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Thoracic Outlet Syndrome

It is a term that is used for different conditions. Thoracic outlet syndrome occurs when the nerves or blood vessels in the chest outlet are compressed or stimulated. The thoracic outlet is a space between the clavicle and the first rib. This space is essential because important vessels and nerves pass through it. The critical nerves from both sides of the cervical vertebrae join together and create a network called the Brachial plexus.
Thoracic outlet syndrome is more common in women aged 20-50 years.

Thoracic Outlet Syndrome

Signs OF Thoracic outlet syndrome

Symptoms vary depending on which nerve or blood vessel is compressed. Nerve compression symptoms are much more common than blood vessel compression symptoms. In 90% of cases, the symptoms are due to pressure on the brachial nerve network, and 10% are due to pressure on the subclavian vessels. Depending on which nerve from the brachial plexus is pressed, sensory and motor symptoms appear in the path of activity of that nerve.

Neurological symptoms

  • Sensory disorders in the inner forearm and palmar area (falling asleep, tingling)
  • Muscle weakness and atrophy of the long flexor muscles of the fingers and small muscles of the palm (intrinsic muscles)
  • Problems with delicate hand movements
  • Cramps in the inner forearm (extensor digitorum flexor)
  • Arm and hand pain
  • Tingling and numbness in the shoulder, neck, arm, and hand
  • Rapid fatigue of arms and hands
  • The prominence of the superficial veins of the hand

Reasons OF Thoracic Outlet Syndrome

Sometimes a congenital disorder from birth can cause thoracic outlet syndrome, but it is more likely to develop after an accident or lifestyle. There are many reasons for this compression and can include the following:

  • Improper Posture and Weak Muscles

     These are the leading causes of this syndrome. Fixed positions, for example, in production line workers, bank or insurance employees, students, etc., can cause shoulders to droop and tilt the head forward. Also, carrying heavy weights such as suitcases, school bags, etc. can be another cause of shoulder drooping and causing disease symptoms. Hanging shoulders make this space narrower.

  • Cervical Rib

     The most common cause of thoracic outlet syndrome. The cervical rib is a bony appendage next to the transverse appendage of the seventh cervical vertebra, which is usually absent. Still, its presence in some people causes pressure on the nerves and vessels that pass between it and the clavicle. Of course, not everyone who has a cervical rib has these problems. Only one out of ten people with a cervical rib will suffer from thoracic outlet syndrome.

  • Repetitive Movements Of The Arms at A Level Above The Head:

     In some jobs (for example, construction workers, plastering and painting, teachers, university professors, etc.) or sports (such as swimming, javelin or discus throwing, etc.), hands are too much above the head. Goes. In these people, the nerves and vessels in the thoracic outlet space are compressed to the surrounding tissues and cause the symptoms of thoracic outlet syndrome.

  • Whiplash Syndrome

     
    Soft tissue injuries around the cervical spine, such as muscles, tendons, and ligaments caused by the sudden forward and backward movement of the head and neck, which is common in car accidents, is one of the causes of thoracic outlet syndrome.

  • Fracture Of The Clavicle

     A fracture of the clavicle may change the size of the chest cavity.

  • Accidental Trauma

     Sometimes a car accident causes bleeding in this space and narrows it.

  • Muscle Hypertrophy (Increase In Muscle Volume)

     In some people, such as bodybuilders or weightlifters, the scalene muscles that are close to this space are enlarged, or some have congenitally more muscles in this area, or the muscles they have in this area are changed in a way that can Put pressure on the nerves and blood vessels of this area.

  • Weight Gain

     As extra muscle mass increases, excess fat in the neck may compress nerves or subclavian vessels.

  • Tumour In The Neck

     In rare cases, a tumour may be the cause of the compression.

  • pregnancy

  • Other Medical Problems

     
    Hormonal disorders in the thyroid or the level of estrogen in the body, rheumatism, or changes in the curvature of the spine in the form of kyphosis or scoliosis can cause this disease.

Thoracic Outlet Syndrome

Diagnosis OF Thoracic Outlet Syndrome

The diagnosis of this disease can be more complicated than other common diseases around the shoulder because there may be many symptoms to explain. The doctor first tries to find the cause of the problems by talking to and examining the patient. One of the examinations is that the patient’s upper limbs are placed in certain positions so that more pressure is applied to the vessels and nerves exiting the chest. If the patient’s symptoms appear or become more severe, the doctor suspects this disease.

  • Tests

Hand Over Head Stress Test (EAST)

The patient in a standing position holds his arms up, as shown in the figure, so the elbows are slightly behind the head. The patient is asked to open and close his hands for three minutes. Pain, heaviness, feeling of weakness in the arms, numbness, and tingling in the hands are positive signs of this clinical test.

Although this test helps diagnose thoracic outlet syndrome, it is unreliable due to the positive results of this test in some asymptomatic people.

Imaging tests: To better see and evaluate the bones, muscles, tendons, and blood vessels, the doctor may order imaging tests. Imaging tests may include X-rays, CT scans (CTS), and MRIs. An x-ray of the neck may show the presence of a cervical rib. CT scan can show bony changes in the place, and MRI can show the changes that have narrowed the thoracic outlet space.

Electromyography (EMG and NCV)

Nerve and muscle tape check whether the upper limb nerves are under pressure.

Other tests: The doctor may use special blood circulation tests to check for vascular involvement. Angiography is used to check the pressure in the subclavian artery, and venography is used to check the pressure in the subclavian vein. Doppler ultrasound can also help the doctor check whether the artery or vein is under pressure.

Treatment OF Thoracic Outlet Syndrome

Treatment of thoracic outlet syndrome usually does not involve surgery.

  • Non-Surgical Treatment

Physiotherapy: 
The best treatment method for this disease is physiotherapy, usually a combination of advanced equipment, manual treatments and sports exercises. Physiotherapy treatments may include the following:

  • Using surface heat modalities such as hot pack or infrared
  • Using deep heat modalities such as ultrasound or laser
  • The use of electrotherapy analgesic modalities, especially P.S and Interferential
  • Manual local massages or using clinical massagers
  • Dry needling to release painful muscles
  • Muscle stretching exercises
  • Isometric exercises of neck, shoulder, and upper limb muscles
  • Correct the patient’s physical condition
  • Strengthening exercises for weak muscles

Nonsteroidal anti-inflammatory drugs: Naproxen and ibuprofen can reduce pain and swelling.

Weight loss: Being overweight can pressure the shoulder muscles supporting the collarbone.

Lifestyle changes: You may need to change your workplace, avoid strenuous activities, and even change everyday activities that aggravate your symptoms.

The treatment of this disease is primarily satisfactory; however, in cases where the disease has become prolonged and chronic, some changes in the nerves and muscles may not fully recover.

  • Surgical Treatment

Rarely, if the mentioned measures fail to resolve the symptoms caused by the pressure on the nerve, the attending physician may decide to use surgery. During the surgery, the neck rib or strong tissue band that presses on the nerve or the extra muscles in the chest exit space may be removed, or the pressure of the poorly welded clavicle on the nerve may be put the pressure of the poorly welded clavicle on being removed.

The treatment of this disease does not require surgery most of the time. Surgery may even worsen the patient’s condition, or the patient’s problems may recur sometime after surgery due to the formation of adhesions in the tissues of the operation site, so the decision to perform surgery for this disease should be considered as done by a doctor.

Thoracic Outlet Syndrome

Prevention OF Thoracic Outlet Syndrome

If you have symptoms of thoracic outlet syndrome, you can keep your shoulder muscles strong by doing simple exercises. The purpose of these exercises is to stretch the muscles and tissues around the chest outlet. If these exercises are done correctly and regularly daily, most of the time, after a few weeks, they gradually show their positive effects.

Below are 4 simple exercises:

  • Standing in the corner of the wall with your hands at shoulder height, rest the palms of both hands on the wall. Slowly bend your body forward until you feel a slight stretch in your chest muscles and the front of your shoulder. Hold the position for 15-30 seconds and return to the starting position. Repeat this movement three times.
  • Neck Stretch: Place your left hand on your head and your right hand behind your head. Pull your head toward your left shoulder until you feel a gentle stretch on the right side of your neck. Hold this position for 5 seconds, then change the position of your hands and repeat the exercise in the opposite direction.
  • Shoulder Rolls: Move your shoulders up, back, and down in a circular motion.
  • Neck Retraction: Pull your head back, keep your jaw level and hold for 5 seconds.

Remember to increase the number of exercises gradually. Exaggeration in doing exercises can increase your problems, but with a bit of patience and gradually increasing the number of exercises over a few weeks, you can feel their beneficial effects. If any of these movements cause pain, they should be stopped immediately. In general, exercises should be done under the supervision of a physiotherapist.

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