The Thoracic Outlet Syndrome-part 1

The condition known as thoracic outlet syndrome is not one thing but the name given

to a collection of symptoms, all ascribed to problems with compression of blood vessels or nerves as they pass through the anatomical thoracic outlet. This structure is outlined by the first rib, the collar bone or clavicle and the neck scalene muscles, with the neurological and vascular structures passing through it to reach the axilla and travel into the arm. Diagnosis of these related conditions is difficult and there is little clarity or consensus about them.

The signs and symptoms of thoracic outlet syndrome are widely variable and no objective and reliable test has been developed to narrow down the precision of diagnosis for patients with thoracic outlet syndrome. Due to this imprecision it is not clear what the incidence of thoracic outlet syndrome is in the general population although there are more female patients presenting with symptoms, particularly with poor muscle development and posture.

The nerves and blood vessels travel in what is termed a bundle, moving down from the cervical spine and towards the arm, going through three, mostly triangular spaces, on the way. Compression of the bundle can occur in any of the three triangles, which are already small when the arm is by the side, reducing further in size as the arm moves into certain postures. Postures which increase the tightness of the spaces are used as diagnostic tests to figure out which structures are causing the compression and which are being compressed. Doctors and physiotherapists test by placing the limb of the patient in a specific posture known to be stressful and asking them to perform a repeated muscle action such as fist clenching. This heightens the demand on the blood supply or neurological control required.

Patients who are at greater risk of developing thoracic outlet syndrome are anyone who repetitively moves their shoulders close to the end of ranges of the joint, especially outward rotation and abduction (moving the arm out away from the body sideways). Swimmers are common presenters and this diagnosis should be considered if they report pain when the shoulder is at full range. All activities or sports which require repeated shoulder movements in extreme ranges make the tendency to develop this problem more likely. Patients may complain of symptoms related to changes in blood supply to the arm or of neurological symptoms.

Initial presentation of thoracic outlet syndrome is variable and differences exist depending on whether the structures compressed are nerves, blood vessels or both. Symptoms can vary widely and span from mild and intermittent to disabling and severe. Typical presentation divides into three types, nerve involvement, blood vessels involvement and the non-specific remainder which cannot be attributed. It is unusual for the main arm vein or artery to be compressed and occurs more commonly in younger sports people who do a lot of overhead throwing.

Obstruction of the artery involves changes in colour of the arm, pain on using the muscles due to insufficient blood flow and general widespread arm and hand pain. It may start off mildly but if the obstruction becomes severe patients are usually forced to seek medical advice. Nerve related thoracic outlet syndrome is secondary to compression of part of the brachial plexus, the complex web of major nerves travelling from the neck to the arms. Symptoms are rarely of nerve compression on its own, with loss of muscle bulk in hand muscles and problems holding rackets or balls a common complaint.

Pins and needles and feeling loss in the arm can be the result of nerve structure compression although pain is not a common complaint in this group. Activities which tend to bring on or worsen this condition are once again mostly sporting, with overhead and repeated actions the main culprit. The last group of patients who may be included in thoracic outlet syndrome are the biggest group by far, complaining of pain in the shoulder blade, cervical spine and arm regions. Onset of symptoms more commonly follows a trauma of some kind in this group and their ongoing symptoms cannot be well explained, with no general agreement as to whether they fit into thoracic outlet syndrome or not.

by: Jonathan Blood Smyth.

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