An onset of pain, numbness or tingling in the neck, shoulder, arm or hand can be more than a little disconcerting, especially when they start affecting a person’s daily life. There are several potential explanations for these worrisome symptoms, but we’re looking at a lesser-known vascular issue known as thoracic outlet syndrome.
The vascular outlet is the space between a person’s collarbone and first rib. If the collarbone isn’t supported properly, it can compress the nerves, blood vessels and muscles in this space, leading to problematic and painful symptoms known as thoracic outlet syndrome (TOS). TOS is caused by varying issues, including anatomical defects, disease, injury/physical trauma, pregnancy, poor posture, and repetitive shoulder motion resulting from sports or the workplace.
Charles West, Jr., M.D., a vascular surgeon and physician on the medical staff at Texas Health Fort Worth and Texas Health Vascular Surgical Care, a Texas Health Physicians Group practice, says thoracic outlet syndrome can affect a person’s ability to work, play and live a normal life.
“A lot of these people with TOS can’t work, or they get injured and can’t do the activities of daily life such as screwing in a light bulb,” he says. “I’ve been able to help a collegiate volleyball player get back to playing and an electrician become able to go back to work.
“The first option with TOS is physical therapy, especially if a patient’s condition isn’t terrible. If their nerve compression is really bad, surgery can relieve it and they do really well going forward. Whatever a patient’s condition is, we want to give them the best chance to experience improvement.”
According to the National Institute of Neurological Disorders and Stroke (NINDS), symptoms of TOS vary on the type of syndrome the patient is experiencing: neurological, venous or arterial.
- Neurological: muscle atrophy in the fleshy base of the thumb (known as Gilliatt-Sumner hand), a sensation of pins and needles or numbness in the arm or hand, hand color change or coldness, and pain/aching in the neck, shoulder or armpit
- Venous: weak or absent pulse in the affected arm, a coolness or pale appearance in the affected arm, and arm or neck weakness, as well as numbness, tingling, aching or swelling in the hands or fingers
- Arterial: changes in color and cold sensitivity in the hand and fingers, as well as swelling, heaviness, numbness, a sensation of pins and needles, and poor blood circulation in the fingers, hands and arms
West says that neurological is the most common form of TOS, comprising between 80 and 85 percent of cases, followed by venous with 15 percent and the rare arterial form affecting just one percent of patients dealing with the syndrome.
The NINDS reports that thoracic outlet syndrome is sometimes difficult to diagnose due to the presence of similar symptoms common to other injuries or conditions, including injuries to the rotator cuff, cervical disk disorders, fibromyalgia, multiple sclerosis, complex regional pain syndrome and tumors.
So how exactly is thoracic outlet syndrome diagnosed? West says he looks to a patient’s past, as well as what is NOT the problem.
“I look at the history of a patient to see where their issue seems to be coming from and what the problem is … whether it’s pain in the arm and hand, numbness, tingling, neck pain, pain in the shoulders when they raise their arms, headaches, weakness and so on,” he explains. “We do a physical exam to determine if there’s nerve or vascular compression and work toward a diagnosis of exclusion by ruling out other problems such as rotator cuff and musculoskeletal issues. We also do nerve conduction studies and electric diagnostic studies to see if nerves are compressed or damaged. These things give us a strong indication of what the problem is.”
Thoracic outlet syndrome affects women at a higher rate than men, and more often affects younger adults between the ages of 20 and 50.
“I’ve done surgery on both women and men, but it does seem to be more common in women,” West says. “I don’t know that there’s a great reason for that, but it may just be they have a smaller frame. Younger adults are typically more active and injuries are more common. They may have a traumatic history, such as a longtime volleyball player with microtrauma occurring over many years, or they may be able to pinpoint a definitive injury when they fell and hurt themselves, leading to TOS.”
Treatments include nonsurgical options such as physical therapy, nonsteroidal anti-inflammatory medications (to reduce pain and swelling), and weight loss to relieve shoulder muscle stress for patients who are overweight or obese. Lifestyle changes such as avoiding strenuous activities or repetitive motions that aggravate the symptoms may also help. If these treatments do not offer relief, surgery is often the next step.
West says the decision to pursue surgery often depends on the severity of a patient’s condition, the failure of previous treatments and a patient’s patience.
“When you diagnose TOS, surgery may the best treatment but sometimes it’s better to try other things and take a more conservative approach,” he explains. “Because I’ve been doing this for years with few complications, I am probably more on the assertive side, especially if someone has failed at physical therapy. Then I also have patients that don’t want to even mess with physical therapy — they just want me to operate and move on.”
West also says he’s been pleasantly surprised to see how technology has helped patients not only find out what’s ailing them but also provide relief by connecting them to a doctor who can help.
“It’s been interesting in the last several years to see how things have changed,” he says. “These younger patients start to experience symptoms, jump on Google to find out what is causing their problems, and then self-diagnose themselves before they even call me. They go doctor shopping to find someone to help them. It’s an empowering thing.”
Learn more about Charles West by visiting Texas Health Vascular Surgical Care or call 817-767-4248 to schedule an appointment.