The classic thoracic outlet syndrome was seen in women with drooping shoulders carrying heavy shopping bags. This would have been in the days before cars and supermarket trolleys.
Pain would be experienced down the inner side of the arm, forearm, and into the ring and small fingers.
They would wake at night with pins and needles, numbness and pain, as the nerves recover from the day's trauma.
For classical treatment, see below.¹
Inlet, outlet, even the thoracic outlet syndrome name is a bit sus. Just as much goes in as out of this "superior thoracic aperture" formed by the spine, upper breast bone and down sloping first ribs joining them.
Most of your arm nerves come from your neck, and just go past this top opening of your chest cavity. The last two come from inside it, so have to cross over your first rib on the way out. The nerves are not bent sharply here, as the first rib also slopes downward from the spine.
Even though your 8th Cervical nerve exits your vertebral column above the first rib, it also has to cross the rib on the way to your arm. The bone may have a groove here, showing how closely it crosses.
The 8th cervical and 1st thoracic nerves join to make the "inferior trunk of the brachial plexus", which lays across the first rib, sometimes in that notch. There's the rub, so to speak. It's not so much a pinched nerve as a stretched one.
I know this makes little sense without a picture - this shows nerves in black, collar bone and first rib white.
Thoracic outlet syndrome makes more sense to me if a person has a cervical rib - an extra rib above the first. More nerves to your arm now have to climb up and over this extra rib or fibrous band, and are more vulnerable to damage.
Why your little finger?
That's where your 8th cervical nerve goes - the pinkie is part of it's "dermatome," or area of skin supplied with sensory innervation.
The 7th cervical nerve supplies a strip of skin down the middle of your hand, and the 6th supples the thumb.
Your 1st thoracic nerve controls the small muscles between the bones of your hand. Loss of dexterity can be experienced if it is damaged.
Arterial and venous thoracic outlet syndrome are described, where the axillary artery or vein are involved.
Often in young adults, with a history of vigorous arm activity apparently.
Pain on arm use, coldness and pallor might suggest arterial blockage.
A blue swollen arm might suggest venous obstruction.
When I see people with nerve pain down the inner side of their arm to their fingers, often associated with numbness and tingling, I want to know one thing.
Do the numbness and pins and needles spare their thumb or their little finger?
If their little finger is not involved, it will be carpal tunnel syndrome.
If their thumb is not involved, it will be as shown here, with one spinous process not directly on top of the other...
The picture may not look all that convincing, but it was taken straight. The side step is only millimeters.
This sideways step in the line of spinous processes, will be accentuated when she bends her head sideways to the right.
This is explained further on the thoracic spine page.
Conventional accounts of thoracic outlet syndrome mention occipital headache and history of neck trauma preceding their symptoms, most commonly from auto accidents and repetitive stress at work.
Dr. Adam Tanase on a Q&A site said it can be helped by physical therapy and/or chiropractic care, often just by restoring proper biomechanics to the neck.
These accounts fit very well with my experience.
The spinous process of a vertebra is the bone sticking out backwards in the midline of your neck or back.
The 7th cervical is called the "vertebra prominens" because its spinous process is the uppermost obvious one at the base of your neck.
It is pretty easy to mix it up with the next one down. You can be sure by feeling the bone above as you repeatedly move your head to look up and down. C6 moves into prominence as you look down, and all but disappears as you look up. C7 just stays put.
This was first described by Upton and McComas and published in Lancet in 1973. They found in 81/115 cases of carpal tunnel syndrome that there was associated nerve damage in the neck as well.
It is very common in all areas of bodily dysfunction that a symptom often has multiple causes.
Here a long nerve can be damaged in two places, neck and wrist.
Two accidents along a stretch of highway, cause double the delays in your trip.
Our nerves have three highways apiece, carrying materials for repair and day to day running back and forth between the cell body and the business end.
It's a long way from your neck to the tip of your pinky.
Nerves from the small of your back to your big toe are even longer.
That's plenty of distance to get problems.
Thoracic outlet syndrome can coexist with nerve damage further down the arm.
In one study, of 142 TOS patients who already had their first rib removed (23 on both sides,) 73 were subsequently found to have compression of a nerve further down as well.
Electromyography and nerve conduction tests showed carpal tunnel syndrome in 41 of the 73.
"Our results show that proximal compression of a nerve lessens its ability to withstand more distal compression. Once the diagnosis of thoracic outlet syndrome has been made, (consider) the possibility of an additional distal compression neuropathy."
In his Textbook of Orthopaedic Medicine, he says that
"Within two or three weeks, (the typical middle aged sufferer) loses her long standing symptoms and, as long as she keeps to her regime, remains well.
After a time, the nerves lose the heightened sensitiveness resulting from repeated bruising; some months later the patient finds she can relax her precautions a good deal."
His treatment involves sitting up in the evening until the nerves have gone through their process of recovering - until their pins and needles have come and gone.
You need to wedge yourself in a canyon of cushions in an armchair, arms resting on the cushions so that your shoulders are up near your ears.
The pressure off, your nerves are able to recover now, rather than in the middle of the night.
This over, you will be able to go to bed and have an undisturbed night.
That's the easy part, of his thoracic outlet syndrome treatment.
During the day, you need to hold your shoulders slightly shrugged all the time, and right up near your ears all the time you are lifting anything.
This isn't easy.
It has to become a habit.
Have you ever caught your pinky finger in something as you swung your arm past it? It's just as bad as stubbing a toe, and as in the foot, it's usually the fifth that cops it.
Sprained or broken finger?
A fracture or dislocated joint may have bent your finger obviously and abnormally. People usually just act intuitively and immediately pull the finger straight.
Apart from this immediate treatment, the examination can wait. Put it up now (see RICE below.)
If the finger is a bit swollen and very sore, you can examine it to see what is likely to have happened.
Support the finger against its neighbor or a solid surface, and rub up and down the front, back and two sides of the finger to find where it is most tender (and swollen.)
Tenderness on mainly one aspect of a joint may be a sprain or an avulsion fracture (where the ligament pulled a sliver of bone off instead of tearing.)
A sprain will hurt more if you attempt to kink the finger sideways so as to spring the joint open on this side. An avulsion fracture is likely to hurt just as much both ways, or more when you bend it so as to compress the injured side.
Tenderness of one of the bones of the finger, definitely between the joints, may be a fracture. A fractured bone will be tender on all sides (front, back, right and left.) There may be a bump on the bone where it is tender, different to on the other hand.
Put your arm fully up above your head immediately, with an ice pack if available. Keep it there for at least a few minutes. Broken blood vessels take a couple of minutes to stop bleeding.
German homeopathic complexes such as Traumeel cream and tablets are useful. Homeopathic arnica used on its own is also useful.
Obvious blood under a fingernail can be released if testing has excluded a fracture.
Straighten a paper clip and heat the end to red hot, with a match.
Carefully melt a hole in the nail over the middle of the blood, until a drop of dark blood appears.
The blood insulates the underlying nail bed from the heat, so it relieves pain rather than causing it.
From thoracic outlet syndrome to carpal tunnel page.
Reference for study of TOS and double crush syndrome...
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Electromyography is recording the electrical activity produced during muscle contraction.
Nerve conduction studies are tests where a nerve is stimulated electrically at one point and the "action potential" of the nerve impulse is measured further along the nerve, to ensure there is adequate connection between the two points.
Proximal means close to the center of the body.
Distal is further from it.