Chapter 8: More Tests?

Diagnostic Testing

Overuse of Imaging and Diagnostic Tests

• Reason: In many cases, doctors order expensive diagnostic imaging tests, such as MRI scans for back pain, neck pain, thoracic outlet syndrome, herniated discs, and chronic pain, which may reveal incidental findings that do not necessarily explain the patient's symptoms. This can lead to misdiagnosis, overtreatment, unnecessary surgery, unnecessary procedures, and delayed recovery.
• Example: Studies have found that many patients who undergo MRI scans for back pain, neck pain, cervical disc herniation, or spinal pain have findings such as bulging discs, herniated discs, degenerative disc disease, and spinal degeneration, which are common even in people without symptoms. Despite these incidental findings, some patients undergo spinal surgery, cervical spine surgery, or herniated disc surgery, which may not improve their condition and, in some cases, may worsen their pain and disability.

You would think that because an MRI scan can visualize bones, spinal discs, muscles, ligaments, and soft tissues, it would be the most accurate diagnostic test for thoracic outlet syndrome, herniated discs, neck pain, back pain, and chronic pain. Any doctor can order an MRI and immediately arrive at the correct diagnosis.

This is a huge misconception. In fact, the findings on an MRI scan can easily lead your doctor toward the wrong diagnosis, resulting in misdiagnosis, mistreatment, unnecessary surgery, unnecessary injections, failed conservative treatment, chronic pain, and even lifelong disability. I'll provide the proof.

You have numbness in your forearm, pinky finger, and ring finger, and the symptoms continue to worsen. The first doctor diagnoses you with carpal tunnel syndrome and recommends carpal tunnel surgery on your wrist.

You undergo carpal tunnel release surgery, but your symptoms do not improve.

You decide to get a second opinion, so you see an orthopedic surgeon, who diagnoses cubital tunnel syndrome and recommends cubital tunnel surgery on your elbow. You seek another opinion, and that physician also diagnoses cubital tunnel syndrome and agrees that you need ulnar nerve decompression surgery.

Now you have two surgical scars—and no improvement.

A friend tells you that you should have an MRI scan of your cervical spine, so you ask your doctor to order one. He agrees. Now you think this doctor is finally getting to the root cause of your neck pain, arm numbness, hand tingling, and nerve compression symptoms.

Your cervical MRI scan comes back, and the radiologist's report states that you have a herniated cervical disc at C5 and a smaller disc herniation at C6. The doctor walks into the room and says, "I found your problem. You have two herniated discs in your neck. We can begin with physical therapy, cervical traction, and spinal injections, and if those treatments fail, we'll recommend cervical spine surgery."

After physical therapy, cervical traction, epidural steroid injections, and treatment for the herniated disc fail to relieve your symptoms, you undergo neck surgery.

Now you have three surgical scars—and still no improvement.

Then you call me and schedule an appointment.

I discover that your numbness in the pinky finger and ring finger corresponds to the C8 nerve root, not the C5 or C6 nerve roots identified on your MRI. I perform a motion palpation examination and find that your first rib is elevated and locked on the affected side, producing thoracic outlet compression, brachial plexus compression, and thoracic outlet syndrome symptoms.

I perform approximately 15 hours of deep tissue therapy, combined with repeated first rib adjustments and first rib mobilization over a 15-day period. Within 15 to 20 days, your thoracic outlet syndrome symptoms, neck pain, arm numbness, hand tingling, and chronic pain are gone.

This happens all the time. But why?

More Tests?

How could this happen? You saw those herniated discs on the MRI scan yourself.

If you are getting an MRI scan for neck pain, arm pain, numbness, tingling, or suspected thoracic outlet syndrome and want to know the facts rather than just let your doctor determine your fate, you must know the facts—just in case your doctor doesn't. For instance, Japanese researchers at the Department of Orthopaedic Surgery, Keio University, Tokyo, Japan, performed cervical spine MRI scans on 94 volunteers who had never had neck pain, upper back pain, shoulder pain, arm numbness, hand tingling, or chronic back pain. The average age of the people tested was 48 years old. Here are the surprising MRI findings in patients who had absolutely no pain.

• 46% of the patients had degenerative disc disease at one or more levels.
• 37.2% had degenerative changes of the cervical intervertebral discs.
• 30% had disc protrusion (slipped disc, bulging disc, herniated disc, cervical disc herniation).
• 29% had disc protrusions compressing the covering of the spinal cord.
• 4% had visible narrowing of the disc space (disc space narrowing).

Surprisingly, more than 30 percent of these volunteers had herniated cervical discs they didn't know they had. (1) So what if you are one of those patients who had a herniated disc, bulging disc, slipped disc, or cervical disc protrusion for years that never caused you pain? The doctor performs an MRI scan, sees it, blames your neck pain, arm numbness, tingling hands, shoulder pain, or chronic pain on it, and recommends cervical spine surgery, neck surgery, or herniated disc surgery when it never was—and still isn't—the cause of your symptoms.

Another study performed at the Keio University School of Medicine, Tokyo, Japan, investigated degenerative cervical disc disease, cervical intervertebral disc degeneration, posterior disc protrusion, anterior disc protrusion, disc space narrowing, and foraminal stenosis in 497 asymptomatic subjects using MRI scans. (2)

None of these volunteers had neck pain, and none had a previous history of neck injury, cervical spine trauma, cervical disc disease, spinal disorders, or brain injury requiring medical care.

Degenerative cervical discs were found even in younger adults in their twenties.

• 17% of men in their 20s with no history of pain had degenerative disc disease.
• 12% of women in their 20s with no history of pain had degenerative disc disease.
• 86% of men in their 60s with no history of pain had degenerative cervical discs.
• 89% of women in their 60s with no history of pain had degenerative cervical discs.

So degenerative disc disease is a common consequence of aging. However, you cannot say it is normal because many individuals in their 60s had healthy cervical discs with no evidence of degeneration.

Disc protrusions, bulging discs, slipped discs, and herniated cervical discs were also found in these completely pain-free subjects.

• 27% of the patients had posterior cervical disc protrusions.
• 17% had anterior cervical disc protrusions.

The most shocking finding was that 7.6% (38 of the 497 pain-free subjects) had a Grade 2 posterior cervical disc protrusion with spinal cord compression.

A posterior cervical disc protrusion with spinal cord compression means the herniated cervical disc has bulged far enough to indent or compress the spinal cord.

If a doctor found a Grade 2 herniated cervical disc with visible spinal cord compression on your MRI scan, many patients would immediately be hospitalized and prepared for emergency cervical spine surgery. Yet many people are walking around every day with a severely herniated cervical disc and have absolutely no pain.

Now consider another possibility. What if the real cause of your arm numbness, hand tingling, shoulder pain, chronic neck pain, weakness, or thoracic outlet syndrome symptoms was actually compression of the thoracic outlet, but the MRI scan revealed a severely herniated cervical disc compressing the spinal cord? Do you think your doctor would recommend neck surgery? Of course. This is how MRI findings, diagnostic imaging, and incidental findings can sometimes lead to misdiagnosis, unnecessary surgery, and medical procedures that are not medically necessary.

Also, don't forget—after undergoing neck surgery for a herniated cervical disc that was never the true cause of your symptoms, you may still have the thoracic outlet compression, brachial plexus compression, arm numbness, tingling hands, chronic neck pain, and thoracic outlet syndrome symptoms you originally had, plus additional pain, stiffness, scar tissue, or complications resulting from the surgery you never needed.

Doctors Think Diagnostic Tests Are All They Need to Make the Diagnosis

Doctors are learning less and less human anatomy, functional anatomy, clinical anatomy, and biomechanics, and certainly almost no thoracic outlet biomechanics. They don’t think they need to know so much, because they can always order an MRI scan, diagnostic imaging study, or medical imaging test. Do you need these diagnostic tests or is it just that your doctor needs them because his physical examination skills, orthopedic examination skills, and understanding of thoracic outlet anatomy, brachial plexus anatomy, subclavian artery anatomy, subclavian vein anatomy, and thoracic outlet biomechanics are not adequate? This might be the real reason your doctor ordered the MRI for thoracic outlet syndrome.

You don’t know much about these diagnostic imaging tests, and you definitely cannot determine if a cervical herniated disc, bulging disc, slipped disc, or cervical disc herniation found on the MRI is the true cause of your neck pain, shoulder pain, arm numbness, tingling hands, and thoracic outlet syndrome symptoms, or just an old herniated cervical disc from 25 years ago that you did not even know you had.

So, a doctor could easily look you in the eye and say, “It is medically necessary to do this MRI scan, diagnostic imaging study, or medical test to determine what’s wrong with you,” and you would have to believe him. The doctor will show you right on the MRI scan the obvious herniated disc, cervical disc bulge, or degenerative disc disease, read the radiologist’s report to you, and you would have to say, “The cause of my pain is the herniated disc, and if the physical therapy, rehabilitation exercises, injections, or conservative treatment don’t work, I’m headed for spine surgery or cervical spine surgery.”

Some doctors have good intentions. Some think they are doing what is right. Others have no idea what they are doing.

You really need to know if a diagnostic test, MRI scan, CT scan, X-ray, ultrasound, nerve conduction study (NCS), or electromyography (EMG) is medically necessary and whether the findings are going to help your doctor decide the best course of thoracic outlet syndrome treatment, conservative treatment, nonsurgical treatment, or rehabilitation, or simply throw the doctor off the right course.

Making a proper thoracic outlet syndrome diagnosis is the most important step in thoracic outlet syndrome treatment. Wrong!

Sounds right, doesn’t it? However, it isn’t the most important step... making a diagnosis just gives the condition a name. It does not determine the root cause, underlying cause, or true cause of your symptoms. The diagnosis alone does not lead you to the best strategy for your complete thoracic outlet syndrome recovery, chronic pain recovery, or nonsurgical recovery.

1. The diagnosis is thoracic outlet syndrome (TOS).
2. The cause is super contractions (muscle spasms) of the 10 muscles that surround the thoracic outlet, producing brachial plexus compression, nerve compression, blood vessel compression, and thoracic outlet compression. In fact, you cannot detect muscle spasms, chronic muscle tension, abnormal muscle contraction, or excessive muscle tension with an MRI scan, CT scan, X-ray, ultrasound, nerve conduction study (NCS), electromyography (EMG), or other diagnostic imaging test. Period. So why do doctors order so many diagnostic tests for thoracic outlet syndrome?

They claim, “We need to do more testing to really understand what you have.” Most of the time it’s because they don’t know how to use their hands to examine for the muscle spasms, muscle tension, and soft tissue dysfunction that cause thoracic outlet syndrome (TOS), brachial plexus compression, and thoracic outlet compression. Don’t you hate when they don’t touch the area of your pain?

Defensive Medicine

Also, you hear that they order more tests to avoid malpractice. I have only ordered one MRI scan in the past five years. The last malpractice premium I paid for a full year of full coverage was less than $1,000. Many doctors and patients say that physicians are so terrified of being sued, they’ll often order batteries of unnecessary diagnostic tests, medical imaging studies, MRI scans, CT scans, and make unnecessary referrals in order to avoid lawsuits.

It’s these unnecessary diagnostic tests, advanced imaging studies, and medical imaging procedures that drive up our healthcare costs, not the direct cost of medical malpractice.

Doctors Cannot Order Tests to Satisfy a Curiosity!

If a doctor orders a diagnostic test, you might ask, “If you find what you suspect, will that change the approach to treatment?”

If the answer is “no,” then there is no need for the diagnostic imaging test. Just start the treatment, and apply the cost savings toward the care you need. If, after three weeks of aggressive conservative treatment, non-surgical treatment, or thoracic outlet syndrome treatment, you don’t feel any improvement, then order the MRI scan.

You also need to know when a positive MRI finding, diagnostic imaging finding, or abnormal imaging result means it’s time to change the course of care to a more invasive treatment approach, like thoracic outlet syndrome surgery, or when this positive finding is not the true cause of your suffering but only a finding that leads the doctor to recommend surgery that was never medically necessary. For example, recent studies show that as many as 20–50 percent of procedures should never have been been done because their results did not help diagnose disease or greatly improve patient outcomes. The bottom line is that doctors should not order an expensive MRI, CT scan, or diagnostic imaging study simply to satisfy curiosity.

MRI Abuse Can Be Dangerous and Expensive for Patients

Chris Rangel, MD, asked the question, “What is MRI abuse?” in his article, MRI Abuse Can Be Dangerous and Expensive for Patients.

These are the erroneous assumptions that he says providers make about MRI scans.

• MRI will usually yield a correct diagnosis.
• MRI will usually rule out a serious condition.
• MRI is the best of all diagnostic imaging studies.
• MRI will usually help direct further evaluation and lead to the correct diagnosis and treatment.
• MRI is without risks.
• The costs of an MRI do not matter.

It’s been my clinical experience that MRI scans, cervical spine MRI, and other diagnostic imaging studies often identify incidental findings, abnormal MRI findings, disc bulges, disc degeneration, or herniated discs that can confuse the clinical picture, contribute to the misdiagnosis of thoracic outlet syndrome, and lead the doctor to recommend an invasive procedure or surgery that was never medically necessary.

If you walk into a doctor’s office and demand an MRI scan for neck pain, shoulder pain, arm numbness, or thoracic outlet syndrome, you are just begging for surgery.

A positive MRI scan is not a ticket to the operating room.

Doctors are just beginning to understand that a visible finding on an MRI scan of the neck, cervical spine, shoulder, or thoracic outlet is not a ticket to the operating room. In 90 percent, the shoulder MRI scans showed abnormal shoulder cartilage. In 87 percent, the MRI scans showed abnormal rotator cuff tendons. “If you want an excuse to operate on a pitcher’s throwing shoulder, just get an M.R.I.,” Dr. Andrews said in a New York Times article. (4)

Now, more and more people have MRI scans, CT scans, and diagnostic imaging for everything from headaches to foot pain. Doctors do use MRI scans as fishing expeditions to find something to operate on. These scans are easily misinterpreted and can result in misdiagnosis, overdiagnosis, unnecessary surgery, unnecessary spinal surgery, unnecessary shoulder surgery, and other harmful treatments and complications.

What about a cervical herniated disc, herniated cervical disc, cervical disc bulge, or a herniated disc in the neck pinching the spinal cord? Doctors see something on a scan and quickly assume that is the cause of the symptoms. But many people are walking around with abnormal MRI findings, such as cervical disc herniations, lumbar disc herniations, bulging discs, rotator cuff tears, spinal cord compression, degenerative disc disease, and cervical spinal stenosis, yet they have no symptoms. In one study, doctors reviewed cervical spine MRI scans for 35 patients who previously had MRI scans to determine the cause of symptoms of the larynx. These patients had no symptoms of neck pain, cervical radiculopathy, spinal cord compression, or spinal cord symptoms. They found cervical disc herniations, bulging discs, and other abnormalities in these 35 cases, so they expanded the study to a total of 100 patients.

What they eventually found was cervical disc protrusions, cervical disc bulges, degenerative disc narrowing, cervical spondylosis, osteophytes (bone spurs), and spinal cord impingement in many of these patients. Disc protrusions or disc bulges were found in 44 of the 100 cases, disc narrowing in 70 percent of the patients, 24 patients had bone spurs, four patients had very large bone spurs impinging on the spinal cord, and 20 patients had spinal cord impingement—all without symptoms. (3)

So, if your doctor performs an MRI scan for neck pain, arm pain, shoulder pain, numbness, tingling, or suspected thoracic outlet syndrome on the first visit and immediately tells you your pain is coming from a herniated cervical disc found on your MRI, you should get a second opinion immediately to determine whether you have thoracic outlet syndrome (TOS), neurogenic thoracic outlet syndrome, vascular thoracic outlet syndrome, cervical radiculopathy, carpal tunnel syndrome, double crush syndrome, or one of the other 30 conditions that mimic a herniated disc or thoracic outlet syndrome, discussed in Chapter 9.

I know how you feel. You are afraid. You think you need more diagnostic tests, MRI scans, CT scans, X-rays, nerve conduction studies, or EMG testing, and it will put your mind at ease to know the cause of your pain. I keep saying it over and over... Finding the true cause of your thoracic outlet syndrome symptoms can only be done with a thorough, hands-on physical examination.

Why should your doctor’s lack of skill or laziness confuse you, cost you time and money, increase healthcare costs, and drive up insurance premiums until you are forced into an insurance plan with a $5,000 deductible that doesn’t even cover chiropractic care or conservative treatment?

This is a huge problem for patients—not doctors, hospitals, or insurance companies.

I almost never had a patient ask for another diagnostic test or MRI scan after I completed a thorough examination.

They are confident that I am spot-on with my thoracic outlet syndrome diagnosis, differential diagnosis, and determination of the true cause of their symptoms. That is because the patient knows I made the correct diagnosis by finding the actual cause during the hands-on examination. When I examine a patient, I put my thumbs directly into the painful muscles and areas of muscle spasm, myofascial trigger points, scalene muscles, pectoralis minor, and other tissues compressing the thoracic outlet. I ask, “Is that where you hurt?” OH, YEA! When I press down, I tell them—not ask them—that they feel radiating arm pain, nerve pain, numbness, tingling, and pain traveling down the arm. They reply, “OH, YEAH! That hurts down my arm. It’s the same pain I feel.” When I push into the sore muscles compressing the body’s Human Spring mechanism and thoracic outlet, the patient knows immediately that I know what I am doing. I demonstrate confidence because I know exactly what I am looking for, and I have identified the true source of the compression.

Immediately following the examination, I begin treatment of these 10 muscles with a high-powered vibration massage using the Vibeassage® or Vibeassage Pro®, followed by a thorough 1–2-hour hands-on soft tissue treatment of the muscles compressing the thoracic outlet, brachial plexus, and surrounding structures. When patients report significant relief of their neck pain, shoulder pain, arm numbness, tingling, weakness, and other major symptoms immediately after treatment, they know the diagnosis, cause of the compression, and treatment approach are correct.

A few days of really thorough treatment can confirm a thoracic outlet syndrome diagnosis, reassure the patient, and demonstrate whether the symptoms are caused by thoracic outlet compression. I have often determined the cause of the problem before a patient can even get to the MRI scan.

Why don’t I do more diagnostic testing?

I performed a thorough thoracic outlet syndrome examination, and after arriving at the correct thoracic outlet syndrome diagnosis, my treatment demonstrates significant improvement, confirming that we are on the right treatment path. When is diagnostic testing indicated?

Should you consider diagnostic testing, MRI, CT scan, ultrasound, or electrodiagnostic testing if you have persistent thoracic outlet syndrome, chronic neck pain, upper back pain, radiating arm pain, arm numbness, hand tingling, or nerve compression symptoms with no improvement after two weeks of conservative treatment? Four weeks? Six weeks? One doctor's recommendation was that diagnostic testing should begin after 12 weeks of conservative therapy for thoracic outlet syndrome. For example, the American Academy of Family Physicians (AAFP) recommends that unless red flag symptoms are present, physicians should wait six weeks before ordering diagnostic imaging, such as an MRI, for lower back pain. These scans usually do not change treatment or improve recovery any faster, but they may expose patients to unnecessary testing, increased healthcare costs, and even unnecessary spine surgery. (5) I can turn around almost every case to pain free in two to three weeks with daily conservative care. Instead of paying for an expensive MRI scan, those healthcare dollars can be invested directly into treatment, eliminating unnecessary costs and reducing diagnostic confusion.

Many of you do not mind if your doctor orders an expensive MRI, CT scan, or other diagnostic imaging study. However, when your monthly health insurance premium equals your mortgage payment, exceeds your car payment, or you have a $2,500 deductible or higher, those costs suddenly matter. Many physicians order expensive diagnostic tests during the very first visit. If the scan reveals a herniated disc, are they going to recommend expensive spinal surgery that you may not actually need?

My goal for every patient with thoracic outlet syndrome, neck pain, shoulder pain, or chronic upper back pain is to become pain free within two weeks. In particularly difficult cases, I consider ordering diagnostic testing, such as an MRI, if the condition has not improved substantially after approximately 10 days of intensive conservative treatment.

Why would some doctors order these expensive diagnostic tests on the first visit instead of providing 2–12 weeks of conservative treatment first?

Legitimate Reasons for Doctors Ordering Diagnostic Tests

1. Your arm is blue or purple, suggesting possible vascular thoracic outlet syndrome, venous compression, or compromised circulation.
2. Your arm is gray, cold, or shows signs of severe arterial thoracic outlet syndrome, and you may be at risk of losing the limb.
3. You have signs of a blood clot, deep vein thrombosis (DVT), Paget-Schroetter syndrome, or a clot that could become a pulmonary embolism.
4. They suspect your symptoms are caused by something other than thoracic outlet syndrome and need to establish a differential diagnosis.
5. Your condition has not improved after several weeks of appropriate conservative treatment for thoracic outlet syndrome.

Illegitimate Reasons Why Doctors Order Diagnostic Tests

1. They lack confidence in their physical examination and clinical diagnostic skills.
2. They do not know what to look for during a thorough thoracic outlet syndrome examination and hope the imaging study will provide all the answers.
3. You insisted on an MRI, believing that diagnostic imaging alone identifies the true cause of your pain.
4. They have little confidence in conservative treatment for thoracic outlet syndrome and are already preparing you for thoracic outlet syndrome surgery.
5. They are practicing defensive medicine because they fear a medical malpractice lawsuit.
6. You were referred by an attorney following a workers' compensation injury, motor vehicle accident, or personal injury claim, where objective documentation of injury is required.

What do other doctors consider legitimate reasons for diagnostic testing?

• Diagnostic imaging, including MRI, CT, or other testing, may be appropriate if you continue experiencing progressively worsening thoracic outlet syndrome symptoms, neck pain, arm pain, numbness, tingling, or weakness despite at least four weeks of aggressive conservative therapy, as outlined in Chapter 13.
• You have severe pain requiring hospitalization. Your physician may suspect that instead of thoracic outlet syndrome, you have a spinal cord injury, cervical spine fracture, vertebral fracture, spinal infection, spinal stenosis, multiple sclerosis (MS), syringomyelia, brain tumor, spinal cord tumor, or bone tumor.
• You develop new neurological symptoms, including significant arm weakness, leg weakness, abnormal reflexes, abnormal gait, loss of coordination, or suspected spinal cord compression resulting in progressive neurological deficits.
• Your physician suspects thoracic outlet syndrome in combination with a rotator cuff tear, shoulder labral tear, shoulder impingement syndrome, or another significant shoulder injury.
• You sustained an automobile accident, whiplash injury, sports injury, or work-related injury where there is concern for a fracture, dislocation, or other traumatic injury requiring immediate imaging.

Often, advanced imaging tests are unnecessary. A thorough thoracic outlet syndrome physical examination and musculoskeletal examination will usually reveal the cause of the problem, and the thoracic outlet syndrome treatment will often be the same with or without an MRI or CT scan. A patient might say, “I have thoracic outlet syndrome, and the MRI scan showed a herniated cervical disc too.”

I reply, “That’s fine. The treatment will release the muscle spasms causing the compressive forces on the thoracic outlet, reduce the brachial plexus compression, and decrease the pressure on the compressed herniated cervical disc too. The treatment is the same for both conditions, so another diagnostic test usually won’t change my treatment approach. No additional test is necessary.”

Diagnostic Tests That Assist in the Diagnosis of Thoracic Outlet Syndrome

Here is an array of diagnostic tests for thoracic outlet syndrome that a doctor has at his disposal to differentiate thoracic outlet syndrome from other conditions that mimic its symptoms.

1. Cervical spine and chest X-rays
2. Specialized nerve tests (EMG, NCV, SSEP)
3. Venography
4. Venous scintigraphy, CT scan, MRI scan, and PET scan
5. Doppler ultrasonography
6. Plethysmography
7. Magnetic resonance angiography (MRA)
8. Duplex ultrasound scanning
9. CT angiography (CTA)
10. Pulse oximetry
11. Cervical Spine and Chest X-Rays One useful diagnostic imaging test to help differentiate thoracic outlet syndrome from other causes of neck pain, shoulder pain, arm numbness, and hand tingling is the cervical spine and chest X-ray. When I review a patient's X-rays, the most common findings I see in patients with thoracic outlet syndrome include:

• Straightening or reversal of the normal cervical curve ( military neck )
• Cervical disc degeneration and cervical facet joint degeneration
• Bone spurs (osteophytes) and calcium deposits around the costochondral joints
• Cervical ribs (extra ribs)

A Straight or Reversal of the Curve in the Neck

The majority of thoracic outlet syndrome patients have either a straightened cervical spine or a reversal of the normal cervical curve, which is even more severe. The cervical spine is designed to have a normal forward curve ( cervical lordosis ). These spinal curves provide the spine with its natural spring mechanism, allowing it to absorb shock, distribute mechanical stress evenly, and protect the intervertebral discs, joints, nerves, and supporting tissues. Loss or reversal of the cervical curve is commonly seen after whiplash injuries, motor vehicle accidents, sports injuries, and other forms of cervical spine trauma.

The reason the neck straightens or reverses is because the forces acting on the spine are no longer balanced. The muscles on the front of the neck, particularly the anterior, middle, and posterior scalene muscles, continually pull the cervical vertebrae forward, reversing the normal cervical curve.

The scalene muscles attach to the sides of the upper cervical vertebrae and insert onto the first rib and second rib. When these muscles remain in a constant state of contraction, they pull the upper cervical spine downward while simultaneously elevating the ribs, increasing thoracic outlet compression, brachial plexus compression, and compression of the subclavian artery and subclavian vein.

Disc Degeneration and Joint Degeneration in the Neck

When the scalene muscles remain in a chronically contracted state, they not only compress the interscalene triangle of the thoracic outlet, but they also place continuous compressive forces on the cervical intervertebral discs, facet joints, and other joints of the neck. This constant compression, combined with normal movement, can accelerate cervical disc degeneration, degenerative disc disease, cervical spondylosis, and facet joint arthritis.

It is common to find cervical disc degeneration in the lower neck in patients with an old whiplash injury, chronic neck pain, or chronic thoracic outlet syndrome. The reason degeneration develops in the lower cervical discs is because the scalene muscles remain contracted 24 hours a day, seven days a week, continuously compressing the cervical vertebrae and discs until they gradually wear down. In other words, your Human Spring has become chronically compressed.

You cannot see herniated discs, bulging discs, slipped discs, or disc protrusions on standard X-rays. These soft tissue structures are visible only on advanced imaging studies such as an MRI scan or CT scan. If someone tells you they can see a herniated cervical disc on a routine neck X-ray, you either misunderstood what they meant or the statement is incorrect.

Bone Spurs and Other Calcium Deposits on the Bones

As cervical disc degeneration progresses, the discs may become thinner and the body may respond by forming bone spurs (osteophytes) or calcium deposits around the vertebrae and joints. These bony changes are signs of chronic mechanical stress and long-standing degeneration. In many patients, the size of the bone spurs provides clues about how long the degenerative process has been occurring. For example, a 2 mm osteophyte often suggests that the original neck injury occurred approximately seven to ten years earlier. Patients are frequently surprised at how closely the size of these bone spurs corresponds with the timing of a previous whiplash injury, sports injury, or motor vehicle accident.

These bone spurs almost never grow into nerves or directly cause nerve compression. So many doctors have told my patients they need bone spur surgery, cervical spine surgery, or neck surgery for a bone spur in the neck. After a few weeks of my non-surgical thoracic outlet syndrome treatment, they are pain-free. Did I dissolve the bone spur with my hands? No. Bone spurs grow slowly. So, if you have a recent onset of neck pain, arm pain, arm numbness, hand tingling, or thoracic outlet syndrome symptoms, it’s not from the bone spur.

If the doctor tells you that the problem is a bone spur pinching a nerve, causing cervical nerve compression, that needs to be surgically removed, I suggest you call me for a second opinion.

Calcium Deposits on the Joints Where the Ribs Attach to the Spine and Sternum

Humans have 12 ribs. The rib cage protects the lungs. The rib cage also works with spring action and normal rib cage biomechanics to assist in breathing. That is important because you take approximately 23,000 breaths a day, so your rib cage has to expand up and back with a deep breath in and contract down when you exhale. Any restrictions in rib cage movement, chest wall mobility, or thoracic cage mobility can cause labored breathing, shortness of breath, and reduced lung expansion.

Your ribs attach in the back at the thoracic spine through the costovertebral joints. The ribs attach in the front to costal cartilage and then attach to the sternum (breastbone) through the costosternal joints. The lowest two ribs do not attach to the breastbone. That is why these are called floating ribs.

The rib cage expands, with the ribs rolling up and back, as you inhale. The springiness and elasticity of the ribs force the air out as the ribs roll down during exhalation.

Abnormal muscle tension, muscle spasms, and myofascial tightness can have a negative effect on healthy rib cage movement. There are many muscles that attach to the ribs; however, the muscles that are commonly contracted in spasms in thoracic outlet syndrome (TOS) are these muscles.

• The anterior, middle, and posterior scalene muscles attach to the first and second ribs.
• The pectoralis minor muscle attaches to the third, fourth, and fifth ribs.
• The serratus anterior muscle attaches to the upper eight or nine ribs.
• The latissimus dorsi muscle attaches to the last four ribs.
• The intercostal muscles attach between each rib.
• The rectus abdominis muscle attaches to the cartilages of the fifth, sixth, and seventh ribs. When these muscles are in spasm, they restrict normal rib cage movement, thoracic expansion, and chest wall mobility. A restricted rib cage will restrict your breathing and reduce normal lung expansion. It can become so severe that you might think you are having a heart attack, chest pain, or an asthma attack. You can experience a variety of symptoms, including chest pain, pain between the shoulder blades, upper back pain, rib pain, pain with deep breathing, and shortness of breath.

If you know which ribs are restricted and causing your pain, you can track the muscles that may be in spasm, causing the abnormal motion of the ribs and contributing to thoracic outlet syndrome, rib dysfunction, or costovertebral joint dysfunction. For example, if the pain is in the top part of the upper back between the shoulder blades, it most likely involves the first, second, or third ribs. I would look for spasms in the scalene muscles, which are commonly associated with thoracic outlet syndrome.

If the pain is lower between the shoulder blades, I would look for spasms in the serratus anterior, pectoralis minor, and rectus abdominis muscles. I also evaluate the intercostal muscles with all cases of rib cage pain, rib dysfunction, and pain with breathing.

If you have arthritis pain, sternum pain, or chest wall pain in the area where the ribs attach to the sternum, this is called costochondritis. If this condition has been present for more than seven to ten years, scar tissue may have formed, followed by calcium deposits, bone spurs, or joint degeneration on the joint surfaces. The next time you visit your doctor, ask for copies of your chest X-rays, rib X-rays, or thoracic spine X-rays, and see if you can identify these white ridges or calcium deposits on your rib joints.

Extra Ribs in the Neck (Cervical Ribs)

Most cervical ribs (extra ribs in the neck) are seldom clinically relevant and do not cause cervical rib symptoms or thoracic outlet syndrome symptoms. Cervical ribs are generally discovered incidentally on X-rays or other diagnostic imaging. They vary considerably in size and length.

Doctors may recommend cervical rib surgery (neck surgery to remove a cervical rib) for children who present with symptomatic cervical ribs, particularly when there is evidence of neurogenic thoracic outlet syndrome, vascular thoracic outlet syndrome, or significant nerve compression or blood vessel compression. In contrast, asymptomatic cervical ribs are generally considered an incidental anatomical finding rather than a condition requiring treatment. (6)

What determines whether doctors recommend cervical rib removal surgery for you or your child is often the presence of pain or neurological symptoms. If the only finding is the appearance of a cervical rib on an X-ray, and your doctor did not palpate the muscles around the neck, evaluate the thoracic outlet anatomy, assess spinal alignment, examine the first rib, or investigate other potential causes of thoracic outlet syndrome symptoms, neck pain, shoulder pain, arm numbness, or hand tingling, before recommending the conservative treatment described in Chapter 13, you could be proceeding with a surgery that you or your child may not need.

If you are older than 21 years and have recently developed thoracic outlet syndrome, the cause of your thoracic outlet pain, arm pain, or nerve compression symptoms is unlikely to be the cervical rib itself. In many cases, the cervical rib is simply an incidental finding that can distract an inexperienced physician from identifying the true cause of the thoracic outlet compression. It may also lead some doctors to incorrectly conclude that thoracic outlet syndrome surgery is necessary.

It is rare for patients with a cervical rib or anomalous first rib to spontaneously develop neurogenic thoracic outlet syndrome. Sanders reported that during a 28-year period involving approximately 1,000 thoracic outlet syndrome surgeries for neurogenic thoracic outlet syndrome, the incidence of cervical ribs and anomalous first ribs was less than 5 percent.

If a doctor recommends cervical rib surgery or thoracic outlet syndrome surgery, first consult a chiropractor or other qualified conservative care provider and ask them to perform the treatment approach outlined in Chapter 13. Follow the recommended non-surgical thoracic outlet syndrome treatment program for approximately 10 visits. If your neck pain, shoulder pain, arm numbness, hand tingling, or other thoracic outlet syndrome symptoms persist, call me, and let's discuss your options together.

Some doctors brag about how many cervical rib surgeries they perform. I brag about how many patients with cervical ribs, thoracic outlet syndrome, and thoracic outlet compression become pain-free through non-surgical treatment, without ever needing surgery.

1. Specialized Nerve Tests (EMG, NCV, SSEP)

Electromyography (EMG)

The electromyography (EMG), also called an EMG test or needle electromyography, is a diagnostic test used to determine the health of specific muscles and the nerve cells that control them. It is commonly ordered to evaluate nerve damage, muscle disorders, pinched nerves, brachial plexus injuries, peripheral neuropathy, and thoracic outlet syndrome. During an EMG, the technician inserts a needle electrode directly into the muscle to record its electrical activity.

I’ve never had this test, but people tell me it’s painful. One patient stated that it felt like a series of electrical shocks with different intensities. It started feeling like small pricks to a full-size torture shot lasting about half a second. The patient screamed every time the doctor did the higher intensity level.

Comments about the test vary from mildly unpleasant to pain that causes fainting, to pure torture. Some women said it was worse than natural childbirth. Some refuse to finish the test. After the test, the area of the needle insertion might be painful for a few days. Some patients said that their thoracic outlet syndrome symptoms, arm pain, hand numbness, and tingling were worse after the test.

Sometimes the EMG yields useful information, and sometimes the doctor still might not know what’s going on. It certainly cannot tell you what is causing the compression of your thoracic outlet, brachial plexus compression, or vascular compression. EMG results can reveal nerve dysfunction, muscle dysfunction, or problems with getting the signal from the brain to the muscles.

Patients are sent to the EMG lab because they have arm numbness, hand tingling, radiating arm pain, muscle weakness, muscle cramping, loss of grip strength, or progressive weakness. This test is commonly performed to help determine whether surgery is being considered. I am never setting you up for surgery, so I have never ordered one of these tests.

Nerve Conduction Velocity (NCV)

A nerve conduction velocity (NCV) test, also called a nerve conduction study (NCS), measures the speed of electrical impulse conduction through a nerve. During the test, surface electrodes are attached to the skin over the nerves the doctor wants to evaluate. The electrodes stimulate the nerve, and the amount of time it takes for the electrical signal to travel from one point to another is measured. This allows the doctor to determine how fast or slow the nerve impulse is traveling.

The claim is that the nerve conduction velocity test can determine whether a nerve is damaged or compressed. If there is already nerve pain, arm numbness, hand tingling, or radiating pain, then the nerve or artery is already being compressed. Some doctors consider the NCV test their primary objective test for diagnosing neurogenic thoracic outlet syndrome and brachial plexus compression. (8)

The most common reason this test is ordered is when an attorney or insurance carrier wants objective documentation that a patient has a pinched nerve, nerve injury, or nerve compression. Another common reason is to help justify surgery.

The NCV can demonstrate that a nerve is compressed. However, if you tell me you have radiating arm pain, arm numbness, hand tingling, or muscle weakness, I believe you. I do not need a test to validate that you are telling me the truth. I would rather spend the time and money on treatment that reduces the thoracic outlet compression.

Somatosensory Evoked Potential (SSEP)

Somatosensory evoked potential (SSEP) testing measures the electrical signals transmitted from the body to the brain. It evaluates whether nerves are able to send and receive information related to pain, touch, temperature, and other sensory signals. If a doctor suspects a spinal cord disorder, cervical spine disorder, or neurological condition, this test is often combined with an electromyography (EMG). In the less painful version, electrodes are placed on the skin. A more invasive version involves inserting a needle electrode into the nerve or sensory region of the brain. The test measures how long it takes for an electrical impulse to travel along the nerve pathway. Healthy nerves conduct signals quickly, whereas compressed nerves, pinched nerves, or damaged nerves transmit signals more slowly.

1. Venography Venography, also called phlebography or ascending venography, is an imaging test used to evaluate the veins and diagnose venous thoracic outlet syndrome, subclavian vein compression, deep vein thrombosis (DVT), and blood clots. During the procedure, the doctor inserts a thin, flexible catheter through a small incision, usually in the groin. The catheter is guided into the major veins, and contrast dye is injected to produce X-ray images of the veins and surrounding blood vessels.

Doctors can determine whether there is a compressed vein, blocked vein, or blood clot. The veins become easier to visualize after the contrast dye is injected. If a subclavian vein clot or upper extremity deep vein thrombosis is discovered, medications can sometimes be delivered through the catheter to dissolve the clot.

This study is useful for diagnosing venous thoracic outlet syndrome when a blood clot is suspected. However, the test can confuse doctors if the pectoralis minor muscle is compressing the vein. In those cases, the vein often appears enlarged on either side of the compressed segment. If it is suspected that the vein is compressed by muscle spasms, pectoralis minor syndrome, or thoracic outlet muscle compression, then the treatment described in Chapter 13 should be attempted first to reduce the muscular compression before considering surgery.

Contrast venography has traditionally been considered the gold standard for diagnosing a subclavian vein thrombosis or blood clot beneath the collarbone. However, because the procedure is invasive, expensive, and newer noninvasive imaging tests have become increasingly accurate, venography is used much less frequently today. (5)

An MR venography (MRV) uses magnetic resonance imaging (MRI) together with intravenous (IV) contrast dye to visualize the veins. One might assume that if the contrast dye disappears within a portion of the vein, the vein must be blocked by a clot or compressed. However, when I perform an orthopedic examination, the patient often has no symptoms until I position the arm or shoulder in a way that produces dynamic thoracic outlet compression. If an MRV is performed while the arm is relaxed, the vein may appear completely normal. If the MRV is performed while the arm is elevated into the symptomatic position, the subclavian vein compression may become obvious.

In this example, the vein is compressed only when the patient raises the arm. To me, this strongly suggests that the pectoralis minor muscle is excessively tight and is producing dynamic compression of the subclavian vein during arm elevation. I would not recommend surgery for this patient. Instead, I would recommend deep tissue therapy, myofascial release, and treatment of the pectoralis minor along with the surrounding muscles to reduce the muscular compression on the vein. 1. Venous Scintigraphy, CT Venography (CTV), Magnetic Resonance Venography (MRV), and Positron Emission Tomography (PET)

Computed tomography venography (CTV), magnetic resonance venography (MRV), and positron emission tomography (PET) are advanced vascular imaging tests comparable to conventional venography for evaluating vascular thoracic outlet syndrome, subclavian vein compression, subclavian artery compression, venous obstruction, and blood vessel narrowing.

MRV imaging remains one of the preferred imaging methods for detecting brachial plexus compression, nerve compression, and damage to the nerves. Remember, you can have compression of a nerve, but when the compression is removed, the nerve can often recover and restore normal function.

1. Doppler Ultrasonography (Color Doppler Ultrasound)

An ultrasound uses sound waves to create images of the body. Doctors use Doppler ultrasound, Color Doppler ultrasound, or vascular ultrasound to determine whether there is compression of the arteries or veins, subclavian artery compression, subclavian vein compression, vascular thoracic outlet syndrome, or other abnormalities affecting the blood vessels. Color Doppler sonography is a noninvasive imaging test (no contrast dye injected into the bloodstream) that provides real-time visualization of blood flow through the arteries and veins.

Doppler ultrasound can help determine whether there is widening or stretching of an artery ( aneurysm ), narrowing ( stenosis ), blockage of an artery or vein, reduced circulation, or impaired blood flow caused by thoracic outlet syndrome. The examination can identify changes in blood flow velocity as blood passes through a narrowed blood vessel. This technique is also commonly used to detect blood clots, deep vein thrombosis (DVT), and to evaluate the blood supply to tumors.

One limitation of diagnostic ultrasound is that ultrasound waves cannot penetrate bone. Therefore, if a blood clot or vascular compression is located beneath the collarbone (clavicle), it may be missed unless the sonographer properly angles the ultrasound probe around the bone.

1. Plethysmography Plethysmography is a vascular diagnostic test that measures blood flow and circulatory capacity within the arms. Plethysmograph devices are attached to the upper extremities to evaluate circulation and detect changes associated with vascular thoracic outlet syndrome, arterial compression, or venous compression. Although plethysmography can identify impaired circulation, it is not commonly ordered for thoracic outlet syndrome diagnosis, because newer vascular imaging studies provide more detailed diagnostic information.
2. Magnetic Resonance Angiography (MRA)

Magnetic resonance angiography (MRA) is an advanced vascular imaging test used to examine the arteries throughout the body, including the subclavian arteries, carotid arteries, vertebral arteries, neck arteries, and arm arteries. Most MRAs are performed after injection of a contrast dye that enhances visualization of the arteries.

An MRA helps evaluate arterial narrowing (stenosis), arterial compression, vascular thoracic outlet syndrome, aneurysms, arterial enlargement, arterial blockage, and blood vessels at risk for rupture or occlusion.

1. Duplex Scanning (Duplex Ultrasonography)

Duplex ultrasonography (duplex ultrasound) is a form of diagnostic vascular ultrasound that combines two technologies:

1. Color Doppler ultrasound to visualize blood flow through arteries and veins and evaluate vascular thoracic outlet syndrome, subclavian artery compression, and subclavian vein compression.
2. High-resolution diagnostic ultrasound that allows medical radiologists to visualize the anatomy and structure of the body part being examined.

Duplex ultrasound allows physicians to determine the degree of arterial narrowing, complete arterial blockage, venous obstruction, aneurysms, blood clots, and other vascular abnormalities. Duplex scanning is an inexpensive, noninvasive method for evaluating vascular disease, arterial disease, venous disease, and thoracic outlet syndrome pathology.

1. CT Angiography (CTA)

Computed Tomography Angiography (CTA) combines a CT scan with traditional angiography to produce detailed images of the arteries and veins throughout the body. Before the scan, a contrast dye is injected into the bloodstream to improve visualization of the blood vessels. Computer software reconstructs cross-sectional images of the vascular system.

CT angiography helps determine whether a blood vessel is narrowed ( stenosis ), where the narrowing is located, how severe the blockage is, and whether there is subclavian artery compression, vascular thoracic outlet syndrome, an aneurysm, plaque buildup, arterial disease, venous disease, or other vascular obstruction.

1. Pulse Oximetry Pulse oximetry measures blood oxygen saturation (SpO₂) and monitors oxygen levels within the bloodstream. I routinely use a pulse oximeter with a plethysmograph during the examination of patients with suspected thoracic outlet syndrome, subclavian artery compression, or vascular thoracic outlet syndrome. During the examination, I place the shoulder or neck into positions that may compress the artery and then monitor oxygen saturation levels in the affected arm.

I have consistently observed significant reductions in oxygen saturation in patients whose subclavian artery becomes compressed during orthopedic testing for thoracic outlet syndrome.

Pulse oximetry may serve as a useful, rapid, inexpensive, noninvasive clinical tool that provides objective evidence of arterial narrowing and vascular compromise associated with thoracic outlet syndrome. Pulse oximeters range in price from approximately $20 to $1,500. In my experience, both inexpensive and more expensive pulse oximeters produced similar clinical measurements.

I attach the pulse oximeter to the patient's finger and then perform orthopedic examination procedures to determine whether the pulse decreases or disappears.

• I have developed a highly refined sense of touch that allows me to detect when the arterial pulse stops.
• Patients often recognize the moment the pulse disappears because they rapidly develop hand tingling, arm numbness, finger numbness, and other thoracic outlet syndrome symptoms within seconds if the orthopedic test produces subclavian artery compression caused by narrowing of the thoracic outlet. However, the pulse oximeter shows immediately when the pulse stops, which provides a more objective finding. I would recommend everyone have a pulse oximeter at home. They are inexpensive and useful for measuring blood oxygen saturation (SpO₂), oxygen levels, pulse rate, and heart rate. Of course, you probably already have one built into your fitness watch or smartwatch.

What tests do I order if I suspect a blood clot or worse?

If the condition does not appear life-threatening, limb-threatening, or at high risk for permanent damage, and I believe I have enough information to improve the patient's condition, I will begin treatment according to my outline in Chapter 13. If I suspect a blood clot (deep vein thrombosis), venous thoracic outlet syndrome, arterial thoracic outlet syndrome, vascular thoracic outlet syndrome, or another serious vascular disorder, I will order these diagnostic tests immediately.

These are the best diagnostic tests for possible narrowing or blockage (blood clot) of the vein.

• Venous duplex ultrasound (venous Doppler ultrasound)
• Venous scintigraphy (venous scintillation scan)
• Contrast venography (venogram)
• Venous plethysmography (9)

These are the best diagnostic tests for possible narrowing or blockage (blood clot) of the artery.

• Arterial Doppler ultrasound
• Contrast angiography (angiogram) performed in the seated position (9) In the Journal of Vascular Surgery (September 2016), the "Reporting Standards of the Society for Vascular Surgery for Thoracic Outlet Syndrome: Executive Summary" encouraged healthcare professionals to establish consistent diagnostic and reporting standards for neurogenic thoracic outlet syndrome (NTOS), venous thoracic outlet syndrome (VTOS), and arterial thoracic outlet syndrome (ATOS). (11)

These are the diagnostic tests recommended in that publication for each type of thoracic outlet syndrome.

Neurogenic thoracic outlet syndrome (NTOS)

• Cervical spine and chest X-ray
• Electrodiagnostic testing (EMG and nerve conduction studies)
• Ultrasound, CT scan, and MRI scan (not yet shown to consistently correlate with clinical outcomes)

Venous thoracic outlet syndrome (VTOS)

• Chest and cervical spine X-ray
• Duplex venous ultrasound
• Contrast-enhanced positional CT angiography (CTA) or MR angiography (MRA)
• Contrast venography (venogram)

Arterial thoracic outlet syndrome (ATOS)

• Chest and cervical spine X-ray
• Duplex arterial ultrasound
• Contrast-enhanced positional CT angiography (CTA) or MR angiography (MRA)
• Arteriography (arteriogram)
• Hemodynamic testing, including finger plethysmography

Hemodynamic Testing, Including Finger Plethysmography

Again, these are big words for a hemodynamic test and vascular thoracic outlet syndrome test that you can do at home with an easy-to-use pulse oximeter or finger pulse oximeter you can purchase at a local drug store for between $20 and $100. A conventional pulse oximeter measures blood oxygen saturation, pulse rate, and the perfusion of blood flow into the finger, making it a simple screening tool for changes in finger circulation that may occur with vascular thoracic outlet syndrome, subclavian artery compression, or subclavian vein compression. Simply perform the thoracic outlet syndrome orthopedic tests demonstrated in Chapter 7 and observe whether the pulse oximeter reading changes as your arm is placed into different test positions. In conclusion, the use of diagnostic tests for thoracic outlet syndrome can be both helpful and confusing when attempting to make an accurate thoracic outlet syndrome diagnosis. What is clear is that the cause of thoracic outlet syndrome compression, including brachial plexus compression, subclavian artery compression, and subclavian vein compression, can almost always be identified through a thorough hands-on physical examination, as outlined in Chapter 7. You can also review the examination of the 10 muscles that compress the thoracic outlet in Chapter 13 to better understand the muscular causes of thoracic outlet syndrome.

Now it is time to read Chapter 9, "Is It Thoracic Outlet Syndrome, This, That, or All the Above?", which focuses on the differential diagnosis of thoracic outlet syndrome, so you can learn how we determine whether you have thoracic outlet syndrome, a herniated cervical disc, cervical radiculopathy, carpal tunnel syndrome, or another condition that mimics thoracic outlet syndrome symptoms. For example, if a doctor tells you that your tests reveal a cervical herniated disc that is pinching a nerve while your subclavian artery and subclavian vein are also compressed, does that automatically mean you need thoracic outlet syndrome surgery or cervical spine surgery?

The questions I would ask are, "Why is the herniated disc not healing? What muscles remain in a chronically contracted state that continue to compress the disc and prevent normal healing? What muscles are contracting enough to compress the subclavian artery, subclavian vein, and brachial plexus, creating the signs and symptoms of thoracic outlet syndrome?"

Once I identify the specific muscles responsible for compressing these structures, I begin non-surgical thoracic outlet syndrome treatment immediately because I can often reduce the pressure on the herniated disc, brachial plexus, subclavian artery, and subclavian vein before you even receive the results of your next diagnostic test. When thoracic outlet syndrome treatment is started quickly and effectively, and the thoracic outlet syndrome symptoms begin to improve, the rapid reduction in pain, numbness, tingling, weakness, and vascular symptoms often helps confirm both the correct thoracic outlet syndrome diagnosis and the true cause of the compression much faster. As you can see, it is easy for your doctor to recommend thoracic outlet syndrome surgery, cervical spine surgery, or herniated disc surgery when you are not improving and have a definitive finding of a herniated cervical disc on an MRI scan. Because there are more than 30 different conditions, disorders, diseases, and differential diagnoses that mimic the symptoms of thoracic outlet syndrome, it is very easy for even a seasoned physician to misdiagnose thoracic outlet syndrome and the true cause of your neck pain, shoulder pain, upper back pain, arm numbness, hand tingling, arm weakness, and chronic pain. That is why the next chapter is critical for you to read so you can fact-check your doctor's diagnosis, determine the correct thoracic outlet syndrome diagnosis, and, most important, identify the true cause of your nerve compression, blood vessel compression, and chronic pain so there is no delay in your recovery, no unnecessary diagnostic tests, injections, procedures, or surgeries, and no more sleepless nights caused by thoracic outlet syndrome symptoms.

Spring to action and learn how to differentiate thoracic outlet syndrome from carpal tunnel syndrome, cubital tunnel syndrome, cervical radiculopathy, herniated cervical disc, pinched nerve, rotator cuff injury, brachial plexus injury, and 28 other conditions that mimic thoracic outlet syndrome.