• Thoracic Outlet Syndrome

    Posted by on April 27th, 2011 · Comments (13)

    Everything you ever wanted to know about it, via the National Institute of Neurological Disorders and Stroke -

    What is Thoracic Outlet Syndrome?

     TOS is an umbrella term that encompasses three related syndromes that cause pain in the arm, shoulder, and neck:  neurogenic TOS (caused by compression of the brachial plexus), vascular TOS (caused by compression of the subclavian artery or vein) and nonspecific or disputed TOS (in which the pain is from unexplained causes).  Occasionally, neurogenic TOS and vascular TOS co-exist in the same person.  Most doctors agree that TOS is caused by compression of the brachial plexus or subclavian vessels as they pass through narrow passageways leading from the base of the neck to the armpit and arm, but there is considerable disagreement about its diagnosis and treatment.

    Making the diagnosis of TOS even more difficult is that a number of disorders feature symptoms similar to those of TOS, including rotator cuff injuries, cervical disc disorders, fibromyalgia, multiple sclerosis, complex regional pain syndrome, and tumors of the syrinx or spinal cord.  The disorder can sometimes be diagnosed in a physical exam by tenderness in the supraclavicular area, weakness and/or a “pins and needles” feeling when elevating the hands, weakness in the fifth (“little”) finger, and paleness in the palm of one or both hands when the individual raises them above the shoulders, with the fingers pointing to the ceiling.  Symptoms of TOS vary depending on the type.

               Neurogenic TOS has a characteristic sign, called the Gilliatt-Sumner hand, in which there is severe wasting in the fleshy base of the thumb.  There may be numbness along the underside of the hand and forearm, or dull aching pain in the neck, shoulder, and armpit. 

              Vascular TOS features pallor, a weak or absent pulse in the affected arm, which also may be cool to the touch and appear paler than the unaffected arm.  Symptoms may include numbness, tingling, aching, and heaviness. 

               Non-specific TOS  most prominently features a dull, aching pain in the neck, shoulder, and armpit that gets worse with activity.  Non-specific TOS is frequently triggered by a traumatic event such as a car accident or a work related injury.  It also occurs in athletes, including weight lifters, swimmers, tennis players, and baseball pitchers. 

    TOS is more common in women.  The onset of symptoms usually occurs between 20 and 50 years of age.  Doctors usually recommend nerve conduction studies, electromyography, or imaging studies to confirm or rule out a diagnosis of TOS.

    Is there any treatment?

     Treatment begins with exercise programs and physical therapy to strengthen chest muscles, restore normal posture, and relieve compression by increasing the space of the area the nerve passes through.   Doctors will often prescribe non-steroidal anti-inflammatory drugs (such as naproxen or ibuprofen) for pain.  If this doesn’t relieve pain, a doctor may recommend thoracic outlet decompression surgery to release or remove the structures causing compression of the nerve or artery.

    What is the prognosis?

     The outcome for individuals with TOS varies according to type. The majority of individuals with TOS will improve with exercise and physical therapy.  Vascular TOS, and true neurogenic TOS often require surgery to relieve pressure on the affected vessel or nerve. 

    If this is what Phil Hughes has, hopefully he’s feeling better soon.

    Comments on Thoracic Outlet Syndrome

    1. KPOcala
      April 27th, 2011 | 9:06 pm

      Sometimes a rib has to be removed, that ranks high on “procedures” that I hope is never performed on me. In 1997 I had a “stretched nerve” in the brachial plexus. I went from curling 50# dumbells to curling 10-15 in the space of two days in my left arm. I lost 80% strength on dumbell dumbell shoulder presses, left side. The amazing thing was I had zero pain, and I was quite scared. An EMG test found the problem and I recovered in 3-4 months from onset. I had never heard the phrase “stretched nerve”, the neurologist said that rest was the only cure… It was. When I was reading about Phil’s symptoms I had a hunch it was going to be something along those lines. BTW, don’t ever let yourself get talked into an EMG unless every other test has been performed. It sucks in a whole new way…. Here’s to Phil’s rapid recovery.

    2. Evan3457
      April 27th, 2011 | 9:08 pm

      …and this is why when a player says something’s wrong with him, until it’s proven otherwise, I believe him.

      Except for Pavano.

    3. Raf
      April 27th, 2011 | 9:12 pm

      KPOcala wrote:

      Sometimes a rib has to be removed

      I remember John Hudek having similar surgery.

    4. KPOcala
      April 27th, 2011 | 9:17 pm

      @ Raf:
      Yep your spot on… BTW, I saw that this is not a “confirmed” diagnosis. Time freezes in Yankee Land.

    5. Raf
      April 27th, 2011 | 9:27 pm

      KPOcala wrote:

      BTW, I saw that this is not a “confirmed” diagnosis.

      True, I was just sayin’…

    6. KPOcala
      April 27th, 2011 | 9:55 pm

      @ Evan3457:
      It is probably impossible to prove or disprove pain or lack thereof, even w/ the most sophisticated tests and doctors. Evan, you are 100% correct in your belief (Pavano excepted, of course).

    7. MJ Recanati
      April 28th, 2011 | 8:20 am

      Evan3457 wrote:

      …and this is why when a player says something’s wrong with him, until it’s proven otherwise, I believe him.

      Yep. Which potentially means that all those who jumped to conclusions about Hughes’s committment to baseball and his so-called apathetic attitude should be somewhat chastened by their rush to judgement.

      Evan3457 wrote:

      Except for Pavano.

      Much as we hate him, even he deserves the same benefit of the doubt. I don’t see any reason why someone would willingly undergo surgery if they didn’t need it and I certainly don’t see why someone would willingly endure all of the criticism and insults because they felt like three years of truancy was a good trade-off. It just doesn’t add up logically. I’ll always dislike Carla “American Idle” Pavano but I don’t think he just decided to lie about everything for four years.

    8. April 28th, 2011 | 8:53 am

      Good info on this from Marc Carig -

      Yankees pitcher Phil Hughes learned last night that he may have a rare disorder called thoracic outlet syndrome, a condition in which nerves, arteries or veins going to the arm are compressed in an area behind the collarbone.

      The Yankees are sending the 24-year-old Hughes to St. Louis to visit specialist Robert Thompson, who they hope can make a final diagnosis. If Hughes is indeed found to have thoracic outlet syndrome, he wouldn’t be alone.

      The ailment, which has been linked to repetitive motion activities, is thought to have afflicted at least a dozen major league players in recent years. Most of them complained of similar symptoms as Hughes—such as fatigue and a feeling of deadness—before they were diagnosed.

      Some have bounced back, such as Aaron Cook, who underwent surgery with Thompson and bounced back with an All-Star season in 2008. Others have not, such as former Tigers pitcher Jeremy Bonderman, who was never quite the same after undergoing surgery in 2008.

    9. MJ Recanati
      April 28th, 2011 | 8:56 am

      Steve Lombardi wrote:

      Some have bounced back, such as Aaron Cook, who underwent surgery with Thompson and bounced back with an All-Star season in 2008. Others have not, such as former Tigers pitcher Jeremy Bonderman, who was never quite the same after undergoing surgery in 2008.

      We should all hope that, if Hughes has TOS, he’s able to restore his career. It would be a shame if his career were derailed by something like this.

    10. yanksofny
      April 28th, 2011 | 10:48 am

      Long time reader, rare-poster.

      If Hughes does in fact have TOS, it is definitely treatable. I treat patients with this conditions on a daily basis. The main culprits of TOS are the scalene muscles (which are located on the side and front of the neck), pec minor/major muscles, first rib, and sometimes shoulder problems. Usually recovery time occurs in 4 to 6 weeks with conservative care. The good thing with TOS is it has nothing to do with a blood clot; a lot of people associate that with TOS. It has to do with structure (muscle, bone) causing the obstruction, not a clot.

    11. April 28th, 2011 | 10:52 am

      As many noted, the Yankees stressed that he MAY have a mild case of TOS or he MAY NOT. It does seem odd that they would mention TOS if they felt that he may not have it.

      So, if he doesn’t have it, does this leave them back at square one of not having a reason for the dead arm? That may be more troublesome than dealing with the TOS.

    12. KPOcala
      April 29th, 2011 | 8:23 pm

      @ yanksofny:
      “The good thing with TOS is it has nothing to do with a blood clot; a lot of people associate that with TOS. It has to do with structure (muscle, bone) causing the obstruction, not a clot”.

      Unfortunately your training in this subject is not quite inclusive. The condition CAN cause a clot that can lead to a STROKE. David Cone’s aneurysm was caused by TOS, he was lucky that it was caught before he suffered a stroke. J.R. Richard was not lucky, his stroke was caused by an undiagnosed TOS, destroying his brilliant pitching career and nearly losing his life. Even after being carefully evaluated by doctors (note, he had almost no pulse in his right arm), he was given the dreaded “all clear” to pitch. On the day of his worst of three strokes he had gone to a chiropractor for an cervical adjustment.

      I felt compelled to refute “yanksofny’s” comments on the subject. After learning of my stretched nerve condition in the brachial plexus (a condition that can be part of or mimic TOS) I was admonished by my neuroligist not to have any cervical adjustments from a chiropractor both because of my immediate condition and because of arthritis in my neck. Again I’m not trying to “show anyone up”, I felt that anyone that reads this and has any suspicious symptoms to get themselves to a qualified physician.

    13. Raf
      May 2nd, 2011 | 9:19 pm

      Tests came back negative.

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