THORACIC OUTLET SYNDROME

I see many people who complain of numbness and weakness in their arm or numbness and tingling going down the arm. Usually I think of a pinched nerve in the neck, or carpal tunnel syndrome. A rare condition that is not uncommonly diagnosed is Thoracic Outlet Syndrome ( TOS ). Yankee pitcher Phil Hughes was also thought to have this recently, although this was later ruled out.

Thoracic Outlet Syndrome is compression of the neuro-vascular structures in the supra-clavicular region of the shoulder. In lay terms, this is the area between the base of the neck and the shoulder -just where a woman's bra strap lies. The actual anatomic Thoracic Outlet is an interval between the clavicle (collarbone) on top and the first rib below. The area is covered by the scalene muscles in the front and back. These muscles extend from the sides of the upper spine in the neck down to the first rib. Passing through the Thoracic Outlet are the subclavian artery and vein and major nerve bundles ( the Brachial Plexus ). These nerves branch off and descend down the arm. It's blood supply is from the artery.

Rarely, people may have an extra rib -a cervical rib - which abnormally comes off of the C7 vertebra. This, along with tight scalene muscles, can compress the vascular and nerve structures and produce numbness when the arm is overhead.

TOS can be congenital or developmental. It can be post traumatic or be associated with a fractured clavicle. It is more common in woman. It can be aggravated by obesity or enlarged breasts. Or, from weak shoulder muscles like the Traps. But, it may occur for unknown reasons.

Patients will complain of numbness and perhaps some subtle finger weakness or loss of dexterity. Frequently symptoms occur at night, perhaps due to overhead positioning of the arms over the pillow. Commonly the 4th and 5th fingers are numb, and this is frequently a tip-off for me.

Pulse alterations with deep breaths ( Adson Test ) or overhead positions are common with TOS and raise suspicions.

Work-up includes neck and shoulder x-rays, and perhaps an MRI, EMG's, or a vascular surgery consult. Differential diagnosis includes a cervical disc herniation; a peripheral nerve compression syndrome(carpal tunnel or ulnar neuropathy) ; or, rarely, a lung tumor.

Thoracic Outlet Syndrome is usually treated conservatively -ergonomic and positional changes , and, physiotherapy to strengthen the Traps and other shoulder muscles. Surgery is rare. The first rib and tight scalene muscle is removed and this will cure the condition. But, most people with this do not require surgery.

PLATELET RICH PLASMA

PLATELET RICH PLASMA ( PRP ) is on the cutting edge of Orthopedic Surgery. Platelets which aid in blood clotting also contain growth factors which are thought  to enhance tissue healing.

Even a popular magazine like SHAPE ( April 2011 ) mentions treatment with PRP.

Blood is drawn, a vial of blood is spun down: the plasma is separated from the red cells. A fibrin clot is harvested -either in the shape of a round sphere or a flat disc. This clot is sutured over a surgical repair of perhaps a Rotator Cuff or an Achilles Tendon that was torn. Or, perhaps platelet enriched fluid is injected under the skin -along a partially torn or inflamed Achilles Tendon to promote healing.

I have personally used it after repairing  rotator cuff tears. Suturing the disc over the repair may take another 5-10 minutes of surgical time and must be done carefully and meticulously,but it is no big deal, and we hope insures a better surgical result.

But does it ????

Two recent studies independently presented at the recent Academy of Orthopedic Surgeon's Annual Meeting and the American Orthopedic Society for Sports Medicine , respectively, found that PRP enhancement does not make a difference. Studies split between surgical patients with rotator cuff repairs who did have a PRP clot supplementation and those who did not, really had no statistical difference in outcome. It did not matter. Each study included around 80 patients. Ultrasound was used to access healing between 6 and 12 weeks post-op and no significant differences were noted between those patients who were treated with PRP and those that were not.

Yet, is there any harm to this? No, not really.  It can't hurt. There is no added risk -except perhaps infection from contamination. But, this is most unlikely. And, surgeons always like to feel that  doing something extra may improve the outcome.

But, if these studies prove to be valid and are supported by future studies, will insurance companies agree to pay for this supplementary procedure? Or will patients pay out of pocket ? The cost could be $ 1000 or more.

LITTLE LEAGUE PITCHERS SHOULD LIMIT THEIR INNINGS

A recent article in the American Journal of Sports Medicine studied a correlation between excessive pitching and elbow and shoulder injuries.

It is well known that Little Leaguers should not throw curves , but the above paper (March 2011) evaluated 481 male athletes between the age of 9 and 14 who pitched more than a 100 innings -or-pitched less than a 100 innings per year.

Those who pitched over 100 innings ( 29 children) four sustained an injury that either led to surgery or to retirement from baseball. Thus, a 14 % risk.

Young pitchers who only threw less than a 100 innings (the remaining 452 children) only had 20 such injuries and a 4 % risk of long term problems.

This population was followed over ten years and the conclusion was that young pitchers who throw more than 100 innings a year have 3.5 times the risk of sustaining a serious shoulder or elbow condition.

Sure, there may be some technical criticisms of this study -relatively small sample size, for example. But parents should be aware of these risks and ask themselves if it is worth it.

For more information go to stop sports injuries  (   http://www.stopsportsinjuries.org/   )