A friend was recently diagnosed with Thoracic Outlet Syndrome after months of increasing pain and decreasing mobility with her right shoulder/arm. She is confused as to her options and I agreed to help her research her options since TOS appears to be poorly understood. She has already been prescribed painkillers, muscle relaxers, etc. as well as massage therapy, physical therapy, analgesic injections, accupuntcure, dry needling, etc. None of it has worked.
Now that she has a diagnosis (other possibilities were Fibromyalgia and Myofascial Pain Syndrome) I'm trying to find out how to proceed considering her deteriorating condition.
First, as you have noted, the diagnosis must be firm. Is it Thoracic Outlet Syndrome (TOS), or something else. If you are treating the wrong thing, then of course, it won't work.
There are basically two types of TOS. One, unfortunately, is seen mostly in women, and is the type that is not very well understood. In this type, the patient has some of the typical signs of TOS, but no underlying cause, such as a cervical rib or overdeveloped scalene muscles in the neck (body builders/weight lifters). So, this type is very hard to diagnose, and the usual treatments are only somewhat helpful.
In the second type, there is classic symptoms, reproducible on exam, and the patient has an identifiable structural cause, such as the cervical rib, overdeveloped scalene and other muscles in the neck, large first rib, fascial band compressing the neurovascular structures in the lower neck and shoulder, an old clavicle fracture, narrowed space between the clavicle and the first rib, or other structural abnormality. (One rare cause of TOS, especially in smokers, is a Pancoast Tumor in the lung.) This type usually responds to either the discontinuation of body building or the surgical removal of the offending abnormal structure.
But, it is usually the first type that gets most of the attention, because treatments for it are not very successful. This can be due to several things, but probably the biggest thing is, that it is the improper diagnosis in the first place.
So, unless she has an identifiable structural cause, about the only thing that can be done is the physical therapy, weight management, strengthening of the shoulder suspension muscles, proper biomechanics, proper ergonomics in the work place, proper posture, injections of steroids or Botox, relaxation techniques, medications, and the like.
In some cases of recalcitrant TOS, even without an identifiable cause, a resection of the first rib will to tried as a last ditch effort. Again, this will help in some patients. Others are no better off and now have problems from the surgery and well as the continued problems in the arm.
Again, it is very important to make sure that the diagnosis is firm. The nonsurgical treatments are always tried first. If everything fail, and the patient is showing objective signs of nerve compression and obstruction of the vascular structures, then surgical removal of offending structure or the first rib is then tried.
Hi ConcernForFriend, it's lovely to meet you. I'm a 36 year old female and having similar problems as your friend. I've been diagnosed with Cervical Rib Syndrome by my osteopath and after having an xray - which confirmed his diagnosis, my doctor then also agreed. What I would also like to know, is how to treat it!
There doesn't seem any help available at all and it's such a terribly painful thing. My pain also increases during my period, I'm not sure if your friend is the same but for me it's awful, the pain is so bad I can wake up crying and feeling sick it's so extreme. I'm trying to heal myself through regular visits to my osteopath, using muscle relaxants/oils and massage. Does your friend take any medication to help? Has she found anything at all since your message that has helped her?
I truly hope we can all help each other in some small way, as the thought of surgery frightens me!
God bless x x