Classic Thoracic Outlet Syndrome (not!)

By Douglas Nelson
[Table Lessons]

“I am so grateful! I can’t believe it is still better.” These kind words greeted me from the enthusiastic woman tagging my luggage as I was checking in at the airport ticket counter. It took me a moment to place her and the condition she first presented with several years ago.

Ms. L. came to an advanced training at my office. We focused on the relationship of soft tissue and symptoms of neural entrapment. She presented with sensations of numbness and upper extremity pain she had experienced for months. She had been to her physician and numerous other health-care providers to no avail. My co-instructor for this seminar, Seth Will, asked Ms. L. to describe her symptoms to help us better grasp the problem.

“I have pain and numbness on my right arm and hand. There was no specific incident that started it—just something I increasingly noticed as time went on. The numbness isn’t quite the same as friends who have carpal tunnel; it feels more like a glove that dulls my whole hand. I often feel it all the way up my arm and sometimes even into my middle back. The pain is often worse upon arising in the morning, but gets better during the day. Sometimes my hand feels cold and the whole arm just feels heavier than the other side. It has never been intolerable, but it is a serious annoyance that interferes with my life and job.

“I work for an airline at the ticket counter. It has been particularly busy in the last year; staffing cuts eliminated the person who used to help me with baggage. That means I am handling a lot of bags during the day, as well as ticketing passengers.”

For the benefit of the seminar participants, Seth demonstrated precise neural testing for each major upper extremity nerve that might possibly be implicated. Not surprisingly, the tests did not point to any specific nerve as the likely culprit. What would account for neural symptoms, when no specific nerve seems to be compromised?

By the look we exchanged, both Seth and I were pretty sure that we were looking at classic thoracic outlet syndrome (TOS). While this seemed really promising, none of the common tests for TOS were positive either. When a client presents with neural symptoms similar to TOS and concomitant midback pain, the scalene muscles are implicated. We thoroughly examined them, finding nothing remarkable. Since nothing we had done so far seemed helpful, we decided to regroup and start over. We were clearly missing something important that might take us in a different direction.

 Thinking about the mechanics of moving luggage gave me an idea. “Would you please lie face down on the table? I’d like to check something.”

After Ms. L. was situated on the table, I began to slowly press against the spinous processes in her thoracic spine. As I approached the lateral aspect of the spinous process of T4, she reacted strongly.

“That’s it. When you press there, I feel it right down my arm and into my hand. That makes all the symptoms come back at once.”

As soon as she said this, the source of her problem became clear. A few years previous, I had also seen a few people who presented with neural symptoms that I found perplexing. One person with these symptoms was really helped when I treated her thoracic spine, which I addressed through a treatment protocol best described as “floundering.” Her improvement was dramatic and I resolved to research why this worked. I soon discovered that other clinicians had also discovered the source of atypical upper extremity neural symptoms to be in the thoracic spine.

This condition is called T4 syndrome, which is slightly misleading since the source could be any one of the upper thoracic vertebra from T2–T5. The sympathetic nerves emanating from T2–T5 affect the upper extremity, and there is a close relationship between the segmental nerves and the sympathetic nerve afferents. The sympathetic chain also is strongly affected by problems at the costovertebral joints. The palpatory confirmation of T4 syndrome is a highly sensitive spinous process at the site of entrapment, which must recreate presenting symptoms. I treated muscles affecting the costotransverse junction such as the levator costorum, rotatores longus and brevis, and iliocostalis. With Ms. L., the immediate results were a lessening but not a cessation of her symptoms. We called to check on her two days later; symptoms had continued to decrease. Having not heard from her since then, it was extremely gratifying to know that her symptoms disappeared completely about a week after the session and had not returned in three years. As evidenced by the way she effortlessly tossed my luggage onto the conveyor belt, work hasn’t been a problem either.