“My ring and pinky finger get numb on my right hand and has been going on for three years. Sometimes my shoulder and neck ache, but overhead activities are impossible to do for more than a few seconds. My hands swell and turn blue!”
Sound familiar? Chances are that thoracic outlet syndrome is high on your differential diagnosis for this type of patient. In all likelihood, you are probably correct.
The thoracic outlet is the space between your collarbone and the first rib, with the anterior and middle scalenes completing the passageway. In thoracic outlet syndrome, the medial and lower cords of the brachial plexus are compressed; in addition to, the subclavian artery and vein when your patient elevates her arm. Hence, she experiences numbness, tingling and cyanosis. Cervical ribs are commonly associated with this syndrome.
Three simple tests you should know to diagnose:
1. Adson’s Test – Make the radial pulse disappear. Ask the patient to turn her head to the side that you are testing. She should then extend her neck backwards as far as possible and abduct her arm to shoulder level. The radial pulse should disappear within 30 seconds.
2. Elevated Arm Test (Roo’s test) – Easy enough… Ask the patient to hold her arm straight up in the air and open and close her hand multiple times. She shouldn’t be able to make 30 seconds.
3. Costoclavicular Test – Likely the least sensitive of the bunch, but ask the patient to move the shoulders backwards and down. This should result in the loss of the radial pulse.
From this point, you should order labs to rule out other systemic causes, followed by radiography, MRI and possibly Doppler or angiography depending on your clinical suspicion for other pathology. Once you feel confident that your patient has thoracic outlet syndrome, you should not consider anything other than conservative treatments at this point, states emedicine.com. You don’t want your patient to have a permanently damaged brachial plexus!
Treatments include the typical physical therapy orders, with stretching and heat being the most important. Supplement care with long-acting nonsteroidal anti-inflammatory medications, such as Arthrotec, Celebrex or Voltran, coupled with muscle relaxants if necessary. Stress to your patient to perform home exercise programs to keep symptoms in check.
Facts from emedicine.com:
– 23% of cervical soft tissue pathology
– 9:1 female to male ratio