Thoracic Outlet Syndrome
This condition is often misdiagnosed or diagnosed late, and has an increased incidence in musicians who spend many hours in positions that predispose them to it, especially when repetitive movements are involved. Violinists, violists, flautists and drummers are at risk, as are other musicians who spend long periods with their arms elevated making repetitive movements, and there is a higher incidence in females and an average age of onset of 20 to 50 years of age, although high performing young musicians in their teens who practise excessively are also at increased risk of developing it. Students in music schools and conservatoires not infrequently develop the condition. Thoracic outlet syndrome can lead to severe and serious sequelae and can be career-threatening, although it is treatable.
It is defined as compression of one or more of the neurovascular structures which traverse the thoracic outlet, which may affect neurological or vascular structures depending on which components of the neurovascular bundle (the brachial plexus and subclavian artery and vein) are compressed. Symptoms can be neurological (most common), vascular, arterial (rare but very important as this can lead to ischaemia of the arm), or mixed.
Predisposing factors include congenital abnormalities affecting the thoracic outlet (10% of patients with cervical ribs develop the condition), poor posture, repetitive stress , long periods of having the arms elevated, hyperextension injuries, fracture of the clavicle, prolonged physical or emotional stress, and over-practising.
Symptoms are often initially attributed to other conditions, and can include pain in the neck, shoulder and/or upper arm, chest pain, problems with fine hand and finger movements (string players may report a loss of vibrato quality or fine coordination), aching of the forearm, numb fingers, Raynaud’s , swelling of the arm, or even ischaemia of the arm in the event of a subclavian artery clot. If not treated effectively, thoracic outlet syndrome can wreck careers and can lead to chronic pain syndromes.
Investigations may include XR of the cervical spine (to exclude cervical ribs), CXR, nerve conduction studies, CT angiography, and MRI of the neck, clavicle and shoulder.
Prompt referral and treatment is required—in the event of neurogenic symptoms, for relief, and in the event of venous or arterial compression for thrombolysis and/or thoracic outlet surgical decompression, which usually requires cervical or first rib removal on the affected side. Neurogenic thoracic outlet syndrome usually improves with conservative measures, which may include rest, change of playing technique and instrument set-up, improvement in posture, taking more breaks when practising, physiotherapy etc. Surgical management may be required if conservative measures are not successful. As stated above, this may consist of first or cervical rib removal, but scalenectomy and brachial plexus neurolysis may also be used.
A recent study of 5 professional musicians (3 violinists and 2 violists) who developed thoracic outlet syndrome found that all 5 managed to resume their playing careers following successful surgery for the condition.