It doesn’t seem like too long ago when Thoracic Outlet Syndrome was unheard of, or at least a controversial diagnosis. It’s been called many names over the course of the last few decades, but the short version of the condition is this: there is a rich network of nerves and blood vessels that exit the spine to supply the arm and hand. The group of nerves is called the brachial plexus, and it passes out through the collarbone and first rib. Ordinarily, it’s big enough to carry the nerves through without issue. But when that changes, we have issues like neck pain, shoulder pain and even numbness in the fingers [1].
This is called Thoracic Outlet Syndrome (TOS), and it can be caused by physical trauma, repetitive injuries, anatomical differences and even pregnancy. Sometimes, doctors are unable to find the cause. Some sufferers of TOS report numbness or tingling in the fingers, weakened grip or arm fatigue, and even arm pain, swelling and hand discolouration.
Perhaps due to this last bit, it can often be misdiagnosed. Because of the wide variety of symptoms and severity, and the lack of substantial studies currently available, awareness for the condition can be poor. But that doesn’t mean presentation is uncommon.
There are thought to be three types of TOS: The first is the neurogenic type that affects the nerves of the brachial plexus and accounts for approximately 90% of cases [2] . The second is the venous type, whereby the blood vessels are compressed in the thoracic outlet, resulting in blood clots. The third and rarest type is the arterial form which causes aneurysms. It is possible to have a combination of the three, with each type bringing a different set of symptoms to the table.
In some cases, surgical intervention is recommended after physical therapy and medication fails to cure the condition. So where does chiropractic factor into the conversation? A new case report has looked at the case of a 24-year-old who presented with a stiff neck and upper back (right trapezius region) as well as abnormal sensation in her hands.
The Case In Question
The patient in the present case was a 24-year-old, right-handed building inspector who was suffering constant tingling in her dominant hand. At the time she presented for chiropractic care, sleeping on her right side aggravated the condition (which constantly affected her little finger), and she was beginning to experience waning grip strength in the affected side.
While she reported having been in a car accident three years prior, she had survived without “apparent” injury, and had no recent history of trauma. Other than the paraesthesia and right-sided neck and trapezius pain, she reported being of good health. Prior to presenting for chiropractic care, she consulted a neurologist, who confirmed “significant muscular atrophy and weakness (3/5) of the first interosseus muscle, abductor pollicis brevis and abductor digiti minimi. [Muscles affecting the hand and the little finger]” The chiropractic examination confirmed that low sensation was present in the C8-T1 area as well as the ulnar nerve area. Deep tendon reflexes were +2 (more sensitive) in the extremities on both sides. Other abnormal results were returned for wrist and elbow areas, and the patient undertook electromyography which also revealed abnormal electrical activity in the median and ulnar nerves.
This confirmed the neurologists findings, as did functional tests of the hand. An MRI was undertaken to rule out other pathology. While her neck disability index was low, she reported must higher pain scores in the arm, shoulder and hand. Based on the clinical findings, she was diagnosed with chronic neurogenic thoracic outlet syndrome and commenced a course of chiropractic care where she received ten sessions of Diversified Technique adjusting.
While the full protocol can be noted in the case report (referenced below – 2), it is worth noting that a 50% improvement in her symptoms and pain were noted following chiropractic care (With at-home stretching exercises as recommended by her chiropractor). Her neck stiffness and trapezius pain resolved completely, and her hypoaesthesia “mostly” resolved. While she had some remaining muscular atrophy at the thenar and hypothenar emminances (at the base of the affected finger), her symptoms were largely resolved and surgical intervention was not deemed necessary.
Two years later, having changed to a chiropractor close to home, she reported no changes or escalations since her cessation of care.
While certainly, no generalisations can be made through one single case report, it is the discussion of thoracic outlet syndrome in this case report that makes it a robust and noteworthy contribution to evidence. The authors rightly point out that TOS is a challenging diagnosis, and often creates significant pain and impairment for sufferers. They also point out the benefits of imaging, orthopaedic and neurological examinations and objective outcome measures when diagnosing and managing the condition. While there is much left to be written in terms of chiropractic evidence on the topic, it is certainly worth considering that if chiropractic care was of assistance in this case, it may be a potential contributor to improvement in other cases of thoracic outlet syndrome. Only more research will show this, but we look forward to seeing what emerges.
References:
- Staff Writer, Mayo Clinic. “Thoracic Outlet Syndrome.” https://www.mayoclinic.org/diseases-conditions/thoracic-outlet-syndrome/symptoms-causes/syc-20353988
- Mathieu, J., Lemire, J., Steiman, I., and Provencher, B (2023). Differentially diagnosing chronic upper limb paraesthesia in a 24-year-old patient: is thoracic outlet syndrome the culprit? A case report. Journal of the Canadian Chiropractic Association. https://chiropractic.ca/wp-content/uploads/2023/05/126799-1_Chiro_67_1i_Lemire.pdf
