Solve the Medical Riddle: Her Left Shoulder and Arm Are Painful and Her Fingers Tingle, Fourth Week

Editor’s note: Welcome to our ThirdAge feature that gives you a chance to play medical sleuth as we share the details of what happened when a patient presented with a problem that stumped the physician at first.

The first week of this riddle, the patient reported her symptoms. The doctor referred her to a physiatrist, a specialist in non-surgical physical medicine and rehabilitation. The second week, the physiatrist proceeded with the examination. Both physicians used the components of the classic S-O-A-P notes, which are as follows:

S=Symptoms or Chief Complaint

O=Objective Findings

A=Assessment or Analysis

P=Treatment Plan or Recommendation

Last week, we let you know what some people had suggested as possible diagnoses. This week, the doctor will reveal the actual diagnosis. Then we’ll begin a new riddle for the following month!

The Doctor Reveals the Diagnosis

All of the guesses were excellent but those that came closest to the actual diagnosis were the repetitive stress scenarios mentioned by Maureen and Katie, and the age-related cervical spondylosis that Suzanne’s sister with the long ballerina neck had. However, Diane’s actual condition turned out to be neurogenic thoracic outlet syndrome (TOS).

TOS is a complex clinical entity characterized by various neurovascular signs and symptoms of the arm related to impingement, pressure, overuse, or trauma.

TOS can have either neurologic origin, which is what Diane was dealing with, or vascular origin involving an artery (brachial/axillary) or vein (subclavian).


Some doctors consider a “combined neurovascular TOS” that can involve various components of the brachial plexus, the blood vessels, or both at different sites between the base of the neck and the axilla (armpit).


The arterial form is caused by compression of the subclavian artery, the venous form is caused by compression of the subclavian vein, and the neurologic form is caused by compression of the brachial plexus, a network of spinal nerves.

True (classic) neurologic TOS, which is rare, is caused by congenital anomalies. Usually these anomalies include a taut fibrous band or an extra cervical rib, which may necessitate surgery. Diane did not have these issues.

The physiatrist referred Diane to a physical therapist.For most patients, conservative treatment is recommended. Stress avoidance, work simplification, and job site modification are also recommended to avoid sustained contraction and repetitive or overhead work that exacerbate symptoms.

Chronic pain elements can be addressed through exercise programs, good posture, and self-management.

The potential outlet space can be maximized through a program of stretching and strengthening of the shoulder-elevating mechanism. Trapezius and rhomboid strengthening such as shoulder shrugs and bilateral shoulder retraction while standing or lying prone are useful.