Is It TOS, This, That, or All the Above?

Thoracic Outlet Syndrome—Differential Diagnosis, Differential Diagnosis of Thoracic Outlet Syndrome, and Conditions That Mimic Thoracic Outlet Syndrome

Differentiating Thoracic Outlet Syndrome from 30 Other Conditions and Disorders That Mimic Thoracic Outlet Syndrome

Diagnosis is the act or process of identifying or determining the nature and cause of a disease, injury, musculoskeletal disorder, neurological disorder, vascular disorder, or compression syndrome through evaluation of the patient's medical history, symptoms, physical examination, orthopedic examination, neurological examination, vascular examination, and review of laboratory tests, diagnostic imaging, and other diagnostic studies.

A differential diagnosis (sometimes abbreviated DDx, ddx, DD, or D/Dx) is a systematic investigative method that doctors use to identify the exact diagnosis or diagnoses from many possible medical conditions, disorders, diseases, injuries, and nerve compression syndromes that produce similar signs and symptoms.

This chapter is about the differential diagnosis of thoracic outlet syndrome (TOS) and how to distinguish neurogenic thoracic outlet syndrome, venous thoracic outlet syndrome, and arterial thoracic outlet syndrome from the many other conditions that can mimic thoracic outlet syndrome.

Patients with thoracic outlet syndrome are among the most misdiagnosed, underdiagnosed, overdiagnosed, mismanaged, misinformed, and mistreated patients in medicine today. Treatments fail when the treatment is applied to the wrong diagnosis. Failed attempts at conservative treatment, non-surgical treatment, physical therapy, chiropractic care, massage therapy, medications, injections, or even surgery are often related to an incorrect diagnosis or an incomplete differential diagnosis (1). Keeping it simple, the patient is misdiagnosed.

One study demonstrated that surgeons sometimes favored their own preferred diagnosis, which influenced treatment recommendations and reimbursement for particular surgical procedures (2).

Differential Diagnosis

You have probably heard the term differential diagnosis mentioned on television programs such as House, Grey's Anatomy, or Dr. Oz, but never fully understood what it means. Determining the differential diagnosis is a systematic process used to identify which possible disease, disorder, injury, nerve compression syndrome, vascular condition, or musculoskeletal condition best explains your particular combination of symptoms, signs, medical history, physical examination findings, orthopedic test results, neurological examination findings, vascular examination findings, and diagnostic imaging results.

The doctor develops a list of possible diagnoses and, by evaluating your symptoms, medical history, physical examination, orthopedic examination, neurological examination, vascular examination, laboratory tests, MRI findings, X-rays, CT scans, ultrasound studies, nerve conduction studies, electromyography (EMG), and other diagnostic tests, gradually eliminates the diagnoses that are impossible, unlikely, or less probable until arriving at the most likely diagnosis or combination of diagnoses.

In other words, a headache may have many different causes. Doctors use your medical history, symptoms, physical examination findings, neurological examination, diagnostic imaging, laboratory studies, clinical reasoning, and experience to determine the correct diagnosis and identify the underlying cause of your condition.

The correct diagnosis is essential because even the best treatment for the wrong diagnosis will not resolve your condition. In fact, an incorrect diagnosis can delay recovery, worsen your symptoms, lead to unnecessary medications, unnecessary injections, unnecessary surgery, chronic pain, permanent disability, dependence on prescription drugs, avoidable complications, or, in rare cases, become life-threatening.

In a Washington Post article, it was stated that misdiagnosis, delayed diagnosis, and incorrect diagnosis are believed to affect 10–20 percent of cases (3). In 1991, the Harvard Medical Practice Study found that medical misdiagnosis accounted for 14 percent of adverse events and that 75 percent of these diagnostic errors involved negligence, such as a failure by doctors to follow up on test results (4).

Dr. Joseph Mercola, an osteopathic physician, stated that he feels this is a reminder that the healthcare system is responsible for promoting unnecessary tests, dangerous drugs, and questionable medical procedures (5). I have to agree that doctors make a lot of diagnostic errors, diagnostic mistakes, and misdiagnoses with patients who have thoracic outlet syndrome (TOS).

In 90 percent of the literature that I read in the national database of science called PubMed, the diagnosis of thoracic outlet syndrome is difficult because no single thoracic outlet syndrome diagnostic test has been accepted as the gold standard. However, by using nerve conduction studies (NCS), electromyography (EMG), X-ray examinations, MRI scans, CT scans, ultrasound imaging, vascular studies, and other diagnostic imaging tests, doctors can often rule out other conditions that mimic thoracic outlet syndrome.

Doctors commonly perform poor physical examinations and then spend $2,000–$20,000 on diagnostic testing, medical imaging, MRI scans, CT scans, electromyography (EMG), and nerve conduction studies (NCS) to determine that you don't have the 29 other conditions that mimic thoracic outlet syndrome, so it must be thoracic outlet syndrome. That is really an inefficient use of your insurance dollars. No wonder patients who are uninsured can't get affordable healthcare. As I said before, go to a doctor's office with $500 in your pocket and ask for a diagnosis. You will be surprised how quickly they diagnose you and tell you surgery is not medically necessary.

Why Is Thoracic Outlet Syndrome So Difficult to Diagnose?

There Are 30 Other Conditions and Diseases That Have Similar Symptoms as Thoracic Outlet Syndrome

If you have been diagnosed with a herniated disc, bulging disc, slipped disc, cervical disc herniation, cervical radiculopathy, cervical spondylosis, shoulder acromioclavicular (AC) joint separation, clavicle fracture malunion, shoulder tendonitis, shoulder impingement syndrome, rotator cuff inflammation, rotator cuff tear, intercostal neuritis, cubital tunnel syndrome, cubital tunnel compression, carpal tunnel syndrome, Guyon's canal syndrome, Guyon's canal compression, or median nerve entrapment, you might be misdiagnosed. You might actually have thoracic outlet syndrome (TOS).

Thoracic outlet syndrome also mimics the pain and symptoms associated with atherosclerosis, Paget-Schroetter syndrome, venous thoracic outlet syndrome, Pancoast tumor, spinal cord tumor, complex regional pain syndrome (CRPS), multiple sclerosis (MS), syringomyelia, Raynaud's phenomenon, cervical ribs, double crush syndrome, and myofascial pain syndrome.

Thirty Percent or More of Patients Have Herniated Discs, But Don't Have Pain (3)

You could have a herniated disc, bulging disc, or slipped disc, which you might think is the source of your nerve compression, pinched nerve, neck pain, arm pain, numbness, tingling, or radiating pain, but many people have herniated discs that not only compress the nerves but also the spinal cord, yet they never develop symptoms. This can be a real diagnostic challenge for the doctor trying to determine whether your symptoms are caused by a herniated disc, cervical radiculopathy, or thoracic outlet syndrome. This is especially true, even if the condition falls within the doctor's area of expertise.

Nerves, Blood Vessels, and Other Structures Can Be Compressed at Many Points from the Neck to the Fingertips

What doctors are looking for is evidence of nerve compression and blood vessel compression at all the areas where the brachial plexus nerves, subclavian artery, and subclavian vein pass from the neck and thorax to the fingertips. Besides becoming compressed at the neck by cervical herniated discs, the nerves and blood vessels involved in thoracic outlet syndrome can also become compressed at the shoulder, elbow, forearm, wrist, and palm of the hand, causing arm pain, numbness, tingling, weakness, and circulation problems.

You Could Have Two, Three, or Four Different Compression Conditions at the Same Time

What confuses doctors even more is that you could have thoracic outlet syndrome along with another peripheral nerve compression syndrome called double crush syndrome, or thoracic outlet syndrome with multiple compression disorders called triple crush syndrome or quadruple crush syndrome. You could even have a complete lockdown of your entire human spring mechanism from head to toe, a condition that is commonly misdiagnosed as fibromyalgia, chronic pain syndrome, or myofascial pain syndrome.

Diagnostic Tests Cannot Detect Muscle Superspasms

None of these diagnostic tests, including MRI scans, CT scans, X-rays, ultrasound, or electrodiagnostic studies, can detect the muscle superspasms that compress the thoracic outlet, brachial plexus, blood vessels, and nerves. Because doctors cannot see these powerful muscle contractions on diagnostic imaging, many try to convince you they do not exist. This is simply not true.

There Are No Diagnostic Tests for an Elevated First Rib

Doctors know that muscle spasms are a major cause of thoracic outlet compression. That is why surgeons perform thoracic outlet syndrome surgery to remove the scalene muscles and the first rib that has been pulled upward into the thoracic outlet tunnel by these powerful muscle contractions. Do you realize that many therapists stretch your neck to the side, elevate the first rib even higher into the thoracic outlet, increase brachial plexus compression, and actually make your thoracic outlet syndrome symptoms worse?

The easiest way to detect muscle superspasms, first rib elevation, and thoracic outlet compression is through skilled hands-on palpation. That is the simplest, fastest, and least expensive diagnostic examination available. Unfortunately, hospitals and many healthcare systems are not reimbursed for thorough hands-on physical examinations, deep tissue therapy, manual therapy, and first rib adjustments.

Are You Getting This Yet?

Do you wish there were a way to fact-check your doctor's diagnosis of thoracic outlet syndrome or another compression syndrome? In this chapter, I am going to teach you exactly what to look for so you can verify your doctor's examination, diagnosis, and treatment recommendations.

Here are 10 reasons to suspect you may have the wrong diagnosis.

1. Your doctor does not spend enough time performing a thorough physical examination.
2. Your doctor does not touch or palpate you during the examination.
3. Your doctor does not evaluate all 10 muscles that contribute to thoracic outlet compression.
4. Your doctor orders MRI scans, X-rays, or other diagnostic tests on your first visit after only a brief examination.
5. Your doctor is making a diagnosis outside his or her area of expertise.
6. Your symptoms and physical findings do not match your doctor's diagnosis.
7. Your symptoms do not improve or become worse despite treatment.
8. Your doctor believes additional diagnostic tests are the answer instead of improving the physical examination.
9. Your doctor believes thoracic outlet syndrome does not exist or is extremely rare.
10. Your doctor asks you what you think is wrong instead of determining the diagnosis through a thorough examination.

If you want to know how many different diagnoses can produce symptoms similar to thoracic outlet syndrome, here is a comprehensive list of thoracic outlet syndrome differential diagnoses that I have compiled.

• Traumatic cervical disc herniation (C6 nerve root compression)
• Traumatic cervical disc herniation (C7 nerve root compression)
• Traumatic cervical disc herniation (T1 nerve root compression)
• Cervical radiculopathy, brachial plexus injury, or brachial neuritis
• Cervical spondylosis
• Neck trauma and whiplash injury
• Thoracic disc injury or thoracic disc herniation
• Clavicle injury or acromioclavicular (AC) joint injury
• Clavicle fracture malunion
• Inflammatory shoulder disorders (shoulder tendonitis and shoulder arthritis)
• Shoulder impingement syndrome
• Rotator cuff tendinitis and rotator cuff inflammation
• Intercostal neuritis (pinched nerve between the ribs)
• Compressive neuropathy—cubital tunnel syndrome (ulnar nerve compression)
• Compressive neuropathy—carpal tunnel syndrome (median nerve compression)
• Compressive neuropathy—Guyon's canal syndrome (ulnar tunnel syndrome)
• Compressive neuropathy—median nerve entrapment syndrome
• Compressive neuropathy—double crush syndrome
• Compressive neuropathy—triple crush syndrome
• Compressive neuropathy—quadruple crush syndrome
• Peripheral vascular disease (atherosclerosis)
• Paget-Schroetter syndrome (effort thrombosis or venous thoracic outlet syndrome)
• Pancoast tumor (superior sulcus lung tumor)
• Spinal cord tumor or spinal cord neoplasm
• Complex regional pain syndrome (CRPS) (reflex sympathetic dystrophy)
• Degenerative spinal cord disease—multiple sclerosis (MS)
• Degenerative spinal cord disease—syringomyelia
• Raynaud's phenomenon
• Cervical ribs and fibrous bands causing thoracic outlet syndrome
• Myofascial pain syndrome

I am going to go through each one of these possible diagnoses that mimic thoracic outlet syndrome (TOS) and explain how to differentiate them from thoracic outlet syndrome symptoms. That way, you will become more educated on how to distinguish these conditions from thoracic outlet syndrome, so you can evaluate your doctor's thoracic outlet syndrome diagnosis and determine whether it is accurate.

Cervical Disc Injury (Cervical Disc Herniation)

Cervical disc herniation, herniated cervical discs, bulging discs, and slipped discs are commonly considered in the differential diagnosis of thoracic outlet syndrome. Herniated discs are usually caused by significant trauma, such as a whiplash injury, motor vehicle accident, car accident, a blow to the top of the head, a fall onto the head, sports injuries, or a heavy lifting injury that creates compression of the cervical spine. Because the cervical discs are relatively strong, a substantial traumatic force is generally required to produce a cervical disc herniation. If you have not experienced a significant trauma but your MRI scan of the cervical spine reveals a herniated disc, it is much less likely that the disc herniation is the true cause of your neck pain, arm pain, numbness, tingling, or radiating nerve pain.

Many patients who come to me have MRI findings showing cervical disc herniations or bulging discs. After two or three weeks of treatment, when they are free from pain, they often ask, "Where did the disc go?" If another MRI scan were performed, the disc herniation would almost certainly still be present. The difference is that there is no longer enough pressure on the injured area for the disc to compress the nerve and produce radiating pain, numbness, tingling, or weakness. Therefore, the herniated disc, bulging disc, or slipped disc is often not the primary problem. The real problem is the abnormal compression of the spine created by chronic muscle contractions surrounding the injured cervical disc.

You could reasonably hypothesize that if the muscle spasms surrounding the injured cervical disc are released, there may no longer be enough pressure to produce cervical nerve root compression, radiating arm pain, or neurological symptoms, and you would be correct. Cervical disc herniations usually occur on only one side of the spine. If you experience numbness in both arms, the symptoms are usually not caused by a unilateral cervical disc herniation. A centrally herniated cervical disc can occasionally produce symptoms in both arms, but this is highly uncommon. During more than 30 years of practice, I have rarely encountered this presentation.

For your doctor to conclude that a cervical disc herniation is the actual cause of your symptoms, there should be a clear history of trauma immediately before the onset of your neck pain, arm pain, numbness, or tingling. Cervical discs generally do not herniate while you are sleeping, sitting at the computer, using a cell phone excessively, or performing prolonged overhead work.

Your symptoms should closely correspond to the date of the traumatic injury. If X-rays demonstrate bone spurs or degenerative changes, those findings generally represent changes that developed over many years. The timing of your symptoms should match the age of the injury. If they do not, the cervical disc herniation is probably not the correct diagnosis or the true cause of your symptoms.

A cervical disc injury typically compresses one specific cervical nerve root, producing a predictable pattern of pain, numbness, tingling, and weakness that follows a dermatome. In contrast, the pattern of thoracic outlet syndrome symptoms is often more widespread, variable, and unpredictable throughout the entire arm.

How to Understand the Findings of an MRI Scan of the Neck

If your MRI scan of the cervical spine suggests a cervical disc herniation, it does not automatically mean that the disc is responsible for your symptoms.

1. If the radiologist's MRI report does not state that the disc is compressing, impinging upon, or encroaching on the nerve root, then the disc is not pinching the nerve. If a radiologist identifies true nerve root compression, this important finding is almost always documented because it directly influences diagnosis and treatment.
2. If the report states that the disc is encroaching upon or compressing the thecal sac, it simply means that the disc is pressing against the protective covering surrounding the spinal cord or nerve roots, not necessarily the nerve itself.
3. Even if the report states that the disc is compressing or contacting a nerve root, this still does not prove that the cervical disc herniation is causing your neck pain, radiating arm pain, numbness, tingling, or muscle weakness. Numerous scientific studies have shown that many completely asymptomatic individuals have MRI scans demonstrating herniated cervical discs, including discs directly contacting nerve roots, without experiencing any symptoms.

Orthopedic tests that evaluate compression of the blood vessels within the thoracic outlet should remain negative because a cervical disc herniation affects the nerves rather than the arteries or veins. Swelling of the hands should not be present.

C6 (Sixth Cervical) Nerve Root Compression – The pain, numbness, and tingling usually involve the thumb, index finger, the outer forearm, and the lateral aspect of the arm.

C7 (Seventh Cervical) Nerve Root Compression – The pain, numbness, and tingling usually involve the back of the arm, the back of the forearm, and extend into the middle finger. This is one of the most common locations for a cervical disc herniation.

C8/T1 Nerve Root Compression – The pain, numbness, and tingling usually travel down the inside of the arm toward the ring finger and little finger side of the hand. This symptom pattern also commonly occurs in neurogenic thoracic outlet syndrome, making the differential diagnosis more challenging.

1. Trauma—Cervical Disc Injury—Sixth Nerve Root

There is a clear history of neck trauma, such as a whiplash injury, motor vehicle accident, sports injury, or fall before the onset of symptoms. The pain, numbness, and tingling follow the C6 dermatome involving the thumb, index finger, lateral forearm, and outside of the arm.

There should be no swelling of the hands. Thoracic outlet syndrome vascular tests evaluating compression of the blood vessels should remain negative because this condition affects only the nerve root. The same treatment approach that reduces thoracic outlet compression also reduces compression affecting the cervical disc, so follow the recommendations in Chapter 13.

2. Trauma—Cervical Disc Injury—Seventh Nerve Root

There is a definite history of cervical spine trauma before the onset of symptoms. The pain, numbness, and tingling involve the back of the arm, back of the forearm, and middle finger. This represents one of the most common patterns seen with a C7 cervical disc herniation.

There should be no swelling of the hands. Thoracic outlet vascular compression tests should remain negative because the condition affects the cervical nerve root rather than the blood vessels. The same treatment that reduces thoracic outlet syndrome compression also reduces pressure affecting the cervical disc, so follow the recommendations in Chapter 13.

3. Trauma—Cervical Disc Injury—T1 Nerve Root

There is a clear history of neck trauma before symptoms begin. The pain, numbness, and tingling extend down the inside of the arm toward the little finger side of the hand. This pattern is frequently confused with cubital tunnel syndrome, ulnar nerve compression, or ulnar neuropathy.

This pattern is also one of the most common presentations of neurogenic thoracic outlet syndrome, making the differential diagnosis of thoracic outlet syndrome particularly difficult. Your doctor must know how to examine the elbow for ulnar nerve compression while also evaluating the thoracic outlet.

To ensure my diagnosis is correct, I first treat the neck muscle spasms contributing to compression around the elbow and restore normal motion to the joint. I then treat the muscles responsible for compressing the thoracic outlet, because many of these same muscles also increase compression of the cervical spine and aggravate a cervical disc herniation.

There should be no swelling of the hands. Thoracic outlet vascular compression tests remain negative because this condition affects the nerve root rather than the arteries or veins. The same treatment that decompresses the thoracic outlet also helps decompress the cervical disc, so follow the recommendations in Chapter 13.

4. Cervical Radiculopathy, Brachial Plexus Injury, or Brachial Neuritis

In the younger population, cervical radiculopathy is usually the result of a cervical disc herniation, herniated cervical disc, or an acute neck injury causing the pinching or compression of a cervical nerve root as it exits the opening (neural foramen) between two vertebrae. The intervertebral disc maintains the space for the nerve to pass and protects against cervical nerve compression.

Cervical disc herniation accounts for approximately 20–25 percent of cases of cervical radiculopathy. Some doctors believe that cervical radiculopathy symptoms in older adults are caused by bone spurs (osteophytes) or calcium deposits growing into the neural foramen where the nerve exits the spine. They suggest that decreased disc height, degenerative disc disease, and cervical spondylosis narrow the opening where the nerve passes. This almost never happens.

I always suspect a misdiagnosis in these cases. That is because a calcium deposit or cervical bone spur takes almost a decade to become large enough to appear on an X-ray. Therefore, if you suddenly develop shooting arm pain, radiating arm pain, arm numbness, or tingling in the arm, it is highly unlikely that the symptoms are caused by an extremely slow-growing bone spur.

There will be no swelling of the hands. Orthopedic tests for vascular thoracic outlet syndrome, subclavian artery compression, or subclavian vein compression will be negative because cervical radiculopathy, brachial plexus injury, and brachial neuritis affect only the nerves and not the blood vessels. The same treatment approach that decompresses the thoracic outlet can also decompress a cervical disc herniation and reduce cervical nerve root compression, so follow the recommendations in Chapter 13.

5. Cervical Spondylosis

Cervical spondylosis, also called degenerative cervical spondylosis, degenerative arthritis of the neck, or cervical osteoarthritis, is a condition involving abnormal wear of the cervical discs, facet joints, and cartilage of the neck. It is one of the most common causes of chronic neck pain, neck stiffness, and degenerative changes of the cervical spine.

You cannot wake up one day with a bone spur pinching a nerve. That is simply preposterous. If your doctor finds a bone spur (osteophyte) on an X-ray or MRI at the same spinal level as your nerve root pain, it usually indicates that the area has been chronically inflamed for years. The pain is much more likely to be caused by muscle spasm, cervical compression, or a compressed cervical disc, which then compresses the nerve root. These conditions often respond well to the treatment approach presented in Chapter 13.

The pain associated with cervical spondylosis is usually chronic. It generally does not radiate down the arm unless a cervical disc herniation, bulging disc, or narrowed cervical disc space is also present. The area where the disc space is most narrowed is the most likely location for cervical nerve compression. This typically produces a predictable pattern of arm pain, arm numbness, hand tingling, and nerve pain following the distribution of the affected cervical nerve root.

There will be no swelling of the hands. Orthopedic tests for vascular thoracic outlet syndrome, arterial thoracic outlet syndrome, or venous thoracic outlet syndrome will be negative because cervical spondylosis affects the nerves and joints rather than the blood vessels.

6. Neck Trauma

Neck trauma, including whiplash injury, whiplash-associated disorder (WAD), motor vehicle accident injuries, sports injuries, or work-related neck and shoulder injuries, can both cause and mimic thoracic outlet syndrome. A traumatic injury may produce any combination of neurogenic thoracic outlet syndrome, vascular thoracic outlet syndrome, cervical disc herniation, brachial plexus injury, or cervical radiculopathy.

A whiplash injury can produce a cervical sprain, cervical strain, and damage to the muscles, ligaments, tendons, fascia, and other soft tissues, similar to a sprained ankle. The trauma may also cause a herniated cervical disc, thoracic outlet syndrome, brachial plexus compression, or, in severe cases, a cervical spine fracture. You should be thoroughly examined by your chiropractor or another qualified healthcare professional after this type of injury.

Most importantly, trauma to the cervical spine and the surrounding muscles, tendons, ligaments, and connective tissues creates inflammation, protective muscle spasms, and increased muscle tension that can compress the thoracic outlet, brachial plexus, subclavian artery, and subclavian vein, leading to thoracic outlet syndrome symptoms, including neck pain, shoulder pain, arm numbness, hand tingling, and arm weakness.

7. Thoracic Disc Injuries

A thoracic disc herniation, thoracic herniated disc, or thoracic disc injury rarely mimics thoracic outlet syndrome. Although I have seen many thoracic disc herniations, most do not create significant symptoms that cannot be successfully addressed using the treatment approach recommended in this book.

Therefore, just because your doctor identifies a thoracic disc herniation or bulging thoracic disc on an MRI does not mean it is the cause of your upper back pain, shoulder pain, neck pain, or thoracic outlet syndrome symptoms. In my experience, it is one of the least likely conditions to mimic thoracic outlet syndrome and is rarely the primary source of pain.

• There will be no swelling of the hands. Orthopedic tests for subclavian artery compression, subclavian vein compression, vascular thoracic outlet syndrome, or venous thoracic outlet syndrome will be Clavicle Injuries (Collarbone Injuries)—Acromioclavicular (AC) Joint Injury

Since the clavicle (collarbone) sits on top of the brachial plexus nerves, subclavian artery, and subclavian vein, forming the roof of the thoracic outlet, an injury to this bone can cause thoracic outlet syndrome (TOS). Acromioclavicular (AC) joint injury, commonly called an AC joint sprain, AC joint separation, or separated shoulder, is often seen after bicycle falls, contact sports (football and soccer), and auto accidents.

The acromioclavicular (AC) joint is located at the top of the shoulder where the collarbone (clavicle) joins the shoulder blade (scapula). The ligaments that stabilize this joint can tear during trauma. If the ligaments are completely torn, this can result in an AC joint sprain, AC joint separation, or shoulder separation, which is usually easy to recognize.

With this injury, you will often see a noticeable step-off between the collarbone and shoulder when comparing the injured side with the unaffected side. Clicking or popping may occur with shoulder movement, and there is usually localized pain directly over the AC joint.

You should not have the typical thoracic outlet syndrome symptoms, including arm numbness, hand tingling, radiating nerve pain, or swelling of the hands. Orthopedic tests for thoracic outlet syndrome, including tests for compression of the subclavian artery and subclavian vein, should be negative because this injury affects the shoulder joint rather than producing vascular thoracic outlet syndrome.

8. Clavicle Fracture Malunion (Malunion of a Broken Collarbone)

When the collarbone (clavicle) breaks, doctors sometimes have difficulty restoring the bone to its normal alignment because it cannot be immobilized in a cast like an arm or leg. In some cases, the fracture is stabilized with a metal pin or plate. Although the hardware may later be removed, it is sometimes left in place.

If the fracture heals in an abnormal position, this is called a clavicle fracture malunion. If the malunion is responsible for thoracic outlet syndrome, the thoracic outlet syndrome symptoms should begin immediately after the injury or immediately after the collarbone shifts during healing.

If the collarbone has been completely healed for several months before arm numbness, hand tingling, neck pain, shoulder pain, or other thoracic outlet syndrome symptoms develop, the healed clavicle malunion is unlikely to be the cause of the thoracic outlet compression.

When a clavicle malunion is severe enough to compress the brachial plexus, subclavian artery, or subclavian vein, patients may experience arm numbness, hand tingling, arm swelling, and positive thoracic outlet syndrome orthopedic tests, but these symptoms typically occur immediately following the injury rather than months later.

9. Inflammatory Conditions of the Shoulder (Shoulder Tendonitis and Shoulder Arthritis)

Shoulder tendonitis, rotator cuff tendonitis, and shoulder arthritis can produce pain throughout the shoulder and may radiate into the neck and upper arm. The pain is usually localized enough that you can place your thumb directly over the painful structure. If pressing on that exact area reproduces the pain, the source is more likely an inflamed shoulder structure than thoracic outlet syndrome, unless the painful muscle is one of the muscles known to compress the thoracic outlet.

By examining the muscles that narrow the thoracic outlet, you can often differentiate shoulder tendonitis from thoracic outlet syndrome. If those muscles are not painful and only the shoulder muscles reproduce the symptoms, thoracic outlet syndrome becomes much less likely.

Patients with shoulder tendonitis or shoulder arthritis should not have the classic thoracic outlet syndrome symptoms, including arm numbness, hand tingling, radiating nerve pain, or hand swelling. Thoracic outlet syndrome orthopedic tests evaluating subclavian artery and subclavian vein compression should remain negative because these inflammatory shoulder conditions do not normally produce vascular thoracic outlet syndrome.

10. Shoulder Impingement Syndrome

The classic symptoms of shoulder impingement syndrome include difficulty reaching behind the back, pain with overhead arm movement, and pain located primarily in the front and top of the shoulder. Patients often develop shoulder weakness, reduced shoulder range of motion, and pain when lifting the arm.

The supraspinatus muscle is commonly weak in both shoulder impingement syndrome and thoracic outlet syndrome, making these conditions easy to confuse. However, shoulder impingement syndrome typically produces symptoms centered within the shoulder joint rather than the neck, upper back, or thoracic outlet. Shoulder popping or cracking is also common.

During my 30-year career, I have never referred a patient for shoulder impingement surgery. Once excessive muscle tension around the shoulder is reduced and normal shoulder mechanics are restored, the shoulder generally begins to heal naturally.

Patients with shoulder impingement syndrome should not experience the classic thoracic outlet syndrome symptoms, including arm numbness, hand tingling, radiating nerve pain, or hand swelling. Thoracic outlet syndrome orthopedic tests evaluating vascular compression should be negative because this disorder affects the shoulder joint rather than the subclavian artery or subclavian vein.

11. Rotator Cuff Inflammation (Rotator Cuff Tendonitis and Rotator Cuff Disease)

The most common symptom of rotator cuff inflammation, rotator cuff tendonitis, and rotator cuff disease is shoulder pain. The pain is usually located on the top, front, and side of the shoulder and becomes worse when lifting the arm away from the body. Weakness of the shoulder muscles is common, particularly weakness of the supraspinatus muscle.

Pain and weakness in the supraspinatus muscle may also occur in thoracic outlet syndrome, making these conditions difficult to distinguish without a careful examination.

The pain usually becomes much worse at night, especially when lying on the affected shoulder. Persistent pain and muscle guarding may eventually contribute to the development of a frozen shoulder (adhesive capsulitis).

Patients with rotator cuff tendonitis or rotator cuff disease should not experience the classic thoracic outlet syndrome symptoms, including arm numbness, hand tingling, radiating nerve pain, or hand swelling. Thoracic outlet syndrome orthopedic tests evaluating subclavian artery and subclavian vein compression should be negative because this disorder primarily involves the shoulder tendons rather than the thoracic outlet.

It is important to remember that muscle tears, ligament tears, and tendon tears generally heal over time. We see this every day with severe ankle sprains, where torn ligaments often recover without surgery. The same principle frequently applies to many rotator cuff injuries.

12. Intercostal Neuritis (Pinched Nerve Between the Ribs)

Intercostal neuritis, also called a pinched intercostal nerve, commonly produces pain between the shoulder blades or in the middle of the upper back. Although many patients think the pain is coming from the shoulder, it is usually a deeper, dull, aching pain that begins between the shoulder blades and may radiate into the chest or arm.

If there is a sudden sharp, burning pain between or beneath the shoulder blades, the problem is often a misaligned rib, rib dysfunction, or costovertebral joint dysfunction rather than thoracic outlet syndrome.

One of the strongest clues is chest pain where the rib attaches to the sternum (breastbone). Patients frequently report pain during deep breathing because the ribs normally rotate upward and backward with each breath. As a result, many people begin taking shallow breaths to avoid the pain.

Unlike thoracic outlet syndrome, intercostal neuritis usually does not produce the classic combination of arm numbness, hand tingling, hand swelling, or positive thoracic outlet syndrome orthopedic tests involving compression of the brachial plexus, subclavian artery, or subclavian vein.

• Muscle spasms in the scalene muscles can restrict the normal movement of the first and second ribs, narrowing the thoracic outlet and causing upper back pain, neck pain, and pain many people mistakenly describe as shoulder pain.
• Muscle spasms in the pectoralis minor muscle can restrict the movement of the third, fourth, and fifth ribs, contributing to thoracic outlet compression, pain between the shoulder blades, upper back pain, and chest wall pain.
• Muscle spasms in the serratus anterior muscle attach to the upper eight or nine ribs and can produce pain between the shoulder blades, upper back pain, mid-back pain, and restricted rib movement that may mimic thoracic outlet syndrome symptoms.
• Muscle spasms in the latissimus dorsi muscle, which attaches to the lower four ribs, can contribute to mid-back pain, rib pain, shoulder pain, and restricted movement of the rib cage.
• Muscle spasms in the intercostal muscles, located between each rib, can produce intercostal neuritis, rib pain, chest pain, pain with deep breathing, and pain between the shoulder blades.
• Muscle spasms in the rectus abdominis muscle, which attaches to the cartilage of the fifth, sixth, and seventh ribs, can contribute to rib pain, chest wall pain, upper abdominal pain, and restricted movement of the rib cage.

You should not have hand swelling, arm swelling, or other signs of vascular thoracic outlet syndrome. Orthopedic tests for thoracic outlet syndrome that evaluate compression of the subclavian artery and subclavian vein should be negative because this condition primarily irritates the intercostal nerves rather than compressing the major blood vessels of the thoracic outlet.

13. Compressive Neuropathy—Cubital Tunnel Syndrome (Cubital Tunnel Compression)

The cubital tunnel is a narrow passageway at the back of the elbow that allows the ulnar nerve to pass between the humerus, ulna, and surrounding soft tissues. Cubital tunnel syndrome, also called ulnar nerve entrapment at the elbow, occurs when the ulnar nerve becomes compressed. This is the nerve you irritate when you hit your "funny bone," causing numbness, tingling, and radiating nerve pain into the ring finger and little finger.

Patients commonly experience elbow pain, especially when bending the elbow or turning the wrist. An isolated case of cubital tunnel syndrome should not produce neck pain, shoulder pain, upper back pain, or thoracic outlet syndrome symptoms unless another compression neuropathy is present at the same time.

You should never experience radiating pain from the elbow to the shoulder or neck with isolated cubital tunnel syndrome, because ulnar nerve compression produces symptoms that travel down the arm rather than upward.

You should not have hand swelling, arm swelling, or signs of vascular thoracic outlet syndrome. Thoracic outlet syndrome orthopedic tests evaluating subclavian artery and subclavian vein compression should be negative because cubital tunnel syndrome affects only the ulnar nerve, not the major blood vessels.

14. Compressive Neuropathy—Carpal Tunnel Syndrome

Carpal tunnel syndrome is caused by median nerve compression at the wrist. The classic carpal tunnel syndrome symptoms include hand numbness, hand tingling, hand pain, and burning sensations that radiate from the wrist into the thumb, index finger, middle finger, and part of the ring finger, but not into the forearm, shoulder, or neck. The median nerve contains fibers originating from the C6, C7, C8, and T1 nerve roots.

The median nerve becomes compressed beneath the transverse carpal ligament (flexor retinaculum) as it passes through the carpal tunnel.

Carpal tunnel syndrome symptoms often worsen with repetitive hand use, just as thoracic outlet syndrome symptoms worsen with repetitive arm use. The difference is that thoracic outlet syndrome commonly produces neck pain, shoulder pain, upper back pain, arm numbness, and symptoms extending well above the wrist. Patients with carpal tunnel syndrome frequently have restricted motion or instability of the small wrist bones, producing a cracking or popping sensation within the wrist.

You should not have hand swelling, arm swelling, or signs of vascular thoracic outlet syndrome. Thoracic outlet syndrome orthopedic tests evaluating compression of the subclavian artery and subclavian vein should be negative because carpal tunnel syndrome compresses only the median nerve. Likewise, isolated carpal tunnel syndrome should not produce neck pain, shoulder pain, or upper back pain unless another condition, such as thoracic outlet syndrome, is also present.

15. Compressive Neuropathy—Guyon's Canal Syndrome (Ulnar Tunnel Syndrome)

Guyon's canal syndrome, also called ulnar tunnel syndrome, is caused by ulnar nerve compression at the wrist. Compression within Guyon's canal produces hand numbness, hand tingling, and pain that involve primarily the ring finger and little finger. Symptoms radiate only from the wrist into the hand and do not extend into the forearm, shoulder, or neck.

You should not have hand swelling, arm swelling, or signs of vascular thoracic outlet syndrome. Thoracic outlet syndrome orthopedic tests evaluating subclavian artery and subclavian vein compression should be negative because Guyon's canal syndrome affects only the ulnar nerve. Likewise, isolated Guyon's canal syndrome should not produce neck pain, shoulder pain, or upper back pain unless another compression neuropathy, such as thoracic outlet syndrome, is also present.

16. Compressive Neuropathy—Median Nerve Entrapment (Pronator Syndrome)

Median nerve entrapment, commonly called pronator syndrome, is caused by compression of the median nerve in the forearm. The muscles in the front of the forearm often feel extremely tight or hard. Pressing deeply into the center of the forearm muscles frequently reproduces pain that may radiate into the forearm, wrist, and hand. The median nerve contains fibers from the C6, C7, C8, and T1 nerve roots.

Patients should not have hand swelling, arm swelling, or signs of vascular thoracic outlet syndrome. Thoracic outlet syndrome orthopedic tests evaluating compression of the subclavian artery and subclavian vein should be negative because median nerve entrapment affects only the nerve. Likewise, isolated median nerve entrapment should not produce neck pain, shoulder pain, or upper back pain unless another compression neuropathy, such as thoracic outlet syndrome, is also present.

17. Compressive Neuropathy—Double Crush Syndrome

Double crush syndrome occurs when the same nerve is compressed in two different locations. A common example is thoracic outlet syndrome occurring together with carpal tunnel syndrome, producing double nerve compression involving the brachial plexus and the median nerve.

Because one of the compression sites may involve the thoracic outlet, patients may experience hand swelling, arm swelling, vascular thoracic outlet syndrome, and positive thoracic outlet syndrome orthopedic tests due to compression of both the nerves and the subclavian blood vessels.

18. Compressive Neuropathy—Triple Crush Syndrome

Triple crush syndrome occurs when a nerve is compressed at three separate locations. An example would be thoracic outlet syndrome, cubital tunnel syndrome, and carpal tunnel syndrome occurring simultaneously.

Patients may develop hand swelling, arm swelling, positive thoracic outlet syndrome orthopedic tests, and symptoms involving both nerve compression and vascular compression, because one of the compression sites involves the thoracic outlet.

19. Compressive Neuropathy—Quadruple Crush Syndrome

Quadruple crush syndrome refers to four separate sites of nerve compression occurring simultaneously. Although rarely discussed in the medical literature, I have seen it many times. An example would include thoracic outlet syndrome, hyperabduction syndrome, cubital tunnel syndrome, and carpal tunnel syndrome occurring together. I have even seen these four compression neuropathies combined with a cervical herniated disc.

Patients may experience hand swelling, arm swelling, and positive thoracic outlet syndrome orthopedic tests, because both the brachial plexus nerves and the subclavian blood vessels may be compressed.

20. Vascular Disease—Atherosclerosis

Atherosclerosis is a progressive vascular disease in which plaque buildup inside the arteries gradually narrows and blocks blood flow. Symptoms usually do not develop until the arteries become significantly narrowed.

When coronary artery disease develops, patients may experience shortness of breath, chest pain, angina, chest pressure, chest tightness, sweating, nausea, lightheadedness, palpitations, and difficulty breathing.

Some patients experience chest tightness, radiating arm pain, and difficulty taking a deep breath, symptoms that can closely mimic thoracic outlet syndrome, rib dysfunction, or compression of the nerves or blood vessels within the thoracic outlet.

Significant narrowing of the carotid arteries may produce stroke symptoms, including weakness, difficulty speaking, confusion, dizziness, difficulty walking, blurred vision, facial numbness, arm numbness, leg numbness, severe headache, and loss of consciousness.

If these symptoms occur, call 911 immediately, as they may indicate a heart attack or stroke, both of which are medical emergencies.

21. Paget-Schroetter Syndrome (Effort Thrombosis)

Paget-Schroetter syndrome, also called effort thrombosis, is an upper extremity deep vein thrombosis (DVT). Although it is associated with the thoracic outlet, it is not thoracic outlet syndrome. It occurs when one or more blood clots develop within the axillary vein or subclavian vein because of restricted blood flow as these veins pass through the thoracic outlet.

To better understand how Paget-Schroetter syndrome, subclavian vein thrombosis, and effort thrombosis differ from thoracic outlet syndrome, refer to Chapter 12, "Paget-Schroetter Syndrome?", where this potentially life-threatening condition is discussed in detail.

22. Pancoast Tumor (Superior Sulcus Tumor)

A Pancoast tumor, also called a superior sulcus tumor or pulmonary sulcus tumor, is a lung cancer that develops at the apex (top) of the lung. It is seen more commonly in smokers.

Unlike many other forms of lung cancer, Pancoast tumors often do not produce cough or shortness of breath during the early stages. Instead, they frequently present with symptoms that closely resemble thoracic outlet syndrome, including shoulder pain, arm pain, hand weakness, arm numbness, hand tingling, and brachial plexus compression.

General symptoms of lung cancer may include fatigue, unexplained weight loss, loss of appetite, general malaise, depression, and an overall feeling of poor health. Because these tumors often mimic orthopedic conditions such as thoracic outlet syndrome, they are sometimes diagnosed late.

This tumor grows slowly and can grow into the ribs and vertebrae. It can compress the subclavian artery, subclavian vein, and brachial plexus, just like thoracic outlet syndrome (TOS). Symptoms include arm pain, shoulder pain, chronic shoulder pain, upper arm pain, commonly radiating down the arm; upper arm muscle weakness, hand muscle weakness, grip weakness, arm weakness, and tingling, numbness, and paresthesia in the ring and fifth fingers. These are also common thoracic outlet syndrome symptoms.

However, there is not the same pain pattern as in thoracic outlet syndrome. There is no significant change in symptoms with activity, arm position, posture, or repetitive arm movements. The symptoms are typically constant and uniform throughout the day. This symptom pattern, along with a history of smoking or prolonged exposure to a smoke-filled environment, is common with a Pancoast tumor (superior sulcus tumor).

The other less common, yet unique, signs and symptoms of Pancoast tumor include Horner syndrome, characterized by decreased sweating on one side of the face (anhidrosis), a drooping eyelid (ptosis), and constricted pupils (miosis) on one or both sides. These are not signs or symptoms of thoracic outlet syndrome.

The definitive diagnosis of a Pancoast tumor is best made with magnetic resonance imaging (MRI), X-ray, computed tomography (CT), and biopsy.

23. Spinal Cord Tumor or Neoplasm

These spinal cord tumors grow fairly slowly, and symptoms develop gradually. Spinal cord tumor symptoms generally do not change significantly with movement, posture, or arm position. If there is a spinal cord tumor, your deep tendon reflexes may be abnormal, indicating spinal cord compression. Ask your doctor to evaluate your reflexes during a neurological examination. You may also develop bladder dysfunction, bowel incontinence, leg weakness, paralysis of one or both legs, hemiparesis, or paralysis affecting one side of the body.

You might have swelling of the hands and positive orthopedic tests suggesting compression of the blood vessels, because a spinal cord tumor can affect both the nerves and blood vessels.

A spinal cord tumor will not improve with thoracic outlet syndrome treatment. If you follow the treatment program outlined in Chapter 13 exactly as recommended and experience no improvement during or after treatment, you should discuss the possibility of a spinal cord tumor or spinal neoplasm with your physician. I have never had a patient with a spinal cord tumor because these tumors are rare.

24. Complex Regional Pain Syndrome (Reflex Sympathetic Dystrophy)

It is easy to understand why complex regional pain syndrome (CRPS), also called reflex sympathetic dystrophy (RSD), is often confused with thoracic outlet syndrome. Complex regional pain syndrome is a chronic pain disorder that usually affects an arm or leg after an injury, and the pain is often far greater than expected for the severity of the injury. If the symptoms occur only in the leg, it is obviously not thoracic outlet syndrome.

With thoracic outlet syndrome, there may or may not have been an injury. Many patients develop severe neck pain, shoulder pain, arm pain, arm numbness, tingling hands, and chronic pain without any significant trauma or objective findings. Both conditions can produce burning arm pain, hypersensitivity to touch, cold intolerance, swelling of the arm, skin temperature changes, skin color changes, and skin texture changes, making the differential diagnosis difficult.

There may be joint stiffness, swelling, muscle weakness, and reduced function in the affected area. However, complex regional pain syndrome does not produce muscle spasms in the muscles that compress the thoracic outlet. If the muscles in spasm are the muscles that compress the thoracic outlet, then thoracic outlet syndrome should be strongly considered.

You should not have swelling of the hands. Orthopedic tests for vascular compression should be negative because complex regional pain syndrome primarily affects the nerves rather than producing subclavian artery or subclavian vein compression.

I have never seen a confirmed case of complex regional pain syndrome in my office during more than 27 years of practice. I have evaluated many patients who had previously been diagnosed with CRPS, but they were ultimately found to have thoracic outlet syndrome or another condition. Personally, I dislike this diagnosis because it often suggests the condition is simply too difficult to diagnose. If you have been diagnosed with complex regional pain syndrome, you should be thoroughly evaluated to rule out thoracic outlet syndrome and other compression disorders.

25. Degenerative Spinal Cord Disease—Multiple Sclerosis (MS)

Multiple sclerosis (MS) is a chronic autoimmune disease in which the body's immune system attacks the central nervous system, including the brain and spinal cord.

The immune system attacks myelin, the fatty protective covering surrounding nerve fibers, and may also damage the nerve fibers themselves. The damaged myelin forms scar tissue (demyelination), disrupting nerve signals traveling between the brain, spinal cord, and the rest of the body. This leads to multiple sclerosis symptoms such as numbness, tingling, weakness of the arms or legs, balance problems, muscle spasms, fatigue, and coordination problems. MS commonly affects vision, causing blurred vision, double vision, partial vision loss, complete vision loss, or pain with eye movement.

Thoracic outlet syndrome does not affect vision. With thoracic outlet syndrome, you will typically have pain and tenderness in the muscles that compress the thoracic outlet, and compression of those muscles may reproduce your neck pain, shoulder pain, arm numbness, tingling, or weakness. This does not occur with multiple sclerosis.

You should not have swelling of the hands. Orthopedic tests for subclavian artery or subclavian vein compression should be negative because multiple sclerosis affects the central nervous system rather than producing vascular compression.

26. Degenerative Spinal Cord Disease—Syringomyelia

Syringomyelia is a slowly progressive spinal cord disorder in which a fluid-filled cyst (syrinx) develops within the spinal cord. As the syrinx enlarges, it compresses and damages the spinal cord, disrupting the transmission of nerve signals between the brain and the arms and legs. This can produce progressive arm weakness, leg weakness, muscle stiffness, chronic neck pain, shoulder pain, back pain, chronic pain, headaches, numbness, tingling, muscle atrophy, and loss of bladder function.

The way to differentiate syringomyelia from thoracic outlet syndrome is as follows.

You should not have swelling of the hands. Orthopedic tests for subclavian artery or subclavian vein compression should be negative because syringomyelia affects the spinal cord rather than compressing the blood vessels. Syringomyelia will not improve with the thoracic outlet syndrome treatment program described in Chapter 13.

Physicians primarily diagnose syringomyelia with magnetic resonance imaging (MRI) of the spinal cord. However, if you begin the treatment program outlined in Chapter 13 and experience significant improvement in your symptoms, syringomyelia becomes much less likely as the cause of your condition.

27. Raynaud's Phenomenon

You will have an exaggerated response to cold exposure, cold temperatures, or emotional stress. Raynaud's phenomenon, also called Raynaud's disease or Raynaud's syndrome, is a vascular disorder that causes finger discoloration, cold fingers, cold hands, toe discoloration, numb fingers, and poor circulation. It is believed to result from spasms of the small blood vessels (vasospasm) that reduce blood flow to the fingers, toes, and other extremities. It involves overactivity of the sympathetic nervous system, causing blood vessel constriction, reduced blood flow, and decreased oxygen delivery to the tissues.

Chronic cases of Raynaud's phenomenon can lead to skin atrophy, fingertip ulcers, tissue ischemia, ischemic gangrene, and tissue damage. As oxygen becomes depleted, the fingers may become blue (cyanosis), white (pallor), or red as circulation returns. A severe case of vascular thoracic outlet syndrome may also produce discoloration of the arm when blood flow is significantly reduced. Raynaud's phenomenon is often accompanied by tingling, numbness, burning pain, and a painful pins-and-needles sensation. However, Raynaud's phenomenon does not typically produce upper back pain, neck pain, shoulder pain, collarbone pain, supraclavicular pain, muscle spasms, or tenderness commonly associated with thoracic outlet syndrome.

You should not have swelling of the hands or arm swelling. Orthopedic tests for thoracic outlet syndrome and subclavian artery or subclavian vein compression should be negative because Raynaud's phenomenon is caused by vasospasm rather than mechanical compression of the blood vessels or brachial plexus.

In more than 30 years of practice, I have never seen a confirmed case of primary Raynaud's phenomenon. I have evaluated many patients previously diagnosed with Raynaud's phenomenon, but they were ultimately found to have thoracic outlet syndrome, vascular thoracic outlet syndrome, neurogenic thoracic outlet syndrome, or another musculoskeletal disorder.

28. Cervical Ribs and Fibrous Bands

Many doctors believe that cervical ribs, also called extra ribs or congenital cervical ribs, are inherited anatomical variations that can predispose patients to thoracic outlet syndrome (TOS) or directly cause thoracic outlet compression. The most important common-sense principle is that cervical ribs remain in the same anatomical position throughout life.

If you first develop thoracic outlet syndrome symptoms, such as neck pain, shoulder pain, arm pain, numbness, tingling, hand weakness, or arm weakness, in your 20s, 30s, or 40s, and your doctor discovers cervical ribs on an X-ray, it is easy to assume they are causing the compression of the thoracic outlet. However, this assumption is not always logical. You have had those cervical ribs since skeletal maturity. If they were truly the cause of your thoracic outlet syndrome, you would reasonably expect symptoms to have appeared much earlier. Therefore, treatment should generally focus on correcting the mechanical compression and underlying biomechanical dysfunction, rather than assuming the cervical ribs are solely responsible.

Because every individual has unique anatomy and genetic variation, there may be rare situations in which cervical ribs contribute to thoracic outlet syndrome or make brachial plexus compression, subclavian artery compression, or subclavian vein compression more likely.

The same reasoning applies to fibrous bands. These congenital fibrous bands are present from birth. Unlike cervical ribs, they usually cannot be identified on X-ray, MRI, CT scan, or diagnostic imaging, so physicians may only discover them during thoracic outlet surgery.

29. Myofascial Pain Syndrome

Myofascial pain syndrome is one of the most common musculoskeletal disorders associated with thoracic outlet syndrome and myofascial trigger points.

I have found that the diagnosis of myofascial pain syndrome is best made through a thorough hands-on physical examination that transitions immediately into treatment. My goal during the first visit is to produce a substantial reduction in the patient's neck pain, shoulder pain, upper back pain, arm pain, numbness, tingling, muscle tightness, and other thoracic outlet syndrome symptoms. I can often provide four or five one-hour treatment sessions before many physicians are even able to schedule advanced diagnostic testing. In many moderate cases of thoracic outlet syndrome, the first 10 hours of treatment are sufficient to significantly reduce the muscle tension, myofascial trigger points, and compression responsible for the patient's symptoms.

If I do not suspect a life-threatening condition, I proceed directly with treatment. Improvement following treatment often becomes the most valuable part of the differential diagnosis. Many patients arrive believing they require surgery for a herniated disc, thoracic outlet syndrome, cervical radiculopathy, or another diagnosis that I do not believe is correct. I frequently schedule these patients at the end of the day so I can provide one, two, three, or more hours of intensive treatment. Once they experience significant relief, many realize they no longer wish to proceed with surgery because they recognize that the original diagnosis was incorrect. This occurs frequently.

For many of the disorders discussed in this chapter, improvement with the treatments recommended in Chapter 13 helps demonstrate that those conditions are unlikely to be the true diagnosis. Failed conservative treatment, physical therapy, massage therapy, or other treatment approaches are often the result of an incorrect diagnosis or an incomplete diagnosis. Simply stated, the patient has been misdiagnosed. Many patients could recover if treatment addressed the actual cause of the thoracic outlet compression rather than simply treating symptoms.

Choose an examining doctor who understands thoracic outlet syndrome diagnosis, can accurately identify the cause of your compression, and has extensive experience treating neurogenic thoracic outlet syndrome, vascular thoracic outlet syndrome, arterial thoracic outlet syndrome, and other compression syndromes. Your doctor should have a proven history of successfully treating hundreds or thousands of patients with thoracic outlet syndrome.

The Possible Consequences of Myofascial Pain Syndrome if Left Untreated

• Myofascial pain syndrome causes neck pain, upper back pain, shoulder pain, muscle spasms, and myofascial trigger points.
• When myofascial pain syndrome compresses the thoracic outlet, it becomes thoracic outlet syndrome (TOS).
• When thoracic outlet syndrome leads to subclavian vein thrombosis or blood clot formation, it is called Paget-Schroetter syndrome (effort thrombosis).
• When Paget-Schroetter syndrome causes a blood clot that travels to the lungs, it becomes a pulmonary embolism.
• When a pulmonary embolism blocks blood flow and causes lung tissue death, it is called a pulmonary infarction.
• A severe pulmonary infarction can result in respiratory failure and death.

Spring to Action!

In the next chapter, you will discover why many physicians recommend thoracic outlet syndrome surgery, first rib resection, and scalenectomy, and why understanding the true cause of thoracic outlet compression may lead to more logical non-surgical thoracic outlet syndrome treatment options.