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Thoracic Outlet Syndrome

Causes, Symptoms, Treatments, & Other Resources

New Treatment Option for Thoracic Outlet Syndrome

If you’ve had symptoms like numbness or tingling in your hands or arm, aches or pain in your shoulder or neck, a weakening grip, or the muscles in your hand shrinking, you may have been told you have thoracic outlet syndrome.

What Is the Thoracic Outlet?

The thoracic outlet is an area around the collar bone where the nerves that come from your neck meet up with the blood vessels from your heart and together supply the entire upper extremity (shoulder and arm).  These blood vessels (subclavian artery and vein) and nerves (brachial plexus) travel from the base of your neck to your arm pit (axilla) and is considered the “thoracic outlet” (1). Now that you know what the thoracic outlet is, what is thoracic outlet syndrome?

What is Thoracic Outlet Syndrome (TOS)?

Causes of the different Thoracic Outlet Syndrome

TOS symptoms are positional intermittent compression of the brachial plexus and/or subclavian blood vessels. There are 3 areas that can cause the compression (2).
1. Scalene triangle – Muscle spasms or chronically tight scalene muscles can compress the nerve plexus as the nerves travel through them.
2. Costoclavicular Space – this narrow space can compress the nerves or blood vessels in several ways
3. Pectoralis Minor Space – typically poor posture leads to chronic tightness of this muscle and muscle spasms that in turn compress the structures under the muscle.

Is TOS Serious?

Like most syndromes, there is a variety from very mild cases to life-threatening.  TOS is a group of symptoms in the chest, neck, shoulder, and arms and can be broken into 3 different types:

1. Neurogenic thoracic outlet syndrome (nTOS).

This most common type of thoracic outlet syndrome is characterized by compression of the brachial plexus. The brachial plexus is a network of nerves that come from your spinal cord and control muscle movements and sensations in your shoulder, arm, and hand. This is considered the most common type of TOS, making up 95% of all cases. This creates a numb feeling in the arm. It can be isolated to a single nerve or multiple nerves (3).

2. Vascular thoracic outlet syndrome (vTOS).

This type of thoracic outlet syndrome occurs when one or more of the veins (venous thoracic outlet syndrome) or arteries (arterial thoracic outlet syndrome) under the collarbone (clavicle) are compressed. Which can lead to extremity swelling, cyanosis (blue discoloring of the skin), and possibly deep venous thrombosis (blood clot in arm) (4).

3. Nonspecific-type thoracic outlet syndrome.

This type is also called disputed thoracic outlet syndrome. Some doctors don’t believe it exists, while others say it’s a common disorder. People with nonspecific-type thoracic outlet syndrome have chronic pain in the area of the thoracic outlet that worsens with activity, but a specific cause of the pain can’t be determined (5).

·         Muscle wasting (Gilliatt-Sumner hand)

·         Numbness or tingling in your arm or fingers

·         Pain or aches in your neck, shoulder or hand

·         Weakening grip

Common Symptoms of Thoracic Outlet Syndrome

Arm Pain at Night

Arm pain at night can be miserable.  The pain can interrupt your sleep and erode your quality of life. Irritability becomes increasingly more common.  What are the causes?  When should I worry about it?  What are the treatment options for arm pain at night? The neck is composed of 7 boney building blocks numbered 1- 7. Sandwiched between the bones is a disc that functions as an important shock absorber. The cervical discs are susceptible to injury due to trauma, degeneration, repetitive motion, and surgery. Common disc injuries include disc bulges, and herniations. The injured disc can compress or irritate one or more nerves resulting in arm pain at night. It can…

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Left Arm Numbness

Treatment depends upon the underlying cause of the arm numbness. Left-arm numbness is a warning sign that requires attention. As noted above unexplained numbness requires immediate attention. At the Centeno-Schultz Clinic, we are experts in the treatment of left-arm numbness due to cervical nerve irritation, cervical stenosis, thoracic outlet syndrome, and peripheral nerve injuries. When appropriate first-line treatment should involve conservative care including physical therapy and stretching. Steroid injections should be avoided as they are toxic to orthopedic tissue and can accelerate damage. Surgery for Cervical Stenosis and Thoracic Outlet Syndrome is major surgery and associated with significant risks. These risks…

Read More About Left Arm Numbness

Shoulder Pain at Night

There are several reasons why shoulder pain at night occurs or is aggravated; The common explanations include: Sleep typically involves a static position lasting hours at a time with little or no movement. Sleeping on your side places additional pressure on the tendons and bursa of the shoulder. Sleep can cause muscles and tendons to settle in a slightly different position resulting in additional pressure and reduced blood flow. Identifying the underlying problem is important!  This allows therapy to focus exclusively on the exact problem or problems.  When appropriate conservative care is always the first line of treatment.  Focus is typically on strengthening and improving range of motion. 

Read More About Shoulder Pain at Night

Shoulder Pain When Reaching Across Body

Shoulder pain can make simple chores almost impossible.  Have you ever reached for an object high on a shelf only to have pain that takes your breath away?  What causes shoulder pain when reaching across the body?  What is shoulder impingement?  What does shoulder impingement feel like?  Can a shoulder X-ray show shoulder impingement?  What are the treatment options for shoulder pain when reaching across the body? ulder impingement and rotator cuff injuries are among the most common causes of shoulder pain (1).  Both can cause shoulder pain when reaching across the body. Shoulder impingement is a painful condition in which the bursa and muscles of the shoulder are pinched or compressed. 

Read More About Shoulder Pain When Reaching Across Body

Stiff Neck

Conventional wisdom states that stiff neck symptoms can be treatable with nonsurgical remedies. However, not all stiff neck symptoms are benign, and leaving the stiff neck untreated can lead to a limited range of motion that can affect your overall health and quality of life. A stiff neck can cause pain, tightness, popping, and clicking noises and sensations and affect daily activities. A detailed examination of stiff neck symptoms can determine the exact condition affecting the stiffness of one’s neck. Where does the neck hurt? Neck stiffness can occur at the base of the head, down to the shoulders. This can be associated with pain, crunching noises, or popping sensations and may…

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How Do You Diagnose TOS?

Simply listening to a patient’s history and completing a physical examination is all that is needed to diagnose TOS. But more involved imaging such as X-rays, diagnostic ultrasound, MRIs, EMG (nerve conduction test) are used to rule out the underlying issue (2).

How Long does It Take to Recover from TOS?

Recovery depends on the severity of the syndrome and response to treatment. Thoracic Outlet Syndrome can resolve in a matter of weeks to months or can become chronic and last many years before getting proper treatment.

Can Thoracic Outlet Syndrome Be Cured?

Conservative options for TOS include modification of behaviors by avoiding activities that aggravate symptoms, and arm positions, along with physical therapy programs that strengthen the muscles of the pectoral girdle and help to restore normal posture (6, 7). TOS can be treated successfully with simple physical therapy. A paper by Dobrusin comments on how dysfunctional area treatment can, “decrease muscular tone in the scalene muscles, allow the first rib to become more mobile, and open up the interscalene triangle” (8). Success can vary, as 50% to 90% of patients respond well to conservative care.

Treatment Options

Some patients respond well to medications for this. Pharmacologic interventions often provide symptomatic relief and primarily include analgesics (NSAIDs and/or opioids) for nerve pain, as well as muscle relaxants, anticonvulsants (anti-seizure drugs), and/or antidepressants (9). The downside, if these medications help then you may be on them for the rest of your life!

Additionally, injection of local anesthetic, steroids, or botulinum toxin type A into the anterior scalene and/or pectoralis muscle has demonstrated varying levels of success in observational studies (10). BUT failed to demonstrate any benefit in a larger randomized control trial (11).

If failed those and continues to be debilitating, the patient will be referred to cardiothoracic surgeons for a first rib resection with scalenectomy. Utilizing the “when in doubt, take it out” mentality by removing the rib and muscles that are creating the compression!  But do you need your first rib and scalene muscles and are these surgeries safe?

There is limited research on long-term follow-up outcomes for these patients. In the short term, studies show 6.7% of patients have postoperative bleeding requiring thoracentesis (draining the bleeding from your lungs) or video-assisted thoracoscopic evacuation (small camera into the lung to find the bleeding) of hemothorax (12, 13). Other risks with this type of surgery are wound infection, lymph leak, brachial plexus injury, winged scapula (from injury to the long thoracic nerve), or paralyzed hemidiaphragm (from injury to the phrenic nerve). Hosseinian showed that nerve injuries to the nerves that are being decompressed can be as high as 9% (13, 14)!

NEW Percutaneous-Orthobiologic Approach

Combining the best of interventional orthopedic techniques with the most advanced ortho-biologics can help reduce the conversion of patients that are referred to surgery by a significant number.

We have seen excellent results utilizing a SANS approach with a multi-faceted treatment. Clinic on the link to get a better understanding of the utilization of the SANS approach to treating orthopedic conditions.

Here is an ideal treatment for TOS:

While this treatment is an excellent alternative to more invasive surgeries, these injections are not without risks and need to consider who is able to perform these injections safely and effectively. While many physicians still utilize a “feel and poke” (blind) method for injecting. Please be aware, the risk of complications from blind injections can increase complication rates drastically. The advent of musculoskeletal ultrasound and utilization of fluoroscopic guidance has made it possible to visualize soft tissue and boney structures allowing us to avoid the things we don’t want to inject (nerves, blood vessels) and directly inject the ligament or place injection around a nerve without damaging the nerve! These treatments are highly advanced injections that require advanced training to do these safely – here is a video done by Dr. Centeno explaining interventional orthopedics

Upside…

There are thousands of patients that suffer from TOS and up to 50% may require surgery. We have created a treatment option that is far less invasive and involves far less risk of serious complications with the goal to improve symptoms and overall function without the need for surgery.  If you have been diagnosed with TOS and considering alternatives to surgery, feel free to contact us. We’re happy to discuss and evaluate you further to see if you are a good candidate for this new treatment option!

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Our Doctors Who Treat Thoracic Outlet Syndrome

Christopher J. Centeno, MD

Christopher J. Centeno, M.D. is an international expert and specialist in Interventional Orthopedics and the clinical use of bone marrow concentrate in orthopedics. He is board-certified in physical medicine and rehabilitation with a subspecialty of pain medicine through The American Board of Physical Medicine and Rehabilitation. Dr. Centeno is one of the few physicians in the world with extensive experience in the culture expansion of and clinical use of adult bone marrow concentrate to treat orthopedic injuries. His clinic incorporates a variety of revolutionary pain management techniques to bring its broad patient base relief and results. Dr. Centeno treats patients from all over the US who…

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John Schultz, MD

My passion and specialization are in the evaluation and treatment of cervical disc, facet, ligament and nerve pain, including the non-surgical treatment of Craniocervical instability (CCI). I quit a successful career in anesthesia and traditional pain management to pursue and advance the use of PRP and bone marrow concentrate for common orthopedic conditions. I have been a patient with severe pain and know firsthand the limitations of traditional orthopedic surgery. I am a co-founder of the Centeno-Schultz Clinic which was established in 2005. Being active is a central part of my life as I enjoy time skiing, biking, hiking, sailing with my family and 9 grandchildren.

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John Pitts, M.D.

Dr. Pitts is originally from Chicago, IL but is a medical graduate of Vanderbilt School of Medicine in Nashville, TN. After Vanderbilt, he completed a residency in Physical Medicine and Rehabilitation (PM&R) at Emory University in Atlanta, GA. The focus of PM&R is the restoration of function and quality of life. In residency, he gained much experience in musculoskeletal medicine, rehabilitation, spine, and sports medicine along with some regenerative medicine. He also gained significant experience in fluoroscopically guided spinal procedures and peripheral injections. However, Dr. Pitts wanted to broaden his skills and treatment options beyond the current typical standards of care.

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Jason Markle, D.O.

Post-residency, Dr. Markle was selected to the Interventional Orthopedic Fellowship program at the Centeno-Schultz Clinic. During his fellowship, he gained significant experience in the new field of Interventional Orthopedics and regenerative medicine, honing his skills in advanced injection techniques into the spine and joints treating patients with autologous, bone marrow concentrate and platelet solutions. Dr. Markle then accepted a full-time attending physician position at the Centeno-Schultz Clinic, where he both treats patients and trains Interventional Orthopedics fellows. Dr. Markle is an active member of the Interventional Orthopedic Foundation and serves as a course instructor, where he trains physicians from around the world.

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Matthew William Hyzy, D.O.

Doctor Hyzy is Board Certified in Physical Medicine and Rehabilitation (Physiatry) and fellowship-trained in Interventional Orthopedics and Spine. Dr. Hyzy is also clinical faculty at the University of Colorado School of Medicine in the Department of Physical Medicine and Rehabilitation; In addition, Dr. Hyzy is an Adjunct Clinical Assistant Professor at The Rocky Vista University College of Osteopathic Medicine. Dr. Hyzy also maintains an active hospital-based practice at Swedish Medical Center and Sky Ridge Medical Center. He is also recognized and qualified as an expert physician witness for medical-legal cases and Life Care Planning. He is published in the use of autologous solutions including…

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Brandon T. Money, D.O., M.S.

Dr. Money is an Indiana native who now proudly calls Colorado home. He attended medical school at Kansas City University and then returned to Indiana to complete a Physical Medicine and Rehabilitation residency program at Indiana University, where he was trained on non-surgical methods to improve health and function as well as rehabilitative care following trauma, stroke, spinal cord injury, brain injury, etc. Dr. Money has been following the ideology behind Centeno-Schultz Clinic and Regenexx since he was in medical school, as he believed there had to be a better way to care for patients than the status quo. The human body has incredible healing capabilities…

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Mairin Jerome, MD

Mairin Jerome, MD

Dr. Mairin Jerome is a physiatrist with subspecialty fellowship training in Interventional Orthopedics and Regenerative Medicine. This subspecialty serves to fill the gap for patients who are interested in therapeutic options that lie between conservative treatment and surgery. Dr. Jerome uses regenerative medicine techniques, including prolotherapy and orthobiologics, via X-ray or ultrasound guidance to precisely deliver injections to areas of musculoskeletal injury or degeneration. Orthobiologics refers to tissue harvested typically from a person’s own body, such as platelets (platelet-rich plasma, PRP) or bone marrow, for use in treating painful musculoskeletal conditions. The goal is to stimulate the body’s healing mechanisms to improve pain, function, and decrease inflammation.

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Other Resources for TOS

  • PRP for Herniated Disc, Bulging Disc, and Disc Protrusion

    Dr. Pitts discusses PRP for Herniated Disc, Disc Bulge, and Disc Protrusion Transcript Hello, everybody. This is Dr. John Pitts of the Centeno-Schultz Clinic, where we are the leaders and inventors of much of the field of interventional orthopedics, which is basically treating and diagnosing musculoskeletal, orthopedic-type problems using injections and regenerative agents rather than … Continued


  • New Treatment for Costochondritis – Thoracic Spine Series

    NEW TREATMENT for COSTOCHONDRITIS What is Costochondritis? Your ribs connect with the sternum (breastbone) via cartilage at synovial-lined joint. Costochondritis is rib pain, specifically a chest wall pain caused by inflammation of the rib cartilages or the area where the ribs meet the sternum, known as sternal articulations (1). In a group of 122 patients … Continued


  • Thoracic Radiculopathy – Thoracic Spine Series

    Thoracic Radiculopathy is thoracic spinal nerve irritation caused by mechanical, or chemical, irritation of the spinal nerve. The term radiculopathy refers to the whole complex of symptoms that can be caused by a nerve root pathology. Thoracic spine has 24 nerve roots. 12 on each side. Symptoms typically correlate to the path of that specific … Continued


  • Facet Joint Injection

    The facet joint is a pair of cartilage lined joints at each level of the spine that provides important stability and resists excessive rotation and extension. Dr. Schultz discusses treatment options, risks, and alternatives to traditional steroid injections.


  • Rib Fracture Surgery – Thoracic Spine Series

    Rib Fracture Surgery – Can It Put You at Risk for Additional Fractures? Your Rib Cage Is Important Your rib cage is a vital area that protects the lungs and provides structure for the muscles that allow you to breathe. Rib fractures, which are surprisingly common, often result from some type of blunt force trauma … Continued


  • Herniated Thoracic Disc

    Thoracic Disc Herniations are especially difficult because there aren’t as many treatments available as there are for disc herniations in other areas of the spine. Dr. Markle weighs in on the Pros and Cons of each in this entry of his Thoracic Spine Series.


References:

  1. Yuschak E, Haq F, Chase S. A Case of Venous Thoracic Outlet Syndrome: Primary Care Review of Physical Exam Provocative Tests and Osteopathic Manipulative Technique Considerations. Cureus. 2019;11(6):e4921.
  2. Ciampi P, Scotti C, Gerevini S, et al. Surgical treatment of thoracic outlet syndrome in young adults: single centre experience with minimum three-year follow-up. Int Orthop. 2011;35(8):1179-86.
  3. Teijink JAW, Pesser N, van Grinsven R, van Suijlekom H, van Sambeek MRHM, van Nuenen BFL. [Neurogenic thoracic outlet syndrome]. Ned Tijdschr Geneeskd. 2017;161:D1385.
  4. Moore R, Wei Lum Y. Venous thoracic outlet syndrome. Vasc Med. 2015;20(2):182-9.
  5. Köknel Talu G. Thoracic outlet syndrome. Agri. 2005;17(2):5-9.
  6. Lindgren KA. Conservative treatment of thoracic outlet syndrome: a 2-year follow-up. Arch Phys Med Rehabil. 1997;78(4):373-8.
  7. Novak CB, Collins ED, Mackinnon SE. Outcome following conservative management of thoracic outlet syndrome. J Hand Surg Am. 1995;20(4):542-8.
  8. Dobrusin R. An osteopathic approach to conservative management of thoracic outlet syndromes. J Am Osteopath Assoc. 1989;89(8):1046-50, 1053-7.
    9.Brooke BS, Freischlag JA. Contemporary management of thoracic outlet syndrome. Curr Opin Cardiol. 2010;25(6):535–540.
  9. Foley JM, Finlayson H, Travlos A. A review of thoracic outlet syndrome and the possible role of botulinum toxin in the treatment of this syndrome. Toxins (Basel). 2012;4(11):1223–1235.
  10. Finlayson HC, O’Connor RJ, Brasher PMA, Travlos A. Botulinum toxin injection for management of thoracic outlet syndrome: a double-blind, randomized, controlled trial. Pain. 2011;152(9):2023–2028.
  11. Hawkins AT, Schaumeier MJ, Smith AD, et al. Concurrent venography during first rib resection and scalenectomy for venous thoracic outlet syndrome is safe and efficient. J Vasc Surg Venous Lymphat Disord. 2015;3(3):290-4.
  12. Hosseinian MA, Loron AG, Soleimanifard Y. Evaluation of complications after surgical treatment of thoracic outlet syndrome. Korean J Thorac Cardiovasc Surg. 2017
  13. Jones MR, Prabhakar A, Viswanath O, et al. Thoracic Outlet Syndrome: A Comprehensive Review of Pathophysiology, Diagnosis, and Treatment. Pain Ther. 2019;8(1):5-18.

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