I want to introduce you to Amy. She is in her early 30s, working in an office where she does a lot of computer work, data entry, customer service, and other tasks associated with small office work. Her hours are long, but the nature of the work is such that there are seasonal surges with steady work in between. She is a happy, pleasant and well-adjusted young lady, married with two children. She writes magazine articles and sings for enjoyment.
She came to see me because she had pain in the left side of her chest, radiating down the left arm to the fingers. The arm pain was associated with numbness and tingling. The condition caused her some anxiety because it was recurrent. This pain and numbness had begun the day before she came to see me, but it was far from her first episode. She even sometimes awakens with one or both arms numb and tingling, and this is particularly true of her left arm when she sleeps on her left side.
She went to an emergency room nearby for assessment when it was in its acute stage once in the past. After an extensive (and expensive) cardiac workup, she was told that she had "a muscle strain." Of course, muscle strains are not associated with radiating pain, numbness, or tingling. Nevertheless, this was the label given to her in the emergency room.
She went to her primary care physician about this condition. She was labeled next with a generalized anxiety disorder under the assumption that the recurrent left-sided chest pain that radiated to her left arm was an anxiety attack. She tried to explain that she did not feel anxious prior to the onset of the pain and numbness, but she was referred to a psychiatrist.
The psychiatrist put Amy on anti-anxiety medication. Unfortunately, it did little or nothing to prevent the episodes or to attenuate the intensity of the episodes when they occurred. Eventually, Amy discontinued the medication on her own.
A physical examination showed some decrease in range of motion in her lower neck. The pain she experienced followed a specific nerve as it traveled from its exit point in the neck to her elbow. The numbness and tingling went from her elbow into her thumb and index finger. Her reflexes and muscle strength were quite normal. She could exacerbate the numbness and tingling, however, with specific movements of her neck. She exhibited no sign of anxiety throughout the exam.
It was the x-rays of her neck that told the story. Amy is the proud owner of a 13th pair of ribs, perfectly formed in the lower part of her neck. This is a congenital anomaly which is not altogether uncommon, but hers were especially well developed. When these occur, they attach to the lowest cervical vertebra (C7). They are a known cause of recurrent chest pain with numbness and tingling down one or both arms. They are also associated with a lifelong history of awakening with numbness in one or both arms, and an aggravating tingling, numbness, and pain when the arms are raised, such as when painting, hanging wallpaper, reaching for a book, etc.
The presence of a pair of ribs in the neck can pressurize some of the nerves and blood vessels that exit the thorax and go into the upper extremities. That same source of pressure may cause some irritation, as it did with Amy, on the C-5 nerve that goes to the elbow. A branch of it goes to the pectoralis major muscle in the anterior chest and may cause chest pain. While it is quite common, it is frequently missed in medical exams. Many unnecessary cardiac exams have been triggered by this condition, but emergency room staff often have no choice but to check for cardiac problems to protect the patient as well as themselves.
This condition is called thoracic outlet syndrome (TOS). I have treated many of these successfully. While we cannot cure the condition, we can control it by adjusting the neck and upper thorax and stretching specific muscles that attach to the neck and first rib. Sometimes I will consult a good neuromuscular therapist to reduce the muscle tension in this part of the neck. We can also improve the ergonomics of her workstation by moving the computer monitor to eye level so that Amy does not have to look down to do her work. We may also fit Amy with a custom-made pillow to support her neck while she is asleep.
Amy was relieved to find out that this condition was not in her head after all. However, besides the expense of the cardiac workup, we should point out that Amy has now been to a psychiatrist and labeled with a general anxiety disorder. She does not have an anxiety disorder, but when she went to the psychiatrist, it was billed to her insurance. That means that her insurance company may have already sold this information to be used by companies that may do business with Amy, such as other insurance companies, employers, or mortgage lenders. This could create a nightmare scenario for her. It would be like having something on your credit record that you could not get erased. Once a label has been applied, it tends to stick.
Amy will be just fine. Ironically, the only reason for her to be anxious seems to be what is on her medical record now.