Newswise – “Young” and “athletic” aren’t adjectives often mentioned in the same sentence as vascular surgery, but that’s what’s crazy about thoracic outlet syndrome. The disease strikes young people – often patients in their 20s and 30s – and the usual culprits of vascular disease like diabetes, high cholesterol and high blood pressure play no role.
Professional athletes — often Major League baseball pitchers like former New York Mets pitcher Matt Harvey — are sometimes diagnosed with thoracic outlet syndrome. The disorder can be misdiagnosed, which is particularly concerning given the magnitude of the stakes. Some forms of thoracic outlet syndrome can cause permanent damage. In an extreme case, you could lose an arm due to poor blood circulation.
Two Penn State Heart and Vascular Institute surgeons — Dr. Tarik Ali and Dr. Maria Castello Ramirez — explain the condition, its warning signs, and when you should seek help.
What is thoracic outlet syndrome?
At the base of everyone’s neck there is room for a bundle of nerves, an artery, and a vein. In some people, that space doesn’t provide enough room for all three, Ali said. Or space becomes insufficient when an athlete uses the shoulder and neck muscles frequently and they grow in size. Everything gets pinched, and that’s where the trouble begins.
“It comes in three flavors,” Castello Ramirez said.
Most people — up to 90% of patients with thoracic outlet syndrome, Ali said — get the neurogenic version of the disease, where only the nerve plexus is pinched. As a result, people experience arm symptoms such as pain and numbness. Eventually, the disorder can become debilitating.
The other two – venous and arterial – occur when the vein or artery becomes compressed. These conditions are more serious and usually require surgery.
What’s going on there?
Both the venous and arterial versions of thoracic outlet syndrome can affect blood flow. In the case of the vein, blood clots can develop. Blockages cause swelling in the arm. Often the swelling is so severe that the patient can no longer move their arm. If left untreated, blood return to the arm may be permanently interrupted.
When the artery is compressed, an aneurysm – a swelling in the artery – can occur when blood flow to the arm stops. “People can lose fingers, hands and even arms,” Ali said. “People can die from it in severe cases.”
Vein clots can also be fatal if they travel to the lungs, but the damage is usually localized to the arm. The result is called deep vein thrombosis, a condition where the clot forces blood around the blockage and swelling occurs.
How do you treat it?
“There’s an old saying in surgery,” Ali said. “If you operate for pain, all you will get in return is pain.”
In other words, for the most common neurological version of the disease, doctors generally don’t recommend surgery. Instead, physical therapy is often recommended to relieve pressure on the nerve in the neck as a first-line treatment. It is only after the failure of conservative management that surgery is proposed.
But when it comes to the rarer venous and arterial version of the disease, surgery is required. Doctors often remove the first rib below the collarbone to relieve some of the pressure. They can also remove portions of muscle. Patients usually don’t lack flesh or flesh, Castello Ramirez said. The rib has no function and other muscles come into play to replace their missing counterparts.
When should I ask for help?
“I would say if people have arm swelling and pain in the absence of trauma — if they get really swollen and painful, it could be deep vein thrombosis,” Castello Ramirez said.
If, in addition to pain, your skin feels blotchy and cold to the touch, a vascular issue could be the cause, she said. But any time you experience pain that is debilitating or affecting your ability to lift your arms, talk to your doctor.
How do you diagnose it?
It’s delicate. MRIs do not detect abnormalities. “It’s normal anatomy,” Ali said. If you compare someone with thoracic outlet syndrome to someone who doesn’t, the vein, artery, and nerve and the space between them will likely be very similar.
Vascular surgeons diagnose thoracic outlet syndrome by assessing blood flow using tests such as venograms (injecting dye into the blood and using an X-ray to see it) or ultrasound with arm maneuvers, said Castello Ramirez.
In case of neurogenic syndrome of the thoracic outlet, electromyography can help in the diagnosis.
Outside of the vascular surgeon’s office, it can sometimes be misdiagnosed. Primary care physicians can detect a blood clot and prescribe medication to dissolve it, but they will miss the root cause – thoracic outlet syndrome. This can lead to long-term complications, such as clots that don’t break down. In such cases, relatively simple surgery to remove the rib or part of the muscle will no longer work, Ali said.
Patients should not be afraid to request a test for thoracic outlet syndrome if they suspect it.
The medical minute is a weekly health report produced by Penn State Health. Articles feature the expertise of faculty, physicians and staff, and are designed to offer relevant and timely health information of interest to a broad audience.