Thoracic outlet syndrome F > M 20 – 50

Blood vessels or nerves being compressed between the collar bone and first rib causing neck and shoulder pain with neurological symptoms in the shoulder and upper limb.

Potential structures compressed: scalene strain, elevated rib 1, clavicle (arthritis, fracture), pec minor strain

Neurological (Upper trunk C5,6,7 – less common)

• Painful in neck, chest, shoulder, triceps, forearm,
• Numbness, tingling, pins, and needles
• Caused by constant compression, traction, irritation of brachial plexus
• Caused by bony / soft tissue abnormalities

Neurological (Lower trunk C7,8,T1 – more common)

• Pain in medial forearm, hand
• Numbness, tingling, pins, and needles
• Caused by constant compression, traction, irritation of brachial plexus
• Caused by bony / soft tissue abnormalities

Vascular (Emergency, Hospital)

• Swelling, stiffness, heaviness, coldness in arm
• Discoloured limb, decreased pulse, cramping in arm
• Diffuse paraesthesia
• Aggravated with arm elevation, exercise

Similar diagnoses: Cervical disc herniation, cervical arthritis causing IVF narrowing, Carpal tunnel syndrome, compression of ulnar nerve at elbow

Adson’s test: Sensitivity 50% Specificity 74 – 100%

Roo’s test:  Sensitivity 82% Specificity 100%

Doppler arteriography

Prognosis: Fair to good depending on Neurological or vascular cause

Treatment: Aim is to release the structures causing symptoms. Manual therapy techniques to Scalene muscles, rib 1, clavicle, and pec minor muscle. Surgery may be performed in vascular causes

Foraminal / Central canal stenosis with nerve root compression at Cervical vertebra C5

Symptoms:

• Numbness, tingling, or burning sensation with radiculopathy down arm
• May also present only locally on side of arm with similar neurological symptoms
• Severe pain in neck region
• Painful to turn or extend neck
• Weakness in arm
• Muscle atrophy in shoulder and arm muscles
• Patient may at times sleep in a chair or recliner to prevent neck extension leading to symptoms

A) Cervical Disc herniation (M>F 40-60)

Caused by:

• trauma
• poor posture,
• repetitive activity
• overweight

Diagnosed by:

• Neck compression test (Spurling’s) Positive when peripheral pain, numbness and radiculopathy increases down the arm
• Sensitivity approximately 55% Specificity approximately 87%
• MRI

Treatment:

• Surgery
• Cortisone injection
• Conservative – medication, rest, manual therapy to surrounding musculature
• Disc herniations can heal on their own in 6-9 months

B) Vertebral spurs

Caused by:

• Osteoarthritis
• Trauma / Injury / fractures

Diagnosed by:

• X-ray

Treatment:

• Medication to reduce inflammation and pain
• Cortisone injection
• Surgery
• Manual therapy to surrounding musculature

C) Anterior longitudinal ligament ossification (Thickening)

Caused by:

• Unknown
• Hereditary
• Diffuse idiopathic skeletal hyperostosis (DISH)
• Trauma

Diagnosed by:

• X-ray / MRI

Treatment:

• Medication to reduce inflammation and pain
• Manual therapy to surrounding musculature
• Cortisone injection
• Surgery indicated when airways are potentially being blocked

D) Space occupying lesion (Cyst)

Caused by:

• Genetics
• Chronic inflammatory conditions
• Trauma / Injury to arteries, veins, lymphatics
• Blockages to ducts

Diagnosed by:

• MRI

Treatment:

• Surgery
• Drainage
• Injecting cyst to reduce swelling and pain
• Laser removal

E) Space occupying lesion (Tumour)

Symptoms:

• May include systemic signs such as night pain, night sweats, fever, or enlarged lymph nodes

Caused by:

• Genetics
• Trauma / Injury
• Infectious disease
• Obesity
• Cigarette smoking / Excessive alcohol

Diagnosed by:

• MRI

Treatment:

• Surgery
• Radiation / Chemotherapy

Diabetes

• Numbness and tingling
• Feeling of thirst
• Losing weight
• Urinating often
• Blurry vision
• Hunger
• Tiredness
• Dry skin
• Wounds may have trouble healing
• Prolonged bruising

Type 1

• Condition where the pancreas produces little or no insulin

Caused by:

• Unknown, has genetic links

Diagnostic tests:

• Random blood-sugar test
• Glycated Hemoglobin A1C blood test measures your blood sugar level over 2–3-month period to determine if it is consistently high

Management:

• Insulin injections
• Insulin pump

Type 2 (More common)

• Condition where the pancreas does not produce enough insulin
• Insulin that is produced in the pancreas does not work effectively
• Insulin is produced in the pancreas, but the body’s cells do not respond effectively

Caused by:

• Family history
• Age 45+
• Overweight
• High blood pressure
• Polycystic ovarian syndrome
• Gestational diabetes
• Giving birth to baby over 4.5kg (9lbs)

Diagnostic tests:

• Glycated Hemoglobin A1C blood test measures your blood sugar level over 2-3 month period to determine if it is consistently high
• Fasting glucose test

Management:

• Medication
• Lifestyle changes

Multiple sclerosis (F>M 20-40)

• Peripheral neuropathies
• Commonly unilateral
• Blurred or loss of vision in one eye
• May cause atrophy of muscles or loss of motor control
• May cause tremors
• Weakness in one or both legs
• Clumsiness of limb
• Feeling of walking on cotton wool
• Diagnosed through MRI (looking for lesions on brain or spinal cord), Lumbar puncture looking for abnormalities in antibodies in cerebrospinal fluid associated with MS)
• Often a diagnosis of exclusion as other conditions produce similar symptoms
• Treatment: medications

Local peripheral nerve damage (Axillary / Radial nerve)

• Numbness and tingling
• Sharp, jabbing, or throbbing pain
• Sensitive to touch
• Gradual onset of symptoms
• Caused by local trauma, repetitive movements, crushed, or cut nerves (surgery),
• Medical causes: Diabetes, Multiple sclerosis, Guillain-Barre syndrome
• Electromyography (EMG test), Ultrasound, Nerve conduction test
• Treatment: self-resolving in 12 months, Surgery, or may not fully resolve

Reflex sympathetic dystrophy (Complex regional pain syndrome)

• Chronic limb pain
• Pain is greater than expected than injury that may have caused it
• Continuous throbbing, burning, numbness and tingling
• Sensitive to touch (painful)
• Skin colour and temperature changes
• Not well understood
• May be post-surgery, injury, stroke, or heart attack
• May involve abnormal inflammation or nerve dysfunction