A Pain in the Neck: The Mystery of Thoracic Outlet Syndrome

Dr. Tracci demonstrates the surrender position that can help doctors diagnose thoracic outlet syndrome
Do your fingers go numb when you raise your hands like this? You may have thoracic outlet syndrome.

I went to get a massage. I had the usual complaints — a tight back, sore shoulders. But I also had a new pain, a mysterious pinch that began at the front of my neck and reached all the way to behind my right shoulder blade. What was it? The massage therapist is not a doctor. Yet he quite confidently diagnosed me as having thoracic outlet syndrome (TOS).

Baffled, I looked the condition up and thought that maybe he was right. But how could I know? And was there anything I could do about it? The massage had only helped the pain temporarily. Could it mean something serious?

For answers to these questions, I met with Margaret Tracci, MD, a vascular surgeon with the UVA Heart and Vascular Center. The conversation turned out to be a fascinating lesson in anatomy that renewed my appreciation for the complexity of the body as well as my gratitude for experts like her. It turns out TOS is just one of several issues that everyday primary care doctors may not know how to treat or even accurately diagnose. Pain relief is possible.

Types of Thoracic Outlet Syndrome

I showed Tracci where the pain started on my neck, and she identified that as the scalene muscle and confirmed that some degree of compression and tenderness in that area is fairly common.

The reason for this: That part of the body is essentially very crowded, like an entertainment system that has cords from the TV, cable box and sound system all heading to a single electrical outlet.

Three major structures travel through that space on the front of your neck:

  • Your subclavian artery
  • Your subclavian vein
  • The brachial plexus, a set of thick nerve bundles that exit your cervical spine to innervate (enter) the arm

These three structures run through a space bounded by two layers of muscles at the base of your neck, behind your clavicle and over the first rib.

Compression of each one of these structures results in a distinct type of thoracic outlet syndrome. Repeated pressure or muscle growth can pinch or damage any one of these. And while all three types of thoracic outlet syndrome have distinct effects and treatments, their proximity to one another and overlapping symptoms make this a challenging set of issues to address.

“Even in medicine, people get them confused and think they’re the same thing,” Tracci notes. “It’s a tangle of cords and wires. The anatomy of the thoracic outlet syndrome is on all the medical anatomy tests, because it’s so complex.”

A Range of Risks: Carpal Tunnel, Clots, Aneurysms

Thoracic outlet syndrome with compression of the nerve — called neurogenic thoracic outlet syndrome — can either cause a mild form of pain, like in my case, or it can have more severe consequences. And similar nerve compression is the culprit of the ever-familiar (though not much liked) carpal tunnel syndrome, which may have similar symptoms.

Compression of the subclavian artery, for example, can lead to an aneurysm and the formation of a clot that blocks the artery. This can travel downstream and cause tissue loss in the hand or the fingers.

And when people like baseball pitchers overwork the scalene muscle and compress the subclavian vein, they can end up with scar tissue on the inside of the vein, called Paget-Schroetter syndrome, or effort thrombosis. The vein ultimately clots off with swelling of the arm and intense discomfort, as well as the risk of the clot traveling to the lungs.

How Compression Happens

“If the muscles here are hyper-developed or really tight, you end up getting the compression” that causes TOS, Tracci says. Additionally, pressure can result from “people having a cervical rib. This is above your first rib, a little baby, extra rib that you’re born with and may never know you have if it’s not associated with these types of symptoms.”

“Whatever the reason for the compression of the nerves, inflammation and scarring of the tissue forms around the nerves so that they’re not sliding easily between soft muscle, they’re trapped,” Tracci says. Thus, the pain.

Diagnostic Frustration

The tricky part of this kind of thoracic outlet syndrome is that there’s no surefire diagnostic test, and often symptoms overlap with different causes.

Sometimes, for instance, doctors will have you “raise your arms and see if your pulse goes away,” Tracci explains. But this isn’t a conclusive test. “More than half of people have that, and mostly it doesn’t mean a thing. It’s just physiology: When you put your arms in the surrender position, the artery gets compressed a little bit. But it doesn’t cause real problems for their entire lives.”

If pain persists after physical therapy (see below) and comes with neurological symptoms of the arm or hand, doctors may turn to EMG testing. Doctors can use this nerve stimulation test to “discern what pattern the pain takes, whether symptoms of weakness or pins and needles come from a nerve root distribution or from the cords of brachial plexus. Or whether it’s more peripheral, further out on the arm.”

Tracci agrees that the lack of clear diagnostics for neurogenic thoracic outlet syndrome makes this process difficult for both doctors and patients. They “tend to come to us very frustrated because they’ve been through all of this testing,” with no definitive results.

Treating Neurogenic Thoracic Outlet Syndrome

Surgery for Relief

In her experience, Tracci finds that after diligently ruling out other causes and trying physical therapy, “the majority of people will find relief from surgery.” This procedure “frequently involves taking out the first part of the first rib, which is where the muscles attach, and a section of muscle that will make sure the nerve is free.”

Tracci tells patients that surgery will be “a little bit of both a diagnosis and a treatment. Even with MRI, we don’t always see the fine details, the abnormal ligament bands. So every time we operate on somebody, it’s interesting.”

She admits that sometimes the surgery does not provide relief, and she’s very clear and upfront with her patients about the potential for an inconclusive procedure. Sometimes the cause of the pain remains “fuzzy.” “People are incredibly grateful if you’re frank with them,” Tracci says.

Another risk: People may eventually need “redo” surgery, because their bodies reform scars and the compression comes back.

A Team of Detectives

Still, the reason Tracci and her colleagues see patients from throughout the region here at UVA is due to the fact that they have the expertise and experience to puzzle through the possible sources of pain and the ways to offer relief.

“We have wonderful physical therapists who meet with people in the hospital, both pre- and post-surgery,” she says. “Our physical rehabilitation specialists, pain medicine doctors and neurologists work with us, work through diagnostics before deciding on surgery. We don’t like to sign people up for things that aren’t helpful.”

The surgery for the venous and arterial forms of TOS vary, as they focus on relieving the vein and artery compressions.

Do you have mysterious pain that doesn’t go away?

See your primary care doctor or visit the Heart & Vascular Center.

Put Your Weight Into It

Fortunately, Tracci says physical therapy can prove “incredibly effective.” And if you have the most benign form of TOS, where you’re either really tight or your muscles are unbalanced, even posture changes and exercise can help.

She talks about women she knows who start losing feeling in their fingers while brushing their hair. People ask Tracci, “’Should I stop exercising?’ And I say, ‘Not necessarily. But you may have to exercise differently.’”

In fact, she says that working with light weights, building back and tricep muscles can help counter and prevent nerve compression, even the type that affects people like her — surgeons in the operating room. “We have our arms up all the time!” she laughs.

In terms of my symptoms, Tracci suggests I go to physical therapy. And generally, she encourages people with pain to seek help. “If you don’t get relief, the symptoms can worsen,” she says. “And while we won’t necessarily have a magic bullet to fix it right away, we’ll put our heads together and figure it out.”

Comments (11)

  1. Denise Snavely says:

    We have been on a journey for almost 2 years looking for answers to the constant pain my now 17 year old daughter has in her right arm mostly in the bicep region. This has lead to every diagnostic test there is and doctors diagnosing shoulder problems due to being a fastpitch softball pitcher and now 3 shoulder surgeries later still has the same pain, tightness, heaviness, often numbness & tingling that lead us on our journey to begin with and still a bruising in her bicep that no doctor has ever been able to answer why it happens usually as soon as she starts her post surgery therapy of the arm, especially when raising and abducting her arm. Wondering if TOS has been the main or overlapping problem that’s been going on? Can TOS cause bruising of this type? Any information would be appreciated.

  2. Diane. Garcia says:

    PLEASE HELP!!! I’m on the crazy train. First of all Thank you!. It’s only because of coming across articles like yours that get me out of the very dark days that come with chronic (real) pain. I’m into nearly 3 years of progressive undiagnosed pain. 1 xray, 3 MRIs, 2 rounds of physical therapy and am progressively getting mentally and physically worse. I have a protruding clavicle, torn rotator cuff,winged scapula and rounded shoulder. I have all the secondary issues, extremely strained scalene, SCM and pect major and minor muscles. My vision, sinus, jaw and teeth shifting have been affected as well as digestive issues. Aside from the numbing and tingling ( pins//needles) I have from my eyes down periodically my newest symptom is heaviness and cold right leg,foot and cold right hand. Here’s where I need your help. I started with orthro who only wanted to treat symptoms. I have been turned down by 3 different orthro and vascular groups and don’t know where or who to go to next. I live in a fairly rural town in Northwest IL. Hoping for a Sunny Side of the street and your help. Thanks again!

    • Amy Sarah Marshall says:

      hi Diane, We’re so sorry to hear about all these challenges. It sounds like you’ve been through so much. Unfortunately, we can’t diagnose anything via this blog, and we don’t have provider recommendations for your area. I would definitely hope you can find a provider who will help get to the root of the problem. Wishing you all the best!

  3. Scott Green says:

    I’ve been dealing with so many of these symptoms for over 15 years. Can you treat people that don’t live in Virginia, I live in Chicago? Meaning if I came to Virginia, what would the length of time be needed to get properly diagnosed and treated?

    • Amy Sarah Marshall says:

      Thanks for reaching out, Scott. Yes, UVA serves people from around the world. Unfortunately, we’re not able to provide an estimate on how long a diagnosis and treatment would take in this matter. Your best bet would be to see if your primary care provider can direct you further and then calling the Heart & Vascular Center here if required. Good luck!

  4. Donnamaria schuckers says:

    I have rib removal of my left top rib. No relief they took my scalene muscle. I was deemed partically disablied by State if New York. I still can’t use my left arm and now my right arm is acting the same .gingers go numb Constance pain in and down my right arm. No pain meds no Dr nothing.
    I live with chronic pain every day.

  5. Donnamaria schuckers says:

    Sorry I left out done info this happened in 1983and 1985 one in Elmira Ny, second in Rochester NY.

  6. Jack says:

    I been suffering chronic neck pain for about two years now with headaches since middle school. I had theoratic outlet syndrome with a blood clot in my arm, so I ended up having surgery with removal of my fisrt rib. I surely thought that this was the reason for my neck pain and thought it would go away after surgery, but I’m having constant neck pain still with no relief from acupuncture or physical therapy. I just want to mention that I have been a pitcher my whole life and currently playing. I just want to know if I have compression of nerves or blood vessels. The feeling is just a ache sore neck pain that never goes away now. Plz get back to me!!

  7. Sharon P. Fisher says:

    I have a neck fusion done in 2006 and am now experiencing a lot of pain. Dr. Said it would last about ten years so I am blessed to have had relief for this long.
    I also have a titanium rod in my lumbar spine from 2 thru 5.
    And a diagnosed herniated disc in my thorasic spine. Lumbar spine surgery done in 2013. I am now experiencing considerable pain. Both surgeries were done by Columbia Orthopedics in Columbia MO.
    In 2017 I was diagnosed with Parkinsons. I am a UVA patient already and I live in Lynchburg with my son.
    Can you help me? My medical records are in the UVA system. I am a 77 year old female and I would like to stay ambulatory as long as possible. Thanks for your consideration

    • Amy Sarah Marshall says:

      Hi Sharon, Thanks for reaching out! Unfortunately, we can’t offer medical advice here on the blog. But we can certainly recommend that you see someone for your pain! If you’re at UVA, you can schedule an appointment at the Spine Center through MyChart or by calling 434.243.3633. Best of luck!

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