Neurogenic Thoracic Outlet Syndrome – Making big headlines lately

If you even remotely follow the NBA you might have heard the ongoing drama regarding the health of Philadelphia 76ers’ young guard, Markelle Fultz. The former number one overall draft pick has begun his once-promising career with a bizarre sudden inability to properly shoot a basketball. You don’t need to be an expert to understand that a player who mysteriously loses his jump shot is both equally unheard of as it is concerning for their future career. After over a year of endless speculation Fultz recently saw a specialist and was diagnosed with neurogenic thoracic outlet syndrome (nTOS).

What is Thoracic Outlet Syndrome?

Thoracic Outlet Syndrome (TOS) is a complex and controversial disorder. Generally speaking, it refers to a very broad group of conditions that stems from the compression of nerves and blood vessels between your collarbone and first rib. As both nerves and blood vessels are potentially affected, TOS can be further subcategorized as either neurogenic thoracic outlet syndrome or vascular thoracic outlet syndrome.

How do I know if I have it?

TOS can be a very difficult diagnosis to make even from a clinician’s standpoint. The number of structures that can cause TOS is enormous as it includes all sorts of different muscles, bones, nerves, etc. Compression of your vessels and nerves can also occur at multiple points in your upper extremity and symptoms of TOS can mimic symptoms of other shoulder and nerve-related pathologies. Consequently, the symptoms for one person will not necessarily be the same for another. Often times the condition is diagnosed by ruling out all other potential pathologies. Statistically, if you do have TOS you are far more likely to have neurogenic thoracic outlet syndrome than its vascular counterpart.

Below are some of the most common symptoms of nTOS:

  • Numbness and/or tingling down the arm into the hands
  • Fatigue of the arms particularly with overhead movements
  • Weak grip
  • Vague shoulder pain

What causes it?

There can be many different causes for developing nTOS. It can range from something as simple as poor posture to something more traumatic such as whiplash from a motor vehicle accident. Certain jobs can also predispose an individual to developing TOS – particularly those involving repeated overhead movements such as hairdressers or assembly line workers. Interestingly, women have been found to be up to four times more likely to develop TOS than males.

Treatment

Before doing any treatment, it is important to first seek out a physiotherapist to get a thorough assessment done to rule out any other potential causes. A multidisciplinary approach involving clinicians from varying healthcare disciplines is generally recommended for both assessment and treatment given how complex TOS can be. If TOS is indeed suspected, then treatment typically involves targeting whatever structures are at fault through rehabilitation, manual therapy and exercise. Education regarding eliminating any behavioural or environmental causes is another important component of treatment.

If you are experiencing any symptoms of thoracic outlet syndrome, come into see one of our Registered Physiotherapists for an accurate clinical assessment today.

References:

https://www.sbnation.com/nba/2018/11/13/18090592/markelle-fultz-jump-shot-history-injury-free-throw

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3101069/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3526474/

Orthopaedic Physical Assessment 6th Edition. Magee.

Acute Ankle Sprain: What does it mean and Where to from here?

What does ‘ankle sprain’ mean?

A sprain is a term used to describe a ligament injury, where the ligament has been over-stretched or sometimes torn. They typically occur due to joint trauma, or a joint being taken past its range of motion. An ankle sprain is therefore, an injury to the ligaments connecting the bones of the ankle joint.

What are normal symptoms?

  • Tender to touch
  • Sudden and intense pain
  • Swelling and bruising
  • Joint stiffness
  • Walk with a limp

What ligaments have I sprained?

The ligaments injured, depend on how you have sprained your ankle

Rolling your ankle inwards

Rolling your ankle outwards

How long until I get better?

Sprains are graded from 1 to 3 based on their severity, with 1 being the lowest and 3 the highest.

Grade 1 indicates mild stretching and damage, with 1-2 weeks for recovery

Grade 2 indicates partial tearing, with 4-6 weeks for recovery

Grade 3 indicates complete tearing, with 3 or months for recovery

Is this a serious condition?

Although painful, this is not a condition you should worry about, as ankle sprains make up 40% of all sporting injuries. However, if you have the symptoms depicted above you should go to the hospital for X-rays.

Management

  • Initial Phase (Limit inflammation and bleeding)
    Rest, with the ankle elevated and compressed
  • Crutches, for the first 24 hours to allow for weight-bearing, without being excessive
  • Gradual weight-bearing, to promote ankle motion

Intermediate Phase (Restore pain free motion)

  • Begins when you no longer experience pain at rest
    Involves moving your ankle actively in all pain free directions
  •  Strengthening exercises can begin slowly
  • An ankle brace can be used to help manage pain with work, however, it is important to not become dependent on it

Advanced Phase (Restore function)

  •  Begins when pain free and swelling is no longer present
  •  Involves advanced exercises that aim to strengthen and reduce the chance of re-injury
  • They should be advised by and done in the company of a trained professional

Avoid

  • Alcohol
  • Cigarettes
  • Stress
  • Overwork
  • Complete rest

Reduce Stress

  • When injured, the body produces stress hormones
  • This places strain on the body, prolonging the healing period
  • This response can be reduced through treatment focusing on the nervous system

Restore Ankle Motion

  • Mobilization techniques directed to the foot and ankle joints will promote movement
  • With this, it may also promote a faster healing time

What if I do nothing?

Doing nothing may result in a longer recovery time.  The tissues may not reach the strength they would have otherwise. The ankle joint may become chronically unstable, which can increase the likelihood of:

  • Re-injuring the ankle
  • Developing osteoarthritis

Osteopathic Treatment

Reduce Pain and Swelling

  • Pain and swelling cause discomfort and limited motion
  • If drawn-out, this can result in a longer than usual healing time and increased risk of re-injury
  • Massage and mobilization can be used to minimize these effects

Written by James Goetz for acesportsclinic.com

 

Reference:

1. Adelaide Crows Sports Medicine Clinic [Internet]. 2017 [cited 2 September 2017]. Available from: http://www.adelaidecrowssportsmedicineclinic.com.au/ankle-sprain/

2. Dubin JC, Comeau D, McClelland RI, Dubin RA, Ferrel E. Lateral and syndesmotic ankle sprain injuries: a narrative literature review. Journal of chiropractic medicine. 2011 Sep 30;10(3):204-19. doi.org/10.1016/j.jcm.2011.02.001

3. Ankle Sprains” When should you be concerned? [Internet]. 2017 [cited 2 September 2017]. Available from: http://www.sportdoclondon.co.uk/ankle-sprains-when-should-you-be-concerned/

4. Inversion Ankle Sprains [Internet]. 2017 [cited 31 August 2017]. Available from: https://gymnasticsinjuries.wordpress.com/2012/10/11/inversion-ankle-sprains/

5. Medial ankle sprain [Internet]. 2017 [cited 2 September 2017]. Available from: https://www.slideshare.net/AwiniMohamed/medial-ankle-sprain-53753126

6. Different Grades Ankle Sprain [Internet]. 2017 [cited 2 September 2017]. Available from: http://iwalk-free.com/injury-resource-center/sprained-ankle/

7. Chan KW, Ding BC, Mroczek KJ. Acute and chronic lateral ankle instability in the athlete. Bulletin of the NYU hospital for joint diseases. 2011 Jan 1;69(1):17.doi: http://www.presentationgrafix.com/_dev/cake/files/archive/pdfs/238.pdf

8. Tiemstra JD. Update on acute ankle sprains. Am Fam Physician. 2012 Jun 15;85(12):1170-6. Available from http://familymed.uthscsa.edu/residency08/MMC/Ankle.pdf

9. Ottawa Ankle Rules [Internet]. 2017 [cited 2 September 2017]. Available from: http://www.bmj.com/content/326/7386/417

10. When It Comes To Physical Therapy, Patients Have To Do The Work [Internet]. 2017 [cited 2 September 2017]. Available from: http://www.chelseafootandankle.com/blog/when-it-comes-to-physical-therapy-patients-have-to-do-the-work

11. Kemler E, van de Port I, Backx F, van Dijk CN. A systematic review on the treatment of acute ankle sprain. Sports medicine. 2011 Mar 1;41(3):185-97. doi.org/10.2165/11584370-000000000-00000

6 Things You Have to Know about Concussion

Concussion. That word has become a hot topic as of late. Most of you have an idea of what a concussion might be. However, there are tons of misconceptions and poor information when it comes to concussion.

More importantly, there is a lot of confusion over what to do when you sustain a concussion.

So let’s try to clear up some of this information…

What is a Concussion?

An injury to the brain that affects the way the brain FUNCTIONS which is NOT the result of structural damage to the brain.  This means that the brain is not functioning normally, but nothing has been damaged within the brain tissue.

Therefore, if you performed imaging of a concussed person’s head (CT scan, MRI etc) nothing would appear.  If it did, this would be more indicative of a more serious brain bleed or stroke.  This is one of the reasons we have such difficulty objectively measuring whether someone has sustained a concussion rather than just relying on subjective symptoms.

How do you sustain a concussion?

There are many ways to sustain a concussion but the important thing to note is that direct impact to the head is not required in order to get a concussion.

Concussion can result from indirect (blow occurs elsewhere on the body and impulsive forces result in injury to the brain) or direct (blow to head, face or neck) forces.

So what is happening within the brain?

Truthfully, we still have a lot to learn.  What we believe is happening is a neuro-metabolic cascade.  In our brain (as well as everywhere else in our body) we have sodium/potassium pumps that open up to bring the metabolites in or out.  When we get a concussion, all the pumps get stretched so they all open at the same time and the axon gets clogged with sodium.  Now we have a lot more sodium then normal that we need to get out.  The only way we can get it out is by using energy (ATP).  The problem is, we get our energy from blood flow and there is actually decreased blood flow to the brain from the concussion. Therefore we have a mismatch – we need more energy and we are getting less.

How do we diagnose a concussion?

Diagnosis can only be made clinically.  It should be made by a trained professional, ideally at the sideline or later within the clinic/hospital.

There is no proven blood test or imaging that can be done to diagnose it.

There must be one or more of the following clinical domains:

  1. Symptoms that fall within 3 categories:
    A) Somatic (i.e. headache)
    B) Cognitive (i.e. feeling like in a fog)
    C) Emotional (i.e. lability)
  2. Physical signs (i.e. Loss of consciousness, amnesia)
  3. Behavioural Changes (i.e. irritability)
  4. Cognitive impairment (i.e. slowed reaction times)
  5. Sleep disturbance (i.e. insomnia)

If experiencing symptoms and/or signs in one of the above areas in combination with an appropriate mechanism to induce a concussion you likely have a concussion.

A trained professional will use outcome measures such as SCAT5 or Child SCAT5 in order to more objectively diagnose concussion. cThis can also be a tool used to monitor progress.

What to do once you suspect a concussion?

  1. The number one rule: NO SAME DAY RETURN TO PLAY. If you are in doubt if they have a concussion, sit them out.
    • If you sustain a second concussion before the first has fully healed you are at risk of developing second impact syndrome. A rare, but fatal, consequence of returning to play too soon.
  2. Monitor the concussed person every 15 min for 4 hours, then regularly for 24-48 hours.
  3. Bring the patient to the ER if any of the following is present:
    • Headache that worsens (one that keeps worsening and worsening)
    • Drowsiness or inability to be woken up
    • Inability to recognize people or places
    • Repeated vomiting
    • Worsening confusion/ irritability
    • Seizures
    • Hemiparesis/hemi-sensory loss
    • Unsteadiness
    • Slurred speech
  4. No alcohol or recreational drugs for 24-48 hours
  5. No aspirin, anti-inflammatories or pain killers for 24-48 hours. This can mask worsening headache or other symptoms.
  6. Do not drive until medically cleared

Recovery

While concussion diagnosis needs to be taken seriously the important thing to remember is that 80-90% of concussions resolve in 7-10 days.

If diagnosed with concussion, the earliest a person can return to sport is 7 days post injury. They should see a trained professional to run through a return to play protocol, and will need medical clearance before returning to sport.

If your concussion symptoms are persistent, our treatment can help.  Our physiotherapist will run through a thorough assessment to determine the main cause of your persistent symptoms and come up with an individualised treatment plan to get you back to sport, work or school sooner.