Thoracic Outlet Syndrome-TOS

[aragorn]

I thought I'd share this if anyone is having similar problems.

Since last Christmas I started having pain in my right shoulder, upper back and arm. Soon, there also developed pain in the wrist and thumb (my thumb was constantly tensed upwards). My suspicion is that the problem was caused by too much computer work(with a bad posture), carrying our daughter (sometimes I even prepared dinner while carrying her with my right arm), and too little exercise. I then went to see a physiotherapist, who as it later turns out, probably wasn't the best.

Anyway, with the help of this therapist and the exercises she gave have me, I got rid of the pain in the shoulder and upper back. But the "carpal tunnel syndrome" persisted. One of her theory was that the spine supporting muscles, the multifidus, were too weak and they needed to be trained. She was on the right track, but I somehow lost confidence in her - mainly because her theories about my problems varied a lot.

An then, summer vacation came, and I thought that this thing would go away if I just let the arm rest as much as possible. I started using a 'splint-thingy' on my right arm, but still, the pain persisted. I knew that joint problems in the hands could be a symptom of iron overload (my ferritin was around 130). However, a few rounds of EDTA didn't help either. Could still be related,though.

Anyway, today I finally had an appointment with another physiotherapist through the health care system at work. After asking about my symptoms, and doing some testing, he said that I did not have carpal tunnel syndrome. Instead, he said, I had something called Thoracic Outlet Syndrome. I later looked it up, and the symptoms match precisely. He gave me some new exercises to do everyday, and I feel confident that these will help.

Some basic information about TOS:

From Wikipdia

Thoracic outlet syndrome (TOS) is a syndrome involving compression at the superior thoracic outlet[1] wherein excess pressure placed on a neurovascular bundle passing between the anterior scalene and middle scalene muscles.[2] It can affect one or more of the nerves that innervate the upper limb and/or blood vessels as they pass between the chest and upper extremity; specifically in the brachial plexus, the subclavian artery, and - rarely - the subclavian vein, which does not normally pass through the scalene hiatus.

TOS may occur due to a positional cause - for example, by abnormal compression from the clavicle (collarbone) and shoulder girdle on arm movement. There are also several static forms, caused by abnormalities, enlargement, or spasm of the various muscles surrounding the arteries, veins, and/or brachial plexus, a fixation of a first rib, or a cervical rib. A Pancoast tumor (a rare form of lung cancer in the apex of the lung) can lead to thoracic outlet syndrome in the progressive stages of the disease. The most common causes of thoracic outlet syndrome include physical trauma from a car accident, repetitive strain injury from a job such as frequent non-ergonomic use of a keyboard, sports-related activities and anatomical defects such as having an extra rib. In pregnancy, if a narrow superior thoracic outlet exists previously, the patient can have symptoms for the first time. Joints loosen during pregnancy, making it easier to develop bad posture.[3]

Common orthopaedic tests used are the Adson's test, the Costoclavicular Manoeuvre, and the "Hands-Up" test or "EAST" test. Careful examination and X-ray are required to differentially diagnose between the positional and static aetiologies, first rib fixations, scalene muscle spasm, and a cervical rib or fibrous band.

Symptoms

TOS affects mainly the upper limbs, with signs and symptoms manifesting in the arms and hands. Pain is almost always present, and can be sharp, burning, or aching. It can involve only part of the hand (as in the 4th and 5th finger only), all of the hand, or the inner aspect of the forearm and upper arm. Pain can also be in the side of the neck, the pectoral area below the clavicle, the armpit/axillary area, and the upper back (i.e. the trapezius and rhomboid area). Decoloration of the hands, one hand colder than the other hand, weakness of the hand and arm muscles, and tingling are commonly present.

TOS is often the underlying cause of refractory upper limb conditions like frozen shoulder and carpal tunnel syndrome that frequently defy standard treatment protocols.

TOS can be related to Cerebrovascular arterial insufficiency when affecting the subclavian artery.[4] It also can affect the vertebral artery, case in which it could produce transient blindness,[5] and embolic cerebral infarction.[6]

A painful, swollen and blue arm, particularly when occurring after strenuous physical activity, could be the first sign of a subclavian vein compression related with an unknown TOS and complicated by thrombosis, the so called Paget-Schroetter Syndrome or effort-induced thrombosis.

*Causes

Painful TOS can be attributed to one or several etiological factors:[7]

Congenital abnormalities are frequently found in persons with TOS. These include cervical rib, prolonged transverse process, and muscular anomalies (e.g. in the scalenus anterior muscle, a sickle-shaped scalenus medius) or fibrous connective tissue anomalies.[7]
Trauma (e.g. whiplash injuries) or repetitive strain is frequently implicated.[7]
Rarer acquired causes include tumors, hyperostosis, osteomyelitis, etc.[7]

*Treatment

Most people respond to conservative measures such as medications, rest, chiropractic, occupational therapy, physical therapy, or massage, and stretching. Only a minority of patients with signs and symptoms of TOS ultimately proceed to surgery.[citation needed]

*Physical measures

Stretching and physical therapy are common noninvasive approaches used in the treatment of TOS. The goal of stretching is to relieve compression in the thoracic cavity, reduce blood vessel and nerve impingement, and realign the bones, muscles, ligaments, and/or tendons that are causing the problem.

One commonly prescribed set of stretches includes moving the shoulders anteriorly (forward - called "hunching"), then back to a neutral position, then extending them posteriorly (backward, called "arching"), then back to neutral, followed by lifting the shoulders up as high as possible, and then back down to neutral - repeated in cycles as tolerated.
Another set of stretches involves tilting and extending the neck opposite to the side of the injury while keeping the injured arm down or wrapped around the back.
Physical therapy can include passive or active range of motion exercises, working up to weighted or restricted sets (as tolerated).
Physical therapy usually consists of mobilization of any or all of the articulations of the shoulder girdle, including the 1st rib. Additional myofascial release (MFR) or Active Release Technique (ART) to the connected musculature and use of passive or active range of motion exercises.
Nerve gliding can be performed by extending the injured arm with fingers directly outwards to the side and tilting the head to both sides. A gentle pulling feeling is generally felt throughout the injured side. Initially, only do this and repeat. Once this exercise has been mastered and no extreme pain is felt, begin stretching your fingers back. Repeat with different variations, tilting your hand up, backwards, or downwards.
TOS is rapidly aggravated by poor posture. Active breathing exercises and ergonomic desk setup and motion practices can help maintain active posture. Often the muscles in the back become weak due to prolonged (years of) "hunching" and other poor postures.

Ice can be used to decrease inflammation of sore or injured muscles. Heat can also aid in relieving sore muscles by improving blood circulation to them. While the whole arm generally feels painful in TOS, some relief can be seen when ice or heat is intermittently applied to the thoracic region (collar bone, armpit, or shoulder blades).

 

[Rich]

I thought I'd share this if anyone is having similar problems.

Since last Christmas I started having pain in my right shoulder, upper back and arm. Soon, there also developed pain in the wrist and thumb (my thumb was constantly tensed upwards). My suspicion is that the problem was caused by too much computer work(with a bad posture), carrying our daughter (sometimes I even prepared dinner while carrying her with my right arm), and too little exercise. I then went to see a physiotherapist, who as it later turns out, probably wasn't the best.

I had similar about two years ago. I found switching to a trackerball style mouse for computer work useful and the deep tissue physio massage I had for it with neck exercises eased the problem too.

 

[mcb]

I encountered pain problems from using a mouse many years ago. It has been so long that I don't remember any more exactly what hurt. I was able to settle things down by training my left hand to use the mouse as well as my right hand. For a long time after that I used one hand for the mouse at work and the other hand at home. I also learned to pay more attention to hand position on both the mouse and keyboard, and to notice problems and intervene when they first began to develop.

I still notice a certain level of discomfort if I am doing something highly repetitive, but that doesn't come up often and it clears up when I stop.

 

[aaronfransen]

I've had similar pain for years, always getting worse (and of course I'm an IT person, so kind of mandatory) when using a mouse, to the point where I can't use a mouse for more than a minute without wearing a brace on my wrist.

I *did* find that switching to Apple's trackpad was a huge improvement.

 

[mcb]

I've had similar pain for years, always getting worse (and of course I'm an IT person, so kind of mandatory) when using a mouse, to the point where I can't use a mouse for more than a minute without wearing a brace on my wrist.

I *did* find that switching to Apple's trackpad was a huge improvement.

I noticed that the TrackPad was somewhat more comfortable than a mouse, except when doing highly repetitive tasks, in which case neither is very good. If you have a job that requires such repetition regularly, that could be a very significant problem (and watch out for employers that exploit you and then dump you!).

I currently use a mouse when I am in the office at work and a TrackPad at home. The mouse provides greater precision while the TrackPad is a bit more comfortable. It's a toss-up.

 

[Jacques]

I used to have that kind of problem when I was using my standard mouse.

So I switched to a more ergo mouse and it solved my problem.

Here's a pic of what i am using as a mouse:

 

[Olesya]

I just remembered about taping technique for this kind of problems, especially for rehabilitation. Here's 'Shoulder taping in the clinical setting' pdf _http://www.taping.hk/img/shoulder%20taping%20in%20clinical%20settings.pdf with explanations and pictures as to how to apply. Hope it helps. Best wishes and speedy recovery to you, Aragorn :)

 

[Gaby]

I just remembered about taping technique for this kind of problems, especially for rehabilitation. Here's 'Shoulder taping in the clinical setting' pdf _http://www.taping.hk/img/shoulder%20taping%20in%20clinical%20settings.pdf with explanations and pictures as to how to apply. Hope it helps. Best wishes and speedy recovery to you, Aragorn :)

That is a good idea! Also taping the neck, where the scalene muscles are might help.

 

[nicklebleu]

I think that most of these syndromes essentially come down to poor posture and consequent overwork of some muscle groups.

There is an excellent TEDx talk about this from Dr. Eric Goodman - which can be found here. He also has a personal website with more info at foundationtraining(dot)com.

I have had backpain for most of my adult life, but found what was helping best is kettlebell training, which is mainly resistance training, as well as slow-movement resistance training using the body as weights (like veeeery slow squats, pushups etc.). Since I have started to do that all my backpain has virtually disappeared. And most of all these fancy sounding syndromes (TOS, CTS etc.) are mainly but an extension of back problems.

The other thing I am trying to do is to sit less - which I think is really bad for our posture and back health. I haven't gone down the standing desk route yet - but this is certainly something to consider if working on a computer for prolonged periods of time.

 

[Leòmhann]

I had similar about two years ago. I found switching to a trackerball style mouse for computer work useful and the deep tissue physio massage I had for it with neck exercises eased the problem too.

From my experience as a massage therapist, although more often than not physical therapy is recommended, also, for TOS, I had assisted clients with similar issues (at least symptomatically...frozen shoulder) by utilizing various techniques ranging from myofascial release, deep tissue massage, trigger point therapy, and, last but not least, STRETCHING (Aaron Mattes' Active Isolated Stretching was taught in our massage institute as a form of self-help and found to be quite effective in many, if not most, cases).

Assisted stretching techniques, in your case, of the upper arm, shoulder, and neck, would, if I were helping, be my primary areas of focus [in conjunction with Swedish massage to warm up and increase circulation to the affected area(s), Myofascial release to stretch any tightly contracted fascial areas, commonly referred to as "adhesions," and deep tissue (together with pinpoint "trigger pointing" focused on loosening muscle knots) to really loosen up any highly contracted, rigid, and/or spasming muscle areas].

The stretching would, for the most part be done, only after the target muscle areas were sufficiently warmed up (increased blood circulation to the areas not only results in increased warmth but shows as a reddish tinge).

Also, dehydration plays a big factor in most muscular conditions -- I could often tell, just by palpation [a "sight by touch" use of the fingers/hands that massage therapists (and other clinicians like chiropractors) use as a matter of course all throughout the massage/bodywork session] whether a client was suffering from dehydration. Not enough can be said for drinking a sufficient amount of purified water, truly! :)

 

[aragorn]

I'm happy to inform you that the symptoms in my right hand are almost completely gone. I've been doing the exercises given by the PT every day (it doesn't actually take long to do them), and my hand felt better right after a few days. I'm going to see the PT again tomorrow to have a check up.

I guess there are many exercises that you can do to alleviate TOS, but you can see the ones I was given in the attached image (remember to log in to see it). Really simple and effective! A series of 10-15 pulls/stretches a couple of times a day. You just need one of those resistance bands (rubber band), and they come quite cheap.

 

[Chu]

Glad to hear that Aragorn!

The second exercise looks like Warrior's Breath! Maybe that's something we can add to the benefits of EE. :) The other two look like nice variations for stretching too, during the EE classes or other.

 

[Olesya]

Glad to hear good news, Aragorn! Thank you for posting pictures of the exercise. :)

 

[aragorn]

Glad to hear good news, Aragorn! Thank you for posting pictures of the exercise. :)

I forgot to mention that in the first exercise where you lie on your stomach, and then lift the upper body up, you're supposed to clench your shoulder blades together. Hold it for 4 seconds and then release and lower your upper body back down (it's good to keep a pillow under your forehead). Repeat 10-15 times.

 

[nicklebleu]

Glad to hear you're better, Aragorn.

Will keep these exercises in mind, might come in handy one day - who knows.