PHILADELPHIA -- 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?
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.
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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.