Thoracic Outlet Syndrome - A different shoulder diagnosis

What is thoracic outlet syndrome (TOS)?

The ‘Thoracic Outlet’ describes the compression of nerves (brachial plexus), arteries and veins resulting in pain, and altered sensations in and around the neck, chest and shoulder area. This is a rare syndrome only affecting 8% of the population.

There are commonly three areas of compression;

1.     the border of the 1st rib and the anterior and medial scalene muscles.

2.     the middle of the clavicle (collar bone), 1st rib and upper scapula (shoulder blade).

3.     under the Pec Minor tendon and coracoid process.

How did I get Thoracic Outlet Syndrome?

You may be more at risk of TOS if you have…

o   an extra rib in the neck

o   a previous injury in this area (clavicle or upper ribs)

o   poor posture

o   poor shoulder motor control

o   are between the ages 30-50’s

o   4x more frequent in females

What signs and symptoms might indicate TOS?

These may differ depending on whether it’s the artery or veins involved…

Arterial

-       Pins and needles, numbness, tingling or weakness in the shoulder, arm or hand.

-       Pain with lengthening the arm (nerve)

-       Sensation of arm heaviness, cold or loss of colour

-       Reduced radial pulse strength

Venous

-       Swelling

-       Reddened and/or warm skin

-       Raised veins

Can physiotherapy help?

A physiotherapy assessment is crucial in negating all other possible diagnoses and assists treatment, management and onward referral if necessary. Thoracic Outlet Syndrome is very rare so ruling in or out any other likely causes of your pain is critical.

Conservative management should always be trialled initially to reduce symptoms and improve function and return to work before considering if further imaging may be required and/or if a combination of allied health professionals will be required to assist with overall management.

AC Joint pain - The "Other" Shoulder Pain

Anatomy

The Acromioclavicular (AC) joint is located at the lateral tip of the shoulder. The joint is formed by two bones, the clavicle (collarbone) and the acromion (a portion of the scapula/shoulder blade). In between the joint sits a fibrocartilage meniscal disc and the bones are connected by a number of ligaments, muscles and a joint capsule.

Role

The AC joint acts as a pivot point in the shoulder allowing the shoulder blade to rotate as the arm is lifted upwards. If it is dysfunctional it affects the control of your shoulder.

About

The AC joint is very commonly injured in contact sports that involve tackling like rugby or AFL. This is classified as a traumatic injury in which the ligaments can be torn and the capsule disrupted which results in the bone separating. However, you can also have AC joint pain from overloading the joint or degeneration of the fibrocartilage meniscus. It can also develop into a condition called osteolysis which is quite common in gym goers.

Differentiation from “bursitis” or impingement (common shoulder pain)

Shoulder bursitis/impingement is a very common condition in which the bursa and tendons in the shoulder get inflamed or overloaded. Often a cortisone injection is prescribed which can reduce the pain if the bursa is the main issue. However, if it is not the correct diagnosis then ongoing pain and disability can perpetuate. It is very important to get your shoulder assessed by a physiotherapist to differentiate between the two conditions so the right treatment plan can be selected. Please note that Impingement CAN occur as a result of AC joint pain or injury but is not the primary diagnosis.

Common presentation

·         Pain at the top or tip of the shoulder

·         Difficulty lying on the shoulder

·         Difficulty bringing the arm across the body

·         Pain with lifting an object above your head

·         Pain with gym activities like bench press

General advice

·         Try icing the area especially when it is painful

·         Rubbing voltaren gel on the area can help reduce pain, the joint is superficial enough for the gel to have some effect

·         Applying taping to pull the shoulder upwards can take the pressure off the joint and relieve discomfort

·         A structured rehab program is helpful in making the muscles around the joint stronger so there is less load on the area

·         A cortisone injection can be helpful if conservative treatment isn’t effective, as long as they inject the right spot

·         Most importantly, visit your highly trained physiotherapist for a thorough assessment and in-depth treatment plan