undertaken with a patient suspected of having TOS. There is currently no single clinical sign that makes the diagnosis of TOS with any degree of certainty.

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Additional maneuvers that may be abnormal in TOS include Wright's Test, which involves hyperabducting the arms over the head with some extension and evaluating for loss of radial pulses or signs of blanching of the skin in the hands indicating a decrease in blood flow with the maneuver. Doppler arteriography , with probes at the fingertips and arms, tests the force and "smoothness" of the blood flow through the radial arteries, with and without having the patient perform various arm maneuvers which causes compression of the subclavian artery at the thoracic outlet.

The movements can elicit symptoms of pain and numbness and produce graphs with diminished arterial blood flow to the fingertips, providing strong evidence of impingement of the subclavian artery at the thoracic outlet. It should also be noted that Doppler ultrasound not really 'arteriography' would not be used at the radial artery in order to make the diagnosis of TOS.

Finally, even if a Doppler study of the appropriate artery were to be positive, it would not diagnose neurogenic TOS, by far the most common subtype of TOS.

There is plenty of evidence in the medical literature to show that arterial compression does not equate to brachial plexus compression, although they may occur together, in varying degrees. Lesser degrees of arterial compression have been shown in normal individuals in various arm positions and are thought to be of little significance without the other criteria for arterial TOS. There are three main types of TOS, named according to the cause of the symptoms; however, these three classifications have been coming into disfavor because TOS can involve all three types of compression to various degrees.

The compression can occur in three anatomical structures arteries, veins and nerves , it can be isolated, or, more commonly, two or three of the structures are compressed to greater or lesser degrees. In addition, the compressive forces can be of different magnitude in each affected structure. Therefore, symptoms can be variable. There are many causes of TOS. TOS is also found in certain occupations involving lots of lifting of the arms and repetitive use of the wrists and arms [ citation needed ]. One cause of arterial compression is trauma , and a recent case involving fracture of the clavicle has been reported.

The two groups of people most likely to develop TOS are those suffering from neck injuries due to traffic accidents and those who use computers in non- ergonomic postures for extended periods of time. Other groups which may develop TOS are athletes who frequently raise their arms above the head such as swimmers, volleyball players, dancers, badminton players, baseball pitchers , and weightlifters , rock climbers , electricians who work long hours with their hands above their heads, and some musicians [ citation needed ].

Some people are born with an extra incomplete and very small rib above their first rib, which protrudes out into the superior thoracic outlet space. This rudimentary rib causes fibrous changes around the brachial plexus nerves, inducing compression and causing the symptoms and signs of TOS. This is called a "cervical rib" because of its attachment to C-7 the 7th cervical vertebra , and its surgical removal is almost always recommended. The symptoms of TOS can first appear in the early teen years as a child is becoming more athletic.

Evidence for the treatment of thoracic outlet syndrome as of is poor. Stretching , occupational and physical therapy are common non-invasive approaches used in the treatment of TOS. The goal of stretching is to relieve compression in the thoracic cavity, reduce blood vessel and nerve impingement, and realign the bones, muscles, ligaments, or tendons that are causing the problem. In this case, the clots are formed as the result of overhead motions efforts that compress the vein. Deep vein thrombosis is more common in the legs.

When it occurs in the shoulders or arms, the cause is either recent surgery, a foreign object inserted into the upper body — such as a central line, pacemaker or implantable cardioverter defibrillator — or thoracic outlet syndrome. Aneurysm of the subclavian artery.

Thoracic Outlet Syndrome (TOS)

Sometimes, a congenital from birth abnormality can cause thoracic outlet syndrome, but it is more likely to occur after injury or bodybuilding. A cervical rib is an extra rib that grows from the cervical spine — the neck part of the spine. Between 1 and 3 percent of the population has a cervical rib, which may grow on one side or both, and may reach down to attach to the first rib or may not be fully formed.

Having a cervical rib increases the chance of nerve or blood vessel compression between the rib or its muscles and ligamentous connections sharing this small space. A small percentage of people with a cervical rib develop thoracic outlet syndrome. Abnormal muscle or first rib formation: Some people may have an extra or aberrant scalene muscle an inner muscle of the neck or an abnormal first rib or clavicle collarbone. Any of these abnormal formations can compress blood vessels or nerves. The following events may cause thoracic outlet syndrome, especially in people with the above bone or muscle abnormalities in the neck:.

Arm and hand symptoms that persist long after a whiplash injury may be a sign of thoracic outlet syndrome. Built-up muscles in the neck may grow too large and compress nerves or the subclavian vessels. People who take up swimming, baseball or painting, or who work as hairstylists, auto mechanics or other jobs that require raised arms may develop thoracic outlet syndrome. As with extra muscle mass, extra fat in the neck may compress nerves or subclavian vessels. Tumor in the neck: On rare occasions, a tumor may be the cause of the compression. Ying Wei Lum and his team at Johns Hopkins investigate diagnostic and therapeutic options for thoracic outlet syndrome, which can cause pain and numbness.

Thoracic outlet syndrome is sometimes considered controversial, as symptoms can be vague and similar to other conditions. Evaluate by history to rule out nerve-related conditions, such as carpal tunnel syndrome , cubital tunnel syndrome , cervical spine disease or other types of nerve entrapment, which have similar symptoms and may be confused for thoracic outlet syndrome. Sometimes, tests such as nerve conduction studies or MRI of the cervical spine are necessary to rule these out.

Duplex ultrasound to check for stenosis narrowing or occlusion blockage of blood vessels. Chest X-ray to check for cervical rib or abnormal first rib. Local anesthetic is injected into the scalene muscles of the neck.