More than just a pain in the neck.
is actually a collection of syndromes
brought about by abnormal compression of the neurovascular bundle by bony,
ligamentous or muscular obstacles between the cervical spine and the lower
border of the axilla.
What does that mean?
First of all a syndrome
is defined as a group of signs and symptoms that collectively characterize or
indicate a particular disease or abnormal condition.
- The neurovascular bundle which can suffer compression
consists of the brachial plexus plus the C8 and T1 nerve roots and the
subclavian artery and vein.
- The brachial plexus is the network of motor and sensory
nerves which innervate the arm, the hand, and the region of the shoulder
- The vascular component of the bundle, the subclavian artery and
vein transport blood to and from the arm, the hand, the shoulder girdle
and the regions of the neck and head.
The bony, ligamentous, and muscular obstacles all
define the cervicoaxillary canal or the thoracic
outlet and its course from the base
of the neck to the axilla or arm pit. Look at the scheme of this region and it
all becomes more easily understood.
What are the signs and symptoms of thoracic
It is important to understand that presenting with
the symptoms listed below in no way indicates a definitive diagnosis for thoracic
Professionals understand the importance of coupling diagnostic testing
skills with the patient's report of what hurts and what doesn't seem to be
working properly. Don't self diagnose! Neurologic and vascular
symptoms can be indicative of more serious conditions.
Vascular symptoms include:
- Swelling or puffiness in the arm or hand
- Bluish discoloration of the hand
- Feeling of heaviness in the arm or hand
- Pulsating lump above the clavicle
- Deep, boring toothache-like pain in the neck and shoulder region
which seems to increase at night
- Easily fatigued arms and hands
- Superficial vein distention in the hand
Neurologic symptoms include:
- Parasthesia along the inside forearm and the palm (C8, T1
- Muscle weakness and atrophy of the gripping muscles (long finger
flexors) and small muscles of the hand (thenar and intrinsics)
- Difficulty with fine motor tasks of the hand
- Cramps of the muscles on the inner forearm (long finger flexors)
- Pain in the arm and hand
- Tingling and numbness in the neck, shoulder region, arm and hand
What causes the neurovascular compression?
Compression occurs when the size and shape of the thoracic
outlet is altered. The outlet
can be altered by exercise, trauma, pregnancy, a congenital anomaly, an
exostosis, postural weakness or changes.
Below is a list of the component syndromes
which comprise thoracic outlet
syndrome along with a brief
description of each. Refer to the scheme for questions about the gross anatomy
of the region.
Anterior scalene tightness
Compression of the interscalene space between the
anterior and middle scalene muscles-probably from nerve root irritation,
spondylosis or facet joint inflammation leading to muscle spasm.
Compression in the space between the clavicle, the
first rib and the muscular and ligamentous structures in the area-probably from
postural deficiencies or carrying heavy objects.
Pectoralis minor tightness
Compression beneath the tendon of the pectoralis
minor under the coracoid process-may result from repetitive movements of the
arms above the head (shoulder elevation and hyperabduction).
What sort of activities can cause these compression syndromes?
has been described as occurring in a diverse population. It is most often the
result of poor or strenuous posture but can also result from trauma or constant
muscle tension in the shoulder girdle.
Static postures such as those sustained by assembly
line workers, cash register operators, students of, for example, those who do
needle work often result in a drooping shoulder and forward head posture. This
position of the shoulders and head is also indicative of poor upper body
posture. Middle aged and elderly women who suffer from osteoporosis often
display this type of posture as a result of increased thoracic
Carrying heavy loads, briefcases and shoulder bags
can also lead to neurovascular compression. Humans are not well adapted as
beasts of burden and heavy loads hung form the shoulders and arms can stress the
supporting structures of the shoulder girdle which is basically suspended by the
clavicle and all of the component ligaments and muscles.
Occupations which require repetitive over head arm
movements can also produce symptoms of compression . Electricians, painters and
plasterers may develop hyperabduction syndrome.
Compression of the neurovascular structures also occurs in athletes who
repetitively hyperabduct their arms. Swimmers, volleyball players, tennis
players and baseball pitchers may suffer compression of the neurovascular
structures as well. However, compression of these structures may be caused by
stretching or microtrauma (small tears in muscle tissue) to the muscles which
support the scapula.
Are there other causes of thoracic
Some people are born with an extra rib right above
the first rib. Since this intersection of nerves, vessels, muscles, bones and
ligaments is already quite involved one can imagine what the presence of an
extra rib in the region might do. A fibrous band extends from this cervical rib
to the first rib causing an extra bend in the lower part of the brachial plexus
which may produce a compression in this region.
How is thoracic
The first step to beginning any treatment begins
with a trip to the doctor. Make a list of all of the symptoms which seem to be
present even if the sensations are vague. Make a note of what activities and
positions produce or alleviate the symptoms and the time of day when symptoms
are worst. Also, note when the symptoms first appeared. This list is important
and should also include any questions one may have.
Due to overlapping in terms of symptoms it is
difficult to make a definitive diagnosis; this is why a list is so important.
Certain diagnostic tests have been designed which are very useful for
examination. These tests involve maneuvers of the arms and head and can help the
practitioner by providing information as to the cause of the symptoms and help
in designing an approach to treatment. These tests, accompanied by a thorough
history help in ruling out other causes which may produce similar symptoms.
These include Pancoast tumor, neurofibromas, cervical spondylosis, cervical disk
herniation, carpal tunnel syndrome
and cubital tunnel syndrome. Don't
forget to ask your practitioner about these conditions as well.
Once a diagnosis is decided, every effort is made
for a conservative treatment approach. That means it won't hurt. Should symptoms
persist over 3 or 4 months or if there is intractable pain, vascular loss or
neuralgic loss then surgery should be considered. Surgery is consistent in
relieving pain but muscle weakness and atrophy do not usually improve
Conservative treatment usually includes local heat
and a program which address postural retraining, shoulder strengthening and
stretching exercises. The practitioner will create a treatment program specific
to the presenting symptoms. Below are a few self-stretching exercises. All of
these exercises should be performed slowly and carefully. Each position is
assumed smoothly to the point where a stretch is felt intensely but with no
pain. There should be no bouncing in any of these positions. Hold the stretch
for 30 seconds and then gently and slowly release it. Wait 10 seconds and repeat
the stretch 3-5 times. If the stretches increase the symptoms do not continue.
Stretching the back of the neck
Using the arm which is on the side of the
tightness assume the position which is demonstrated, the head turning away
from the pain (left image). The hand behind the head helps stabilize the
head position. Take a deep breath, exhale slowly while bending the knees
keeping the elbow where it is against the wall.
Another method for stretching the back of the neck can be accomplished by
sitting down in a sturdy chair (right image). Turn the head away from the
tight side, look down until a slight stretch is felt. Reach down with the
hand on the tight side and hold onto the chair. With the other hand pull
the head forward, gently.
Stretching the chest
Sit in a sturdy backed chair with the hands
clasped behind the back of the head as demonstrated (see image, top left).
Bring the elbows back as far as possible during a slow, deep breath in.
While exhaling slowly bring the elbows together letting the head bend
forward slightly (bottom left).
Another method for stretching this area is to
stand facing a corner or a doorway with the arms in a "U" or a
"V" against the wall or door posts (see right image). With the
knees bent lean slightly forward from the ankles.
Stretching the side of the neck
Sit in a sturdy chair. Hold the underside with the
arm of the tight side. Pull the head back making a double chin. Bend the
head away from the tight side and turn the head toward the tight side. It
won't go very far. Lean away from the arm holding onto the chair and reach
with the opposite arm to the top of the head and gently pull to increase
Stretching the shoulder and the chest
There are three exercises for this region:
1. Sit in a sturdy chair next to a table with the
arm placed as demonstrated, palm down. Slide the arm forward while bending
at the waist as far as is possible without pain. Eventually the head
should be level with the side of the table.
2. Stand with back to the table and grasp the edge
with the fingers facing forward. Bend the knees and lower the body
allowing the elbows to bend. Let the knees do the work.
3. Sit on a firm and sturdy surface with the hand
of the tight side grasping the edge. Lean away slowly.
Mobilization of the first rib
Use a large bath towel and grasp it at opposite
corners. sling it across the shoulder of tightness and bring both ends
across to the opposite hip or waist. With the arm on that side pull gently
downward then release slowly.
These stretches are not cures. They may help in
alleviating some of the symptoms of thoracic
but as with any exercise program one should always consult a physician before
beginning particularly when symptoms persist for any length of time.