Dr. Abdullah Al-Fawaz: Numbness in the hand and pain in the shoulder may indicate Thoracic Outlet Syndrome
Dr. Wala’a Hafiz – Many people may assume that numbness in the fingers or shoulder pain is caused by a cervical disc herniation or shoulder tendonitis. However, there is a less common condition that warrants attention, particularly among young people, athletes, and those who spend long hours at computer screens. It is known as “Thoracic Outlet Syndrome” (TOS).
Dr. Abdullah Al-Fawaz, a vascular surgery and interventional specialist, told Al-Qabas that this condition is not a single disease, but rather a group of symptoms resulting from compression of the nerves or blood vessels as they pass through the area below the neck, behind the clavicle (a long, thin bone lying horizontally across the upper chest), and above the first rib, on their way to the arm.
**Common Cases**
Dr. Al-Fawaz emphasized that the significance of this syndrome lies in its ability to hide behind seemingly minor daily symptoms. He noted that the neurogenic type is the most common, accounting for approximately 95% of cases, while the venous type represents between 3% and 5%. The arterial type accounts for no more than 1% of cases.
He mentioned that some references indicate that the neurogenic type is diagnosed in roughly one in every 40,000 people annually, whereas the venous type is diagnosed in one in every 125,000. However, he clarified that actual figures may be higher, as diagnosing this syndrome is not always straightforward.
“Most cases we see in the clinic occur in working-age, active individuals, typically between 20 and 40 years old, with the neurogenic type being more prevalent in women. The syndrome can also appear in swimmers, volleyball players, baseball pitchers, weightlifters, musicians, assembly line workers, and computer users who maintain poor sitting postures.”
**Types and Symptoms**
He explained that symptoms vary depending on which structures are compressed. He outlined the types of the syndrome and their associated prominent symptoms as follows:
1. **Neurogenic Type:** Compression occurs on the nerve plexus supplying the shoulder, arm, and hand. Patients complain of pain in the neck, upper chest, or shoulder, along with numbness or tingling in the hand, weak grip, or worsening symptoms when raising the arms above the head, such as when combing hair or hanging clothes. Sometimes, the numbness does not follow a clear single nerve pathway, which distinguishes it from certain peripheral nerve problems.
2. **Venous Type:** This results from compression of the subclavian vein. Symptoms are usually more obvious and include:
• Sudden swelling in one arm
• A feeling of heaviness
• Bluish discoloration or change in skin color
• Prominent veins in the shoulder or upper chest area
He added that this condition can result from exertion-induced thrombosis following sports activities or weightlifting. He stressed the necessity of rapid evaluation, as it may be associated with venous thrombosis.
3. **Arterial Type:** This is the rarest form of Thoracic Outlet Syndrome but can be the most dangerous if left untreated, potentially leading to:
• Coldness of the hand, pallor, weakened or absent pulse
• Pain when using the arm
• Small sores on the fingers due to poor blood supply or the passage of small emboli from the artery
**Examination and Diagnosis**
Dr. Al-Fawaz stated that clinical examination focuses on identifying any differences between the arms in color, temperature, or swelling, in addition to measuring pulse and blood pressure, and assessing muscle strength and sensation. Physicians also perform tests involving specific arm positions that may trigger symptoms, emphasizing that no single test is sufficient on its own to diagnose the condition.
He added that accurate diagnosis relies on combining medical history, clinical examination, and ruling out more common conditions with similar symptoms, such as cervical disc herniation, shoulder tendonitis, carpal tunnel syndrome, or heart disease if the pain is located in the chest area.
Required examinations may include simple X-rays of the neck and chest to detect an extra rib known as a “cervical rib,” as well as Doppler ultrasound imaging of the blood vessels with arm movement, and CT or MRI scans of the arteries and veins in various positions. Occasionally, nerve and muscle conduction studies are performed. He confirmed that the venous type may require venography, while the arterial type requires investigation for narrowing or dilation of the subclavian artery.
**Treatment**
Dr. Al-Fawaz emphasized that treatment is not one-size-fits-all. Most neurogenic cases begin with targeted physical therapy, such as:
• Improving neck and shoulder posture
• Strengthening scapular muscles
• Performing stretching exercises, alongside modifying work habits and sports practices
• Using painkillers or local injections in specific cases
He noted that if pain or weakness persists and affects daily life despite appropriate treatment, the physician may discuss surgery to decompress the thoracic outlet, which may involve removing the first rib, muscles, or tissues causing the compression.
In the venous type, treatment may begin with blood thinners or thrombolysis early on, followed by surgery to prevent recurrent compression. In the arterial type, treatment is generally surgical, including repair of the artery if it has been damaged.
**Warning Signs**
Dr. Al-Fawaz emphasized that the good news in these cases is that the response to treatment is excellent with correct diagnosis and early intervention, especially before permanent thrombosis or weakness occurs. He stressed that recurrent hand numbness when raising the arm, sudden swelling in one arm, or coldness and bluish discoloration of the fingers are symptoms that should not be ignored. He clarified that the following signs warrant attention:
• Numbness or pain that worsens when raising the hand above the head.
• Sudden swelling or bluish discoloration in one arm.
• Cold fingers, weak pulse, or the appearance of small painful sores.
• Shoulder or neck pain that does not improve despite treatment for disc or shoulder issues.
• A clear difference in the color or size of the arms after sports or weightlifting.
