Scalene Syndrome

December 7, 2018

Thoracic Outlet Syndrome or Scalene Syndrome is poorly understood.  It is significantly confused by Neurosurgeons or Orthopedic Doctors who do not properly examine a patient.  There is a test called an Adson test, where you rotate the neck to opposite side of the arm that’s numb and you abduct the opposite arm away, you stretch the scalene muscles which attach to the 1st and 2nd ribs thereby obliterating the radial pulse, which means the artery that is joining the brachial artery down the arm is compressed causing a glove like numbness with the hand.

This condition is very obvious at nighttime when someone has numbness in the hand where they usually get out of bed and walk around and shake their hand.  The stretching and moving of those muscles slightly with activity reduces the compression of the brachial plexus.

This is confused many times for a nerve compression.  Usually a physician will request an MRI and find a degenerative disk in a high percentage of patients.  This degenerative disk is not correlated with a glove like numbness to the hand.  There is no specific dermatomal distribution as ALL the fingers are numb in a glove-like distribution.  The improvement with a herniated disk in the neck, or a hard osteophytic disk which is present more then 85% of the time, does not correlate with the whole hand.  It correlates with the thumb or a little finger or a portion or weakness of one specific muscle group.

This basically is misunderstood and under-diagnosed.  I see many patients who have come in to have recommended surgery, and they have a scale syndrome or thoracic outlet syndrome.  Thoracic Outlet Syndrome can be related to a possible cervical rib which also contributes to to compression.

Dr. David Roos out of Denver, Colorado over 40 years ago perfected an operation known as First Rib Resection, (I actually assisted in these cases).  These cases are very rare, but the scales syndrome can simply be resolved with muscle stretching.  By stretching the anterior middle scalene where the come from the neck down and attach to the 1st and 2nd ribs behind the clavicle, once these are stretched out (it takes 3-6 weeks minimum), the relief is immediate.  If one exercises these muscles after you stretch them, you can go backwards not forwards.  Exercise tightens these muscles up.  Tightness of these muscles can be due to a minor injury, repetitive exercise, poor posture (forward sloped shoulders) and forward flexed neck.  Lack of exercise contributes to this pain continuing.  The specific focus of stretching with a good Physical Therapist will relieve the problem.  Rarely is their a neurological injury that can be found on a nerve conduction test, and its a primarily a clinical diagnosis.

Palpation of the scalene muscles as it attaches to the 1st and 2nd ribs can many times with a gentle pressure, can cause tweaking of the nerves and create a perception of the sensitivity down the arm.  This is not much different then an Alder Nerve Compression syndrome which can be tweaked on a medial aspect of the elbow going down to the 5th finger.

At any rate, Scalene Syndrome has been known for years and in this day and age of MRI Diagnosis and lack of proper examination, a doctor can jump to the more lucrative financial decision to operate on someone’s neck when in fact, that’s not the case.  I have reviewed many cases, where the surgery was unfortunately already done and the Scalene Syndrome persists because it was the wrong diagnosis and the surgery should not have been performed.

I would encourage all patients to google and research Scalene Syndrome and Thoracic Outlet Syndrome . Patients may have a doctor who’s not really paying attention to a differential diagnosis to all things that may cause numbness of the hand.