Sixers guard Markelle Fultz has been diagnosed with neurogenic thoracic outlet syndrome and is out indefinitely. It is expected that he will miss approximately six weeks while he is undergoing physical therapy.
In trying to understand the diagnosis, the symptoms, and treatment, we turned to a professional qualified to offer some insight.
Medhat Mikhael, M.D., is a pain management specialist and the medical director of the non-operative program at the Spine Health Center at MemorialCare Orange Coast Medical Center in Fountain Valley, Calif. He has extensive experience treating patients with thoracic outlet syndrome (TOS).
Q: What is your experience with TOS, and what is it?
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A: I treat a lot of patients with TOS. I'll start with TOS, how it presents, and what causes it. Patients are usually presented with some neck discomfort, some radiating pain to the shoulder and down the arm, sometimes with occasional numbness or tingling feeling in the arm. If a patient indicates discomfort pinpointed in the neck for example, then they have an MRI on the neck and there is no clear physical finding on the MRI to explain why the patient has these symptoms.
Then the thought about thoracic outlet syndrome begins when there was no clear indication why the patient is experiencing pain from the neck down to the shoulder and arm. TOS then becomes a possible option.
The reason it's called thoracic outlet is because there is a group of nerves in the neck and this group of nerves leave the neck and enter into the upper thorax, into the axilla, and down the arm. They form groups of trunks and roots, it's called the brachial plexus. They unite and form that group, and then individually into nerves, the radial, median, and ulna nerves that supply sensation into the arm. As they exit the neck, into the axilla and the arm, they can be compressed at different levels. One of them is in the neck area.
People experience abnormal swelling, or abnormal spasms in one of the neck muscles, like the anterior scalene muscle, it's common for people who do certain exercises like football, or people who do a lot of heavy weight lifting, sometimes a major stress from a car accident can lead to this as well. If that anterior scalene muscle becomes swollen it can put pressure on the brachial plexus as it tries to pass through to get into the arm. Also, some people have an extra cervical rib in the upper part and that rib can compress on the plexus as it tries to exit the neck to get into the axilla and down the arm.
Q: What is the difference between neurogenic and vascular thoracic outlet syndrome?
A: The neurogenic involves nerves being compressed, and vascular is vessels being compressed. More often we see neurogenic, but sometimes we see both at the same time. It's easier to diagnose vascular because the patient will have change in coloration, temperature feeling, diminishing pulsations, so it would become obvious if it was vascular. But the majority we see is neurogenic.
Q: What is the usual method of diagnosis?
A: There are different ways to diagnose this, and it's not always easy. Sometimes it's clinical. Understand that if a patient has a major compression on the brachial plexus, a brachial plexus MRI can identify it by showing some strangulation of brachial plexus, but you could do a thoracic outlet patient MRI and the MRI can look normal. That would not exclude the diagnosis. You could also do what we call a nerve conduction study, or electromyography, and you can capture some of the nerve compression. Again, if that turns out to be negative, it does not exclude thoracic outlet syndrome, because it's more of a clinical diagnosis. However, if one of these findings are positive it helps to confirm the diagnosis.
Q: Does a clinical diagnosis mean that it's based on their symptoms rather than their test results?
A: Yes, it means that you've excluded other reasons for these symptoms, and clinically the patient shows multiple symptoms of the thoracic outlet. If a patient has a history of car accident or does heavy lifting all the time, there is tenderness in the anterior scalene muscle, if they have some other associated vascular compromise in the adduction of the arm or extension of the arm and externally rotating it. So there are certain clinical tests that we do that would lead us to believe that this is thoracic outlet syndrome. However the best diagnostic measure is to do a diagnostic block and try to figure out if you can block the brachial plexus in the area where it's suspected to be compressed, and the patient gets full relief from such a block.
These are just some of the diagnostic measures that can be used to rule in or rule out thoracic outlet syndrome. Sometimes if the patient exhibits clear symptoms, simply doing an MRI of the brachial plexus can show proof that TOS exists.
Q: Is TOS something that often takes a long time to get a diagnosis?
A: That's correct. And a lot of the time there are physicians that miss the diagnosis. I've seen patients treated in so many ways and seen patients that ended up with a neck surgery or fusion surgery because they thought something else was causing the patient's symptoms and they went ahead an operated and then the patient continued to have the symptoms. A lot of times patients will rush into treatment thinking that they know the cause, thinking that's it's coming from a certain point, but it is not.
Q: Is physical therapy used to treat a scapular muscle imbalance (a diagnosis Fultz received last year) similar to the physical therapy used to treat TOS?
A: In certain ways, maybe. The idea is the same, but not identical. Physical therapists know which muscles need to be calmed down and the ones that need to be more active. In a scapular imbalance, one of the muscles is weak and it pulls or makes the scapula feel abnormal. With thoracic outlet syndrome it would be a different area that is the focal point.
Q: Could a misdiagnosis of scapular muscle imbalance be possible for a patient that has thoracic outlet syndrome?
A: It could be. It's possible. One of the symptoms that I've seen in the thoracic outlet patient is that they feel like some of their discomfort is down by the scapula and certain movement of the scapula, when they move posteriorly and move the scapula back it feels better, and when they go forward they feel that they have more pain, and I think that's a movement that could open the outlet and close the outlet. So the pain experienced could be very similar.
Q: What type of physical therapy is used to treat TOS?
A: Extension exercises of the neck, stretching, opening the area by getting the muscles to expand, getting the muscles of the neck to relax. The idea is that some of these muscles, when they are tight they spasm, particularly after major stresses. Tightness in the neck muscle is what leads into that neuro-compromise of the brachial plexus coming out. Also, massage therapy, ultrasound therapy, application of some neuro-electric stimulation to relax the muscles. Sometimes we use systemic muscle relaxers and sometimes that works, sometimes it doesn't, it's different from one patient to another. There are a lot of stretching exercises used to get the muscles to relax that can help a patient significantly.
Q: What sort of time frame should a patient begin to see improvement or relief?
A: If the patient has six to eight weeks of constant physical therapy and they are doing all the exercises and they practice them regularly and faithfully they should see improvement. If they don't see improvement, a possible therapeutic block (injection) should be the next step.
Q: What types of injections and medications are used to treat TOS?
A: Sometimes we inject botox into the scalene muscle and the patient responds very well and can go for a long time without needing anything and their symptoms improve. It doesn't paralyze the muscles, it just relaxes the muscle. Sometimes we use medications that calm nerve conduction a little bit, which can diminish the firing of the nerve and alleviate the shooting pains down the arm. Some patients do very well with those medications, some patients feel very sleepy, though, so they don't like to take it for a long time.
Q: At what point does TOS require surgery?
A: If a patient has exhausted all conservative measures and continues to have persistent symptoms that do not go away, severe enough that there was more compromise with more tingling and numbness and pain, or if there is some vascular compromise where when the arm is in certain positions it changes coloration, then it would require surgery to decompress the brachial plexus. However, I will tell you that the majority of patients respond to a conservative approach of physical therapy and injections.
We definitely try to avoid surgery because to decompress the brachial plexus is not a simple surgery. It's not considered a major surgery, but it's also not minor. Because you're either removing the cervical rib or decompressing a muscle in the neck, so if there's any way we can avoid it, that's better. If we get to the point that there is vascular compromise then surgery could be warranted, for sure.
Q: In the case of an athlete, if after physical therapy they are no longer experiencing symptoms, once they return to normal activity could the brachial plexus become compressed again?
A: That is possible, yes. That's something that unfortunately we tend to advise. I have patients that are professional athletes that do a lot of weight lifting and you can see that their neck muscles bulk in the same way that you see abs, triceps, biceps, and that can cause the problem. We often advise them to work with their personal trainer to offload the neck when it comes to swelling these types of muscles, because the more that they go back into the same program, the more of a chance that these symptoms will come back again.