Thoracic Outlet Syndrome

by Alakananda Devi (Alakananda Ma), M.B., B.S. (Lond.)

After considering medovaha srotas last month, it is time to go on to look at some conditions of asthivaha srotas. But first, for this month, let us take a look at a localized condition involving mamsa, asthi and majjavaha srotas. Thoracic outlet syndrome falls under vata vyadhi or diseases due to vata, as mentioned in Charak, sutrasthanam, chapter twenty and Madhav Nidhanam, chapter twenty-two, Vata Vyadhi.
Thoracic outlet syndrome refers to conditions involving compression of nerves and blood vessels bound for the arm as they traverse the thoracic outlet (1). More common in women, this syndrome may affect as many as 80 per thousand of the population (2). It typically occurs in young and middle aged adults although children and adolescents may also be affected (3).

Anatomy of Thoracic Outlet Syndrome

In looking at thoracic outlet syndrome we have to consider the three triangles through which the bundle of nerves and blood vessels destined for the arm and hand must pass. First, let us consider the interscalene triangle. The most common site of neural and vascular compression, the scalene triangle is bordered by scaleneus anterior, scaleneus medius and the first rib and contains the trunks of the brachial plexus and the subclavian artery. The second triangle is the costoclavicular triangle, bordered by the clavicle, first rib and scapula. This triangle contains the brachial nerves, subclavian artery and subclavian vein. The third triangle is the subcoracoid space beneath the coracoid process under the tendon of pectoralis minor. The coracoid process is a small hook-like structure on the lateral edge of the superior anterior portion of the scapula.

Symptoms and Differential Diagnosis

TOS (thoracic outlet syndrome) is a cause of unexplained pain in the arm, shoulder and neck. Arterial, venous and neurological symptoms may be involved. Arterial symptoms include coldness, pallor and fatigue of the arm with exercise (3). Venous symptoms include swelling, edema and discomfort of the arm with exercise (3). Neurological symptoms include tingling and pain in the arm and weakness of the hand. Pain involving C5-7 may be felt in the side of the neck radiating into the ear and face. Pain may radiate into the small of the back, the upper pectoral region and down the arm (3). Pain involving C8-T1 radiates from the shoulder down the arm to the ulnar side of the hand. It may cause occipital headaches and may even spread into the chest, mimicking angina (3). The arm may fall asleep at night.

In TOS the symptoms are intermittent and involve the shoulder, hand and arm. Numbness may affect the ulnar nerve (enervating the fourth and fifth fingers) or the whole arm. There may be a history of repetitive motion at the shoulder, such as playing the violin, or of a previous whiplash injury (3). Note that symptoms may develop slowly and progressively months after the whiplash injury occurred. Arm elevation aggravates the symptoms. In carpel tunnel syndrome the pain and numbness are felt in the wrist, forearm and first to third fingers (enervated by the median nerve). Sustained grasping (as on a steering wheel) or pinching actions aggravate the symptoms. Cervical disc pain is constant rather than intermittent, affects the radial side of the arm and is aggravated by turning the neck or lying on the side. In shoulder injury the pain is mainly felt in the shoulder but may radiate into the arm. Numbness is uncommon and shoulder movements aggravate the pain (3). In considering differential diagnosis, it is important to recall that one condition does not preclude another. Indeed, it would be quite likely for a car accident victim to suffer from both cervical disc pain and TOS.

Physical Examination

In all cases of numbness, pain, pallor and coldness affecting one arm, it is important to test the blood pressure in both arms. A difference of 20 mm Hg or more between the two arms is indicative of subclavian artery compression due to TOS (3). Look for differences in colour, temperature, hair growth, nails and muscle bulk between the two arms. Evaluate muscle strength. A weak triceps with strong biceps on the affected side is another characteristic sign of TOS. Arm reflexes are normal in TOS whereas they may be abnormal in cervical disc disorders (3).

Ayurvedic Support for TOS

If you notice signs of subclavian artery compression such as a difference in blood pressure between the two arms, the patient should be referred to a vascular surgeon. In other cases, it is well to see if conservative Ayurvedic measures can manage the situation and prevent the patient coming to surgery.

Two basic principles inform our Ayurvedic treatment of this condition. First: there is no pain without Vata. Therefore, TOS is a localized vata condition. Secondly, chronic pain aggravates vata: therefore, the TOS patient suffers from systemic vata aggravation. Indeed, the TOS patient is experiencing a vicious cycle or positive feedback loop that can be remedied only by managing vata. Their condition has a vata origin, either in repetitive motion or in a car accident. It is a vata condition, yet its symptoms consistently provoke vata, worsening the condition. If the patient has suffered a whiplash injury, they may also be experiencing PTSD, another systemic vata manifestation. And often they have been misdiagnosed, gone undiagnosed or been told that their symptoms are psychosomatic (3), an extremely vata-provoking dilemma. Thus it is essential to manage vata both systemically and locally.

To address first systemic vata, a general vata-soothing formula can be used. Ashwaganda is an obvious choice as dosha pratyanaka for vata, with additional nervine and nerve-healing properties (4). For a patient with high pitta, Vidari can be used instead, since it has shita virya. Guggulu is anti-inflammatory (5) and also vata soothing and effective for the deeper dhatus. Boswellia helps relieve pain as well as reducing inflammation and calming vata (6). Abhyanga using a suitable vata oil blend, followed by svedan, will be highly effective in balancing systemic vata, as will both sesame oil basti and dashamoola tea basti.

Locally, application of mahanaryana oil before a hot shower is a standby that brings daily relief to suffers of TOS and other chronic pain syndromes (7). Specialized in-house treatments include nadi svedan using dashamoola to medicate the steam, dhara treatment to the shoulder region using mahanarayana tailam, as well as marma point therapy. Useful marma points include kakshadhara, in the deltopectoral groove at the level of the first intercostal space, seven fingerbreadths from the sternum (8), adha skanda, between the insertions of deltoid and brachialis on the humerus (9), and kaksha, at the apex of the axillary fossa (10). Massage therapy has beenf ound to be effective for TOS (11)

TOS is related to posture (1, 3). A posture of slumped shoulders and poked forward neck predispose to TOS. If the neck is poked forward, especially in children, recommend an eye exam. Myopic individuals who are not receiving appropriate correction often poke their head forward in an attempt to see better. In fact poor posture may be both a cause and an effect of myopia (12). Yoga and yoga therapy are essential for management of TOS. Tadasana is essential for basic postural correction, accompanied by chest opening poses such as bridge, cat-cow, cobra and triangle. Individuals with significant TOS should see a qualified yoga therapist to avoid re-injuring themselves in a general yoga class.

The unique understandings of Ayurveda concerning the relationship of Vata and pain allow Ayurvedic practitioners to make a significant contribution to the wellbeing of patients with TOS.

Sadat U, Weerakkody R, Varty K. Thoracic outlet syndrome: an overview. Br J Hosp Med (Lond). May 2008;69(5):260-3.
Huang JH, Zager EL. Thoracic outlet syndrome. Neurosurgery. Oct 2004;55(4):897-902; discussion 902-3.
Brantigan CO, Roos DB Diagnosing thoracic outlet syndrome Hand Clin 20 (2004) 27–36
Singh NN, Bhalla M, de Jager P, An Overview On Ashwagandha: A Rasayana (Rejuvenator) Of Ayurvedaan Overview On Ashwagandha: A Rasayana (Rejuvenator) Of Ayurveda African Journal of Traditional, Complementary and Alternative medicines (AJTCAM), Vol 8, No 5S (2011)
Francis,JA, Raja SN et al, Bioactive Terpenoids and Guggulusteroids from Commiphora mukul Gum Resin of Potential Anti-Inflammatory Interest
Bishnoi M, Patil CS, Kumar A, Kulkarni SK. Analgesic activity of acetyl-11-keto-beta-boswellic acid, a 5-lipoxygenase-enzyme inhibitor. Indian J Pharmacol 2005;37:255-6
Jain A, Choubey S, et al, Sida cordifolia (Linn) – An overview Journal of Applied Pharmaceutical Science 01 (02); 2011: 23-31
Lad VD, Durve A, Marma Points of Ayurveda, The Ayurvedic Press, Albuquerque, 2008, p 150
ibid p 190
Ibid p191
Michael Hamm LMP,Impact of massage therapy in the treatment of linked pathologies: Scoliosis, costovertebral dysfunction, and thoracic outlet syndrome Journal of Bodywork and Movement Therapies Volume 10, Issue 1, January 2006, Pages 12-20
Marumoto T, Sotoyama M et al Significant correlation between school myopia and postural parameters of students while studying International Journal of Industrial Ergonomics
Volume 23, Issues 1-2, 1 January 1999, Pages 33-39