Trunk and Thorax Pain: Thoracic Outlet Syndrome

If you are experiencing aching or pain in the shoulder, numbness or unusual coldness in your fingers, or gradual loss of strength in an arm or hand, it is possible you have a nerve problem caused by a condition known as thoracic outlet syndrome.

There are various reasons this condition might develop, but the important thing to keep in mind is that if you have had six months of guided physical therapy without relief, there is a chance you may need surgical intervention from Dr. Williams. This is particularly true when symptoms persist after you have had surgical decompression for cubital or carpal tunnel syndrome.

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Thoracic Outlet Syndrome and Pain

Thoracic outlet syndrome is a group of disorders that occur when blood vessels or nerves in the space between your collarbone and your first rib (thoracic outlet) are compressed by either muscle or bone. This can cause pain in your shoulders and neck and numbness in your fingers.

Common causes of thoracic outlet syndrome include physical trauma from a car accident, repetitive injuries from job- or sports-related activities, certain anatomical defects (such as having an extra rib), and pregnancy. Sometimes doctors can't determine the cause of thoracic outlet syndrome.

Treatment for thoracic outlet syndrome usually involves physical therapy, steroid and Botox injections in neck (specifically, the Scalenus anticus), and pain relief measures. Most people improve with these approaches. In some cases, however, you may need a surgical procedure. When this is the case, Dr. Williams may be able to help.

There are a number of types of thoracic outlet syndrome, including:

  • Neurogenic (neurological) thoracic outlet syndrome. This form of thoracic outlet syndrome is characterized by compression of the brachial plexus by the Scalenus anticus. The brachial plexus is a network of nerves that come from your spinal cord and control muscle movements and sensation in your shoulder, arm, and hand. In the majority of thoracic outlet syndrome cases, the symptoms are neurogenic.
  • Vascular thoracic outlet syndrome. 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.

Thoracic outlet syndrome symptoms can vary, depending on which structures are compressed. When nerves are compressed, signs and symptoms of neurological thoracic outlet syndrome include:

  • Numbness or tingling in your arm or fingers
  • Pain or aches in your neck, shoulder, or hand
  • Weakening grip
  • Arm fatigue with activity
  • Difficulty raising hands above shoulders (washing hair, reaching shelves, working above head, etc.)
  • Coldness in fingers, hands, or arms

Signs and symptoms of vascular thoracic outlet syndrome can include:

  • Discoloration of your hand (bluish color)
  • Arm pain and swelling, possibly due to blood clots
  • Blood clot in veins or arteries in the upper area of your body
  • Lack of color (pallor) in one or more of your fingers or your entire hand
  • Weak or no pulse in the affected arm
  • Cold fingers, hands or arms
  • Arm fatigue with activity
  • Numbness or tingling in your fingers
  • Weakness of arm

In general, the cause of thoracic outlet syndrome is compression of the nerves or blood vessels in the thoracic outlet, just under your collarbone (clavicle). The cause of the compression varies and can include:

  • Trauma. A traumatic event, such as a car accident, can cause internal changes to muscles of neck that then compress the nerves in the thoracic outlet. The onset of symptoms related to a traumatic accident often is delayed. Furthermore, a stretch traction can be the source of the problem. In these cases, the stretched nerve can have bruising and bleeding within the nerve itself.
  • Repetitive activity. Doing the same thing repeatedly can, over time, wear on your body's tissue. You may notice symptoms of thoracic outlet syndrome if your job requires you to repeat a movement continuously, such as typing on a computer, working on an assembly line, or lifting things above your head, as you would if you were stocking shelves. Athletes, such as baseball pitchers and swimmers, also can develop thoracic outlet syndrome from years of repetitive movements.
  • Poor posture. Drooping your shoulders or holding your head in a forward position can cause compression in the thoracic outlet area.
  • Pressure on your joints. Constant pressure on the shoulder or neck—like when military personnel carry heavy or oversized backpacks for extended periods of time—my lead to issues.
  • Anatomical differences. Inherited anatomical differences that are present at birth (congenital) may include an extra rib located above the first rib (cervical rib) or an abnormally tight fibrous band connecting your spine to your rib.

Finding Treatment for Your Pain

If your symptoms haven't been treated early, you may experience progressive nerve damage, and you might need more aggressive treatment. Dr. Williams typically only recommends surgery to treat thoracic outlet syndrome when other, conservative treatments haven't been effective. Surgery has higher risks than do other treatments and may not always treat your symptoms.

Doctors can try to differentiate between vascular or neurogenic problem. To do so, they may use:

  • Electromyography (EMG). During an EMG, your doctor inserts a needle electrode through your skin into various muscles. The test evaluates the electrical activity of your muscles when they contract and when they're at rest.
  • Nerve conduction study. These tests use a low amount of electrical current to test and measure your nerves' ability to send impulses to muscles in different areas of your body. This test can determine if you have nerve damage.

Dr. Williams may recommend surgery to remove a small muscle in order to decompress the brachial plexus nerves. If the problem is vascular in nature, he will refer you to an appropriate specialist in the area.  

It is important to know that thoracic outlet syndrome surgery has risks of complications, such as injury to the brachial plexus. Also, surgery may not relieve your symptoms, and symptoms may recur.

When other doctors are unable to determine the source of your trunk or thorax pain, you should contact our Baltimore, MD office and request a consultation with Dr. Williams. He may be able to identify the root cause of the issue and develop a plan to address it. Contact us today by calling (410) 709-3868 and our staff will be glad to assist you.

Eric H. Williams MD
Specializing in reconstructive surgery and pain relief in the Greater Baltimore area.