Presentation on
Thoracic Outlet Syndrome

by
Dr James Stoxen DC

Dr James Stoxen's bio

Presented at the
12th Annual World Congress on Anti-aging Medicine

Mandalay Bay Hotel and Casino, Las Vegas Nevada
December 4, 2004

A presentation of the most effective diagnosis, treatment and prevention of

Thoracic Outlet Syndrome (TOS)

Chapter IV of IX

History and/or Patient Presentation and

Cause of Thoracic Outlet Syndrome

History and/or Patient Presentation

Symptoms of Thoracic Outlet Syndrome

Any and all of these structures can be compressed leading to an array of symptomatology. Thoracic outlet syndrome relates to nerve and vascular compression symptoms; it leads to upper back and neck pain, shoulder complaints, numbness and even extremity weakness. Some of the more severe symptoms of thoracic outlet syndrome are upper extremity emboli, which occur when the blood supply is diminished when the clot is released into the arm. The arm can become ischemic and an area distal to the emboli can become gangrene, even in very rare situations. Another serious complaint that is not listed in the literature is unnecessary surgery; if more appropriate conservative methods can be used, then surgery would not be necessary. If you told the patient that you were going to do surgery to remove structures from the neck such as the ribs and muscles, the patient is not going to be too keen on this surgery. They are going to be scared

Symptoms and Signs Vary in intensity

There are varying degrees of subluxation that have the rib elevated in perhaps less than that amount on that particular patient; in other words, that there are rib subluxations that do not illicit a full blown thoracic outlet syndrome, but when stressed, you will have to say that the patient because of the biomechanics of the ribs, the ribs are subluxated, but not enough to cause numbness or compression of the subclavian artery vein and brachial plexus. However, when put in a provocative position, they are subluxated just enough to cause the positive test, but not enough to cause brain symptoms in the patient.

Subclavian Artery Compression Signs and Symptoms

You can have subclavian aneurysms and when the compromise of compression of the structures gets severe leading to ischemic, causing weakness of the arm and hand and grip strength, you can have potentially dangerous accidents related to dropping of things by the patient.

What is a careful history

Symptoms

Symptoms of TOS

The common symptoms of thoracic outlet syndrome usually begin with some stiffness in the upper thoracic area like in the ribs around the neck area, specifically in the traps and the upper back.

What is the tingling or numbness in the fingertips? Artery or nerve?

As I mentioned to you, there is tingling in the fingertips. Sometimes the tingling is only seen after conducting provocative tests such as Adsons and Wrights tests which means the symptoms are subclinical. If the patients fingertips or a portion of the upper extremity is numb or tingling without testing then it is a full blown TOS.

The tingling usually happens more in the morning. The reason why it is seen mostly in the morning is because the position of the clavicle is not changing while sleeping. The position of the clavicle changes during the day. When the patient is reaching for a broom, or reaching for something out of a cupboard or waving to a friend, this elevation of the clavicle allows for blood supply to seep through into the arm and allows for the arm to be supplied with spurts of blood because the compression is relieved.

Why are the tingling symptoms more common the morning with TOS?

When the patient is sleeping, there is an aesthetic posture and there is not a lot of movement to stimulate the blood flow, which is why the patient has the tingling in the fingertips in the morning. The other reason is they commonly read in bed at night further compromising the thoracic outlet causing more compression of the vasculkar structures in the sleeping hours.

Why do the hands swell in the morning with TOS?

The patient has the highest degree of swelling in the hands in the morning with TOS. The swelling sensation called “glove sign”: in the morning, the patient feels the need to shake their hands out. Sometimes, the hand shaking method actually does bring blood supply down into the extremities, because they are elevating the clavicle and moving the extremity causing the need for additional blood to the region. The shaking of the hands actually allows the blood to come in and they are shaking the blood down into the extremities. This is something that the patient understands, based on instinct, when in fact they are actually correcting their problem temporarily. The problem is never corrected until you actually remove the compression of the vascular structures by manipulating the first rib inferiorally.

Why do patients with TOS have upper back pain and sometimes shortness of breath at times?

The pain and stiffness travel from the upper thoracic area and patients sometimes complain of chest pain in the upper thorax area. They also may complain of difficulty breathing. They talk about stiffness, and labored breathing and don’t realize it until you bring it to their attention. “Have you noticed lately that your chest feels tight and you have not been able to breathe as well?” And they will answer, “Yes, as a matter of fact I did.” It wasn’t something they were thinking about because they don’t understand the connection.

Why does this happen?

In fact, the reason the patient has a shortness of breath is because when the first rib subluxates in superiorly the intercostals muscles which connects the ribs actually allow not only for the first rib to subluxate superiorly, but the first rib takes the second, third, fourth and fifth ribs with it, because they’re connected. So what you are going to see is superior subluxation of the ribs of the upper thoracic spine and not just the first and second.

Why do so many patients with TOS have headaches too?

The other common symptom patients have with TOS is recurring headaches. The reason why is that they are in a reclining position watching television. Their neck in this position for so long that when they get up, their neck is more in a straightened, military or retrolisthesis position. If they leave their head in this position, they will not be able to see where they are going. It may seem silly, but postural reflexes kick in and an extension of the C0, C1, C2 vertebra occur to compensate for the tucking mechanism caused by the spastic scalenes. This hyperextension at level skull C1, C2, plus axis complex will actually cause compression of the first and second nerve of the spine and radiating headache pain as a result of this compression of the nerves and suboccipital regions.

Cause of Thoracic Outlet Syndrome

We are going to talk about the causative factors of thoracic outlet syndrome that will provide you with some insight on why it is difficult to manage. From what I gathered from the 300 + research articles and scientific papers I have studied, there have been some observations as to the causative factors that I have noted in my experience with patients with thoracic outlet syndrome, none of which was given mention in any of the 300 + scientific papers related to thoracic outlet syndrome. Therefore, it is difficult to say whether or not all of these physicians and scientists are missing something, but this is what research is all about – the sharing of information. I am hoping that we are going to bring some observations that we found and maybe add to the other research that has been done and we will be able to have a better outcome for these patients.

I have found that the most common cause of thoracic outlet syndrome is a combination of things but primarily it is a superior subluxation of the first rib. In other words, the patient is fine for 30 years of their life, they come to you with some upper extremity symptomatology for approximately a year or some length of time and it is becoming worse. What is the difference with the patient who was fine at 31 and then at 32 has these peripheral nerve and vascular symptoms? They have the same structures but different symptoms. They have no growths or tumors. All we have to do is find out what changed, reverse the change and the patient is treated properly.

Static Postural Stress and Traumatic Injury – Two Primary causes of TOS

The cause of thoracic outlet syndrome should be broken down into two main categories. We have the cause of thoracic outlet syndrome into 7 causes in this slide. As I mentioned I broke it down into 2 main causes, traumatic injury and static postural stress. These other causes that are listed here merely “predispose” the patient to thoracic outlet syndrome. In other words traumatic injury such as when a patient is struck from behind in an auto accident, similarly a clip in football or a very hard punch in boxing, or a work injury causing a violent trauma to the anterior muscles of the neck causing a trauma to the anterior muscles of the neck, can cause pulling of the scalene muscles and an elevation of the first rib of the neck as a result of the misalignment due to the trauma.

Static Postural Stress

Static postural stress is what I feel is the most popular and the most common cause of thoracic outlet syndrome. It is where the position of the neck is held in a forward flexing position when the patient is leaning back which strains the scalene muscles because they must hold the head and neck from extending.

Static Postural Stress – Mechanism of Injury

In the literature I studied, it states that the neck is held in the extension position. This position does not cause a strain on the scalene or flexion muscles of the neck. For instance, if you were to take your arm and hold a purse or a liter of liquid and hold it out extended with your arm flexed at 90 degrees for one hour, pretty soon your biceps, tendons, and your joints in your elbow and your shoulders, muscles in your shoulder will become very soar stiff and your elbow will become inflamed.

Example 1: Reading or Watching TV in Bed

The same type of philosophy or theory is that if you are sitting in your bed with two pillows propping up your neck, watching your favorite television show in this position for approximately 1 – 2 hours, the scalene muscles will be in an atonic contractile state for a very long period of time and the same thing will happen to these muscles. The scalene muscles attach on the first rib, so as the tension is increased on the scalene muscles, we feel that the scalene muscles elevate the first rib and cause the subluxation, the scalene muscles also become inflamed as a result of the subluxation, the entire area, as well as the scalene muscles will become inflamed and cause a compression of the thoracic outlet group of structures.

Example 2: Computer use

Computer use where you’re actually leaning back in a reclining chair, or reading in bed, as I have mentioned before, just as much as watching television in bed, which I feel is the most common cause, or laying on a recliner or sofa, with the neck in an extended position.

Example 3: Leaning back in the Car while Driving

Operation of a motor vehicle with the neck extended as well. Nowadays the car seat can be reclined; it can be straight and other various positions. A lot of young people think it’s really cool to lean the seat way back, and sit like this and they may be on a long route for half an hour, an hour or they may be in the car quite a bit; this constant stress on the anterior muscles causes imbalance and raise the first ribs and causes the compression and thoracic outlet syndrome.

Traumatic Epidemiology

Traumatic epidemiology such as whiplash is seen in sports. As you can see a group of boxers that are getting hit, obviously that causes stress to the anterior cervical area and can lead to thoracic outlet syndrome, automobile accidents and traumatic work injuries, as I mentioned before.

Table of Contents Return...

Chapter I Dr Stoxen's Introduction Read it here...

Chapter II Anatomy of Thoracic Outlet Syndrome Read it here...

Chapter III Thoracic Outlet Syndrome Controversy Read it here...

Chapter IV History or Patient Presentation Read it here...

Chapter V Physical Examination Findings Read it here...

Chapter VI Diagnostic Tests for TOS Read it here...

Chapter VII Treatment of Thoracic Outlet Syndrome Read it here...

Chapter IX Case Histories of Patients with TOS