Thoracic Outlet Syndrome: Fact or Fiction? from Whiplash 101
 

Recent article from Whiplash 101

Thoracic Outlet Syndrome: Fact or Fiction? by Christopher J. Centeno, M.D.

Thoracic Outlet Syndrome. The diagnosis inspires fear in the hearts of insurance adjusters and confusion for most medical providers. Thoracic outlet, or TOS as its sometimes known, seems to have gotten this reputation because of its sometimes dubious surgical roots. The surgeries were expensive, carried significant risk for patients, and rarely seemed to help. However, TOS has another side, one with no less controversy, but some basis in science and without the baggage of its surgical past.

The diagnosis of TOS first shows up in the medical literature in the 1960s. The syndrome gets its name from a constellation of symptoms that all originate from compression of an area where the shoulder meets the rib cage, dubbed the Thoracic Outlet. This area is in the front of the neck, between the shoulder and the chest, under the collarbone and above the ribs. If you think of this area as a house, the floor would be the upper rib cage, the walls would be the scalene muscles, and the roof would be the collarbone or clavicle. Since major nerves and vascular structures pass through this space on their way to the upper extremity, any compression can cause weakness, numbness, and vascular changes in the upper extremity…continued at

http://www.whiplash101.com/thoracic_outlet_syndrome.htm

Good article-

this part really applied in my case- probably for many of us...

[Exam is where most practitioners miss the diagnosis. The problem seems to be due to a “compartmentalization” of the body by musculoskeletal specialists. Most MD and DO physicians view the body as disconnected areas. A common problem is the axial and peripheral mindset. For example, many doctors without significant soft-tissue training will limit their exam to the areas of complaint. Since many patients complain of hand symptoms, the exam is often focused from the elbow down. This poses a problem in rendering a correct diagnosis, since the cause in the shoulder and thorax, not in the hand. Because of this over focused exam strategy, the diagnoses of carpal tunnel syndrome or ulnar entrapment at the elbow are frequently made in error. Millions of dollars are paid by insurers each year to doctors treating a shoulder-thorax problem with wrist or elbow surgery. Each year in my practice, I see a hundred or more patients who have had unnecessary carpal tunnel surgery or ulnar releases who are treated successfully without any additional surgery simply by applying the correct treatment to the problem.

The clinician’s exam will reveal much about whether or not proper care has been taken to rule out this diagnosis. First, an exam with only elements such as Phalen’s, Tinnels at the wrist and/or elbow, Carpal or Wrist Compression Test, Sensation, Deep Tendon Reflexes or DTR’s is not adequate to detect this diagnosis. Tests such as the Upper Limb or Brachial Plexus Tension Test (ULTT), Spurling’s Maneuver, Adson’s Maneuver, Scalene Compression Test, First Rib Compression, and/or Shoulder Range of Motion (ROM) should be included. Again, the focus of the exam in a patient that presents with hand paresthesias must include the neck and shoulder, and not just be limited to the wrist. Despite this reality and in some part due to the pressures placed on physicians by managed care, many physicians simply don't’ check anything beyond the area of complaint. This causes massive under-diagnosis of this particular condition.

In general, conservative treatment for TOS is very poor in this country. This is largely due to an over-emphasis on orthopedic and surgical conditions and a de-emphasis on soft-tissue conditions in American PT schools. It’s very common for a patient to be placed in an orthopedic based physical therapy program where lifting weights or work hardening are a focus of treatment. While a few patients respond to this sort of treatment, most are made worse by the increased activity. This does not usually represent malingering or symptom magnification on the patient’s part, but rather the wrong treatment applied to the condition. ]

Dr. Centeno is my doctor, and I will attest to the fact that his exam was more thorough than any other doctor's...except maybe Dr. Sanders. He says at the end of the article that it can be a "minor inconvenience" if treated early and aggressively...he was frustrated for me that I came 3 years after the injury, but now he's used all the "rabbits" in his hat and is moving me into pain management. When Dr. Centeno gives up, it's kind of discouraging (he always seemed to have one more thing to try)...although he said there are a lot of new studies and theories on pain and nerves that may bring help someday. In the meantime, good days/bad days, learning and avoiding what causes flares, etc...

Donna

Donna, I have to agree with you that Dr Sanders does give a very thorough exam ... mine was done after fying half way across the country and after landing in Denver only had little more than 45 min. to make it to his office therefore between the pressure of getting to his office in time and the trip he got a good look at what I feel like! Dr Togut here in Northeast Pa does an excellent exam also! When they (his office) schedule you for the initial, you are told not to have any palns for a 3 hour block! Now just waiting on WC to get their stuff together so I can get back out to Denver for my surgery!!!!!!!!!!

Mark-n-Goober

Mark, I'm glad you got to see him at your worst! I'm sure that helped with your diagnosis. I usually feel so much worse AFTER a doc's exam...I almost wish I could sit around in the office for an hour or two and have them do a recheck! That was especially true after seeing Dr. Sanders...agony all the way home. He was so nice...he called me a few weeks after my appt. to check on me. He encouraged me to have the discs fixed in my neck first (which I had done two months ago)...I don't have the first rib issues, so he would do a scalenectomy on me, but only gave me a 60/40 chance of improvement. At this point I don't plan to pursue the TOS surgery with those odds...plus Dr. Centeno feels I'm at some risk for developing RSD, and gave me about a 20% chance of getting worse! :mad: Anyway, I don't think I've ever had a doctor call to follow up after an exam! I remember reading on the old board that you had been to see him, and really liked him too.

I hope your WC issues are worked out soon and your surgery goes well. Is there a light at the end of the tunnel? A time frame you can look at? If I can be of any help to you or your family while you're in Colorado, let me know!

Donna