Do you constantly have pain in your neck, shoulders, or arms? This condition could be Thoracic Outlet Syndrome (TOS)!

Do you sometimes feel a strange pain or numbness that runs from your neck and shoulders down your arms? Perhaps this pain increases when you lift a weight or raise your arm. If you have symptoms like these, the cause may be a condition with a somewhat complicated name. Today we are talking about such a condition, namely Thoracic Outlet Syndrome (TOS) . Although the name may sound a little scary, if you are properly informed about this, you can reduce many problems.

What is Thoracic Outlet Syndrome?

Simply put, Thoracic Outlet Syndrome (TOS) is a collection of symptoms caused by compression of the nerves or blood vessels in your lower neck and upper chest. Another name for this is "thoracic outlet."

Imagine that there is a small space, like a doorway, between your neck and your chest. This is what doctors call the "Thoracic Outlet." Through this space pass important nerves that go to your arm, as well as arteries that carry blood to your arm and veins that return blood from your arm to your heart. The most important of these are the brachial plexus, a network of nerves that goes to your arm, and the subclavian artery and vein.

Normally, this space called the "thoracic outlet" is large enough for these nerves and blood vessels to pass through without any obstruction. However, sometimes this space can become narrow due to certain anatomical variations in our body or due to injuries to the neck or chest. That's when the problem begins. When this space becomes narrow, the nerves or blood vessels that pass through it start to get pressed by the bones or muscles below. This pressure causes symptoms such as pain and numbness in your arm, shoulder, and neck. These symptoms can be unrelated and varied, so it can sometimes take a while to recognize this as a TOS condition.

But don't worry. Many people can get relief with simple treatments like physical therapy and painkillers. However, if those don't help or if there is a serious blockage in blood flow, surgery may be necessary.

Are there types of TOS?

Yes, doctors divide TOS into three main types, depending on what is causing this throbbing:

Neurogenic TOS (Tos caused by nerve compression)

This is the most common type of TOS . About 95% of all TOS patients have this type. What happens here is that the ``Brachial plexus``, the network of nerves that runs from your neck through your armpit to your arm, is compressed. It most often occurs in people in their 30s. Repetitive stress injuries - especially in sports - and sudden injuries to the neck, such as ``Whiplash`` from a car accident, are the main causes.

TOS caused by venous congestion (Venous TOS)

This is where your ``Subclavian vein`` comes in. This is the main blood vessel that carries dirty blood from the arm back to the heart. It occurs more often in men , usually between the ages of 20 and 30. Symptoms often appear in the arm that is used the most (`dominant arm`).

TOS caused by arterial compression (Arterial TOS)

This is the rarest type of TOS . It affects about 1% of all TOS patients. However, it is the most common cause of sudden blood clots in the arms in people under the age of 40. This type of TOS occurs in your subclavian artery, the main blood vessel that carries oxygenated blood from your heart to your arms. It is often caused by a congenital abnormality. An example is an extra rib in the neck (cervical rib). About 70% of people with cervical rib are women, so this type of TOS is more common in women.

Doctors sometimes combine the two types of venous and arterial TOS and call them "Vascular Thoracic Outlet Syndrome." Both types usually require surgery to relieve symptoms and prevent complications. The nerve-related type of TOS (Neurogenic TOS) responds well to physical therapy and exercise, but some people may need surgery.

How common is this condition?

According to researchers, every year:

• Neurogenic TOS occurs in about one in 40,000 people.
• Venous TOS occurs in about one in 1.25 million people.

However, due to the difficulty in accurately diagnosing this condition, the actual number of people suffering from this disease may be much higher.

What are the symptoms of TOS?

TOS symptoms usually occur on one side of your upper body (neck, upper chest, shoulder, arm, or fingers). You may experience things like:

• Pain: This pain may increase when you raise your arm.
• Numbness or a "crazy" feeling.
• Numbness, feeling nothing in the hand .
• Hand weakness.
• Swelling or heaviness in the hand.
• Skin color changes (skin turning pale or blue).
• Feeling cold when touching the skin.
• Finger wounds take a long time to heal.

These symptoms may vary depending on the type of TOS you have. Because the symptoms depend on what is being compressed (a nerve or a blood vessel). To be precise, they are as follows:

• Your ``Brachial plexus'' is where your arm gets its movement and sensation. So, when this network of nerves is irritated, things like pain and numbness occur.
• Your subclavian vein is the one that carries blood from your arm back to your heart. So, when this vein is blocked, the blood in your arm can't drain properly, causing your arm to swell and feel heavy.
• Your subclavian artery supplies oxygen-rich blood to your arm. So, when this artery is blocked, blood flow to your arm and fingers is reduced. This can cause numbness, tingling, pain, and coldness in your arm.

What does TOS pain feel like? Is it confused with angina?

TOS can cause pain in your neck, upper chest, shoulder, and arm. This can be a dull ache, like a nagging pain, and may worsen when you move your arm.

Some people confuse TOS pain with angina , a heart condition. Angina is chest pain caused by the heart muscle not getting enough oxygen. But there are important differences between the two:

• TOS pain does not come on or get worse with walking. However, angina pain usually does. Angina can be accompanied by other symptoms such as shortness of breath, rapid heartbeat, and dizziness.
• TOS pain usually increases when the affected arm is raised. This does not happen with angina.

Important: Do not confuse TOS with a heart attack or stroke!

This is something you should keep in mind . Some of the symptoms of TOS can be similar to those of serious conditions such as heart attack and stroke, which require emergency medical treatment. For example:

• Chest pain , especially if it comes on suddenly and unexpectedly, can be a sign of a heart attack. However, in a heart attack, there may be additional symptoms, such as shortness of breath, stomach pain, sweating, and a feeling of fear of dying.
• Weakness on one side of the body can be a sign of paralysis. However, paralysis can also have additional symptoms, such as slurred speech, drooping of one or both sides of the face, and sudden loss of vision.

If you have symptoms of a heart attack or stroke, seek medical attention immediately. These are life-threatening emergencies. Delaying treatment can be fatal.

What are the causes of TOS?

Doctors divide the causes of TOS into three main categories:

Congenital causes

These are some of the changes that are present in your body when you are born. For example, you may be born with an extra rib (a `cervical rib`) in your neck. This is close to, and perhaps even connected to, the first rib. Or you may have abnormalities in your ribs, neck muscles, or ligaments. These changes can cause pressure on the nerves or blood vessels in the `thoracic outlet`.

Due to accidents (Traumatic)

These are sudden injuries to your neck and upper chest. Injuries from automobile accidents, especially whiplash, are a prime example of this. Imagine, if you were riding a three-wheeler and had an accident and your neck suddenly snapped, this could happen.

Due to ongoing activities (Functional)

This means that when you do the same thing over and over again, the things in the "thoracic outlet" become damaged. This is a common cause of this among athletes (especially cricketers - bowlers, batsmen, and swimmers) because of the rapid arm movements. Another example is the constant lifting of objects above the head in some jobs. Even someone who works in front of a computer all day with a bad posture can be at risk.

Although some people are born with the risk factors for developing TOS, they may not experience any symptoms until they have a sudden accident to the neck or are constantly doing the same type of work and it becomes damaged.

Who is at higher risk of developing TOS?

You may be at higher risk of developing TOS if you:

• If you play sports that frequently involve repetitive arm or shoulder movements. Examples: cricket, swimming, golf, volleyball.
• If you do weightlifting.
• If you frequently lift heavy bags on your shoulders or lift objects above your head. (e.g., people working in the construction industry, people loading goods)
• If you have suffered an injury to your neck or back, for example `(Whiplash)`.
• If you have tumors or large lymph nodes in the upper chest or armpit.
• If your sitting or standing posture is not good. (For example: people who work on a computer with their back bent all day)

Is TOS a serious condition? What are the possible complications?

If left untreated, Thoracic Outlet Syndrome can lead to serious complications. Some of them include:

• Blood clot in the armpit and related veins (`Axillo-subclavian vein thrombosis`).
• Persistent swelling and pain in the hand, especially in those with venous TOS (`Venous TOS`).
• Tissue death (`Gangrene`).
• Ischemic ulcers occur on the fingers due to decreased blood flow.
• Permanent nerve damage.
• Pulmonary embolism – This is a very dangerous condition.

So, you see, it's not a good idea to just assume that this is just a minor problem. It's very important to diagnose and treat it early.

How do you know for sure if you have TOS? (Diagnosis)

A doctor will examine you and ask you about your medical history to determine if you have TOS. During the physical exam, your doctor will ask you to perform some movement tests. For example:

• `Upper limb tension test` (a test to see if the upper limb is affected)
• `Elevated arm stress test`

During these tests, your doctor will ask you to do simple things like raise your arm, turn your head, and shake your hand. He or she will then look at which movements cause pain or other symptoms. The results can help diagnose the condition.

In addition, your doctor may order lab tests and imaging tests to confirm the diagnosis of TOS and to rule out other causes of your symptoms.

What other tests do you do?

You may need to have one or more of these tests:

• Blood tests .
• Chest X -ray.
• A CT scan of the chest and/or spine .
• EMG test (`Electromyography (EMG)`) – This checks the activity of muscles and nerves.
• Magnetic resonance angiography (MRA) of your blood vessels.
• Magnetic resonance imaging (MRI) of the chest and/or spine .
• Nerve conduction study – This measures the speed at which messages travel through the nerves.

These tests can help the doctor find out:

• Check for congenital abnormalities (e.g., a cervical rib).
• Check how blood flows through your arteries and veins.
• Rule out other conditions that may be causing these symptoms.
• Look at the function of your muscles and nerves.
• Find out exactly where the pressure is.

What are the treatments for TOS?

Treatment for TOS varies depending on the type of TOS you have and your symptoms. The main goal of treatment is to reduce symptoms and prevent possible complications. Your doctor will decide which treatment is best for you.

Here are some possible treatments:

• Physical therapy: This is the first line of treatment for neurogenic TOS. A physical therapist can help you increase your range of motion in your neck and shoulders, strengthen your muscles, and maintain proper posture. This is a great relief for many people with neurogenic TOS.
• Pain relievers: Your doctor may prescribe painkillers, such as NSAIDs (non-steroidal anti-inflammatory drugs), which you can buy at the pharmacy.
• Medications to prevent or dissolve blood clots: People with arterial or venous TOS can benefit from ``Thrombolytic therapy`` (blood clot-dissolving treatment). This involves administering a medication through an IV line or catheter to dissolve existing blood clots and prevent new ones from forming. Your doctor may also prescribe ``Anticoagulant medication``.
• Surgery: Many people with TOS that compresses arteries or veins need surgery. Some people with TOS that compresses nerves may also need surgery if other treatments don't help. Surgeons use different surgical techniques depending on the type of TOS and your body type. For example, decompression surgery removes abnormal bone or tissue that is causing the compression. Other surgeries can improve blood flow by repairing structural problems in the blood vessels. Your doctor will explain to you whether you need surgery, how it is done, and what the risks are.

Will TOS get better on its own ?

No, don't wait for symptoms to get better on their own. If you have symptoms of TOS , seek medical attention right away. While simple things like physical therapy can often help relieve symptoms, some people may need surgery or other treatments to prevent serious complications. Your doctor will tell you what treatment plan is best for you.

Can TOS be prevented?

TOS cannot always be prevented. Because many of the factors that cause it are beyond our control (e.g., genetic factors), there are some things you can do to reduce your risk:

• If you play a sport that requires frequent arm movements, talk to your coach or trainer about exercises that can strengthen the muscles around your shoulders.
• If your job requires you to lift weights or work overhead, talk to a doctor about exercises that can reduce your risk of injury.
• Maintain proper posture. Keep your back straight while sitting, standing, and working.
• Don't stay in the same position all the time. Get up and walk around at least once an hour, stretching your body a little.

If you have TOS, what should you expect? / How can you take care of yourself?

The outlook for someone with TOS varies depending on the type of TOS they have. Your doctor can best tell you about your outlook.

If you have TOS, follow your doctor's instructions on how to take care of yourself. Your doctor may tell you things like:

• Reduce or stop carrying heavy bags over your shoulders and lifting objects over your head as much as possible.
• Work with a physical therapist. Do the exercises he gives you.
• Do exercises you can do at home to strengthen your muscles and improve your posture.
• Limit or avoid certain movements that increase symptoms. Change your daily routine.

When should you see a doctor? / Questions to ask the doctor

If you develop new symptoms or if your symptoms change, talk to your doctor. He or she will tell you how often you should see your doctor and whether you need to have any tests.

If you have recently been diagnosed with Thoracic Outlet Syndrome, here are some questions you can ask your doctor:

• What type of Thoracic Outlet Syndrome do I have?
• What is the reason for this?
• What treatments do you recommend? When should they be done?
• How do we know if the treatment is successful?
• What are the risks of treatment?
• What changes do I need to make in my normal daily routines or habits?
• What can I do at home to reduce symptoms?
• What is my outlook?

Things to remember from this article (Take-Home Message)

Thoracic Outlet Syndrome (TOS) can disrupt your normal life. It can be frustrating to have to take a break from your sports or work. But be patient. By taking care of yourself with physical therapy or other treatments, you can regain your strength and stay well in the long run.

The most important thing is to seek medical advice if you have symptoms, rather than ignoring them. Early detection makes treatment easier and reduces the risk of complications.

If you have any questions about your condition, treatment plan, or outlook, talk to your doctor.

` Thoracic Outlet Syndrome, TOS, neck pain, arm pain, shoulder pain, numbness, nerve compression