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Condition

Thoracic Outlet Syndrome

Compression of the nerves or blood vessels as they pass from the neck into the arm, causing arm pain, numbness, or swelling.

What is thoracic outlet syndrome?

The thoracic outlet is the narrow space between the collarbone and the first rib, where important nerves and blood vessels travel from the neck into the arm. When this space becomes too tight, the structures passing through it can be squeezed. The result is a mix of arm symptoms that can include pain, numbness, heaviness, or color and temperature changes. Because three different structures can be compressed — nerves, the artery, and the vein — there are three types of thoracic outlet syndrome:

  • Neurogenic TOS compresses the brachial plexus. This is by far the most common type and causes arm pain and numbness.
  • Venous TOS compresses the vein and can cause sudden arm swelling and a bluish color.
  • Arterial TOS compresses the artery and is rare but serious. It can cause a cold, pale arm.

Common symptoms

  • Aching, burning, or heaviness in the shoulder, arm, or hand
  • Numbness or tingling, often on the inside of the arm and into the ring and small fingers
  • Symptoms that worsen with the arms overhead (blow-drying hair, reaching into a cabinet, driving)
  • A tired or weak hand with activities like typing or writing
  • Sudden arm swelling, a bluish color, or a feeling of fullness (venous TOS)
  • A cold, pale, or painful hand with activity (arterial TOS)
  • Neck and shoulder pain, sometimes with headaches at the back of the head

Why does it happen?

The thoracic outlet can become tight for several reasons, and often more than one of these is present at the same time:

  • Posture and muscle imbalance. Rounded shoulders and a head-forward posture (common with desk work or phone use) can tighten the scalene muscles in the neck and narrow the outlet.
  • Repetitive overhead activity. Painters, hair stylists, swimmers, baseball pitchers, and weightlifters are at higher risk.
  • Trauma. A whiplash injury, a fractured collarbone, or a shoulder dislocation can cause scarring that narrows the space.
  • Anatomical differences. Some people are born with an extra rib at the top of the chest (a cervical rib) or with tight bands of tissue that crowd the outlet.
  • Changes with weight or muscle bulk. Rapid weight gain or heavy lifting that builds the neck muscles can also contribute.

Treatment options

Most patients with neurogenic thoracic outlet syndrome improve without surgery. Recovery is usually slow and steady, measured in months.

Non-surgical treatment

  • Hand and physical therapy. A therapist-guided program focused on posture, scapular stabilization, and scalene stretching is the most important part of treatment. This is often done for 8 to 12 weeks.
  • Activity and ergonomic changes. Adjusting your workstation, avoiding heavy carrying on the affected side, and modifying overhead activities often help a lot.
  • Medications. Anti-inflammatories and medications for nerve pain can calm symptoms while therapy works.
  • Scalene muscle injection. A diagnostic injection of numbing medication into the scalene muscle can both confirm the diagnosis and give temporary relief.

Surgical treatment

For neurogenic TOS that does not improve with therapy, Dr. Barrera offers nerve-focused surgery that decompresses the brachial plexus without removing the first rib. Venous and arterial TOS are treated by a vascular surgeon and are not performed in this practice.

  • Scalenectomy and brachial plexus decompression. The tight scalene muscles and any fibrous bands crowding the brachial plexus are released through a small incision above the collarbone. This opens the thoracic outlet and takes pressure off the nerves.
  • Pectoralis minor release. In some patients the nerves are also compressed further down where they pass under the pectoralis minor muscle. A small incision below the collarbone releases this muscle and relieves that second site of compression.
  • Distal nerve decompressions. Because TOS often overlaps with carpal tunnel and cubital tunnel syndrome, nerve release at the wrist or elbow may be done at the same time if those sites are also contributing to your symptoms.

Recovery from surgery typically involves several weeks of limited arm use, followed by guided hand therapy to rebuild strength and motion.

What to expect at your visit

Dr. Barrera will take a careful history, examine the neck, shoulder, and arm, and perform provocative tests that reproduce your symptoms with specific arm positions. Because TOS overlaps with carpal tunnel, cubital tunnel, and cervical spine problems, part of the visit is sorting out which condition is driving your symptoms — and sometimes more than one is present. Imaging (chest X-ray or MRI) and nerve studies (EMG / nerve conduction) may be obtained. Together you will build a plan that almost always starts with a structured therapy program.

When to call sooner — go to the ER if serious

Go to the emergency room right away if your arm suddenly becomes very swollen and blue, if it becomes cold, pale, and painful, or if you have sudden weakness. These can be signs of a vein clot or artery blockage and need urgent care. Call the office for worsening arm pain, new numbness that does not go away, or symptoms that keep you from sleeping.

Related

Questions?

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