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Annals of the Rheumatic Diseases, 1986; 45, 916-920
The costoclavicular syndrome: a 'new cause'M DE SILVA
From the Department of Rheumatology, Prince Charles Hospital, Merthyr Tydfil, Mid-Glamorgan
SUMMARY Costoclavicular compression in obese, heavy breasted, middle aged or elderly womenfrom tight, narrow brassiere straps is a common cause of neck, shoulder, and arm pain. Clues todiagnosis and simple treatment measures, including the use of a shoulder pad, are described.
Key words: neck-shoulder-arm pain.
Chronic neck, shoulder, and arm pain is a commonsymptom complex for which many patients attendtheir general practitioners and a variety of hospitaloutpatient clinics.The socioeconomic consequences of chronic back-
ache are well recognised, but similar information onchronic neck, shoulder, and arm pain is scanty.Nevertheless, the cost in lost working hours and thedemand on medical time must be considerable.
This paper describes a common, poorly under-stood, and hitherto undescribed cause of this condi-tion. Awareness of its existence and simple remedialmeasures will reduce morbidity and the demand onlimited resources.
AETIOLOGYThe costoclavicular passage is one of three passages
Accepted for publication 13 May 1986.Correspondence to Dr M De Silva.
that consitute the thoracic outlet; the others are thesuperior thoracic outlet and the costoscalenehiatus.' The neurovascular bundle is vulnerable tocompression in each of these situations. The costo-clavicular passage is formed by the clavicle antero-laterally, the first rib medially, and the scapulaposteriorly (Fig. 1).The costoclavicular syndrome was first described
in soldiers with loaded knapsacks, who developedpain, numbness, and fatigueability of the arms asthey stood at attention.2 The mechanisms of com-pression involved downward movement of the clav-icle against the first rib, with a resultant tendency toshearing of the neurovascular bundle. This samemechanism is thought to explain subclavian veinthrombosis often precipitated by prolonged heavyexercise of the upVer extremities-the Paget-Schroetter syndrome.A similar mechanism operates in usually obese,
ROOTS OF,BRACHIAL PLEXUS
Fig. 1 Schematic diagram oftheanatomy of the thoracic outlet.
ARTERY & VEIN
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The co stoclav'icullar syndromze 917
middle aged or elderly women. Tight, narrowbrassiere straps supporting heavy breasts cut intothe soft tissues around the shoulders and exert directdownward pressure on the clavicles, usually aroundthe junction of the mid and lateral thirds. Ascissoring action of the clavicle against the first ribnarrows the costoclavicular passage and shears theneurovascular bundle. Subluxation of the lateral endof the clavicle relative to the acromial process of thescapula also results. Subjects have a tendency tostoop and be 'round shouldered', developed as aninvoluntary measure to relieve pressure on theirshoulders. This further narrows the costoclavicularpassage by pushing the scapula forwards.
PRESENTING COMPI AINTSPain or ache sometimes accompanied by stiffness inthe neck and shoulders, pain, paraesthesiae, andfatigueability of the upper limbs are the mainpresenting complaints. Symptoms are usually bi-lateral, though more pronounced on the dominantside. They are aggravated by work and exercise,particularly carrying heavy shopping bags. Symp-toms are relieved by rest and sleep, are minimal orabsent in the morning, and become pronounced asthe day progresses. Patients occasionally complainof puffy blue hands.
[)I A G N O S I S
A high degree of suspicion, particularly in thevulnerable group, i.e., obese, heavy breasted,middle aged or elderly women, is essential. The
average patient has had symptoms for severalmonths or years and has attended several differentclinics, e.g., accident, orthopaedics, neurology,rheumatology. She has had no relief from a varietyof tablet and physical treatments and is labelled ashaving cervical spondylosis or brachialgia. Thepatient usually appears with a cervical collar, eitherin situ or in a bag.
EXAMINATIONThe most important clues to diagnosis are the deepgrooves on both shoulders where tight, narrow brastraps have cut. deeply into the underlying softtissues (Figs 2-4). Direct downward pressure with aforefinger in the groove reproduces symptoms.Invariably, there is tenderness over the acromiocla-vicular joint. Movements of the neck and shoulderare free. The former are painless, but shouldermovements may be slightly painful because ofosteoarthritis of the acromioclavicular joint. Thereis no muscle wasting or weakness.
Paraesthesiae when present are likely to involvethe thumb and all fingers and sometimes the wholelimb. They differ from the paraesthesiae of carpaltunnel compression in their distribution and timing.Phalen's and Tinel's signs are absent. Some patientscomplain of puffy blue hands. They lack the classiccolour changes of Raynaud's phenomenon and areunaffected by cold. The normal appearance of thehand in the costoclavicular syndrome helps to differ-entiate it from the shoulder-hand syndrome, whereit is shiny, swollen, warm, and hyperaesthetic.
! | Fig. 2 Brassiere straps cuittintg,g | deep/y itito the underlying soft/~'- tissue
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Fig. 3 Croovevs onshou(lerls (call b
Fig. 4 Grooves osl hslould(er.s ((aiibe clearlx' seetn.
Patients with this form of costoclavicular syn-drome are usually younger than those with polymy-algia rheumatica, customarily a disease of the oversixties. In polymyalgia rheumatica shoulder stiffnessis prominent and bilateral and may be accompaniedby symptoms of systemic upset or arteritis, e.g.,visual disturbances, headache, etc. Great care mustbe taken to exclude the other causes of neck,shoulder, and arm pain (Table 1).
Radial pulses are present, equal, and of goodvolume. Both Adson's manoeuvre and the costocla-vicular manoeuvre are negative. The former is
sometimes positive when the neurovascular bundleis compressed in the costoscalene hiatus and thelatter when compression occurs between the clavicleand an abnormally curved or thickened first rib.These tests are of little use since a positive result,i.e., partial obliteration of the radial pulse, may beobtained in some normal subjects.
In patients with this 'new' syndrome partialobliteration of the radial pulse is sometimesachieved by applying direct downward pressure onthe groove around the shoulder with the patientcarrying a heavy load. The chances of obtaining a
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The costoclavicular syndrome 919
Table 1 Causes ofchronic neck, shoulder, and arm pain
Traumatic -old whiplash injury of the neck (including compensation syndrome)-old fracture
Occupational-porters (meat porters' neck)-painters and decorators-usually induced by painting ceilings, heights,
looking up for prolonged periods2 Cervical spondylosis
Cervical disc lesions3 Thoracic outlet syndrome, including cervical rib
costoclavicular syndrome4 Inflammatory arthritis of the neck and shoulder
- rheumatoid-ankylosing spondylitis- seronegative arthritis
5 Lesions of the shoulder, tendonitis, bursitis, rotator cuff lesions6 Osteomalacia
OsteoporosisPaget's disease
7 Polymyalgia rheumatica8 Shoulder-hand syndrome9 Referred pain, e.g. retropharyngeal pathology, Pancoast's tumour, secondary deposits10 Rare-angina, gall bladder pain
positive test are enhanced by fatigue, which sets inafter the patient has carried the load for 10-15minutes. This manoeuvre is unnecessary, cumber-some, rarely practicable in a busy outpatient clinic,and above all uncomfortable for the patient.
INVESTIGATIONSPatients have often been extensively investigated.No abnormalities are detected on routine bloodtests, full blood count, erythrocyte sedimentationrate, and immunological tests for inflammatoryarthritis. The long duration of symptoms, normalblood tests, and x rays usually showing no more thanminimal degenerative change of the cervical spineand acromioclavicular joint exclude most otherconditions to be considered in the differentialdiagnosis.The approximation of the clavicle to the first rib
that occurs when direct downward pressure isapplied on the grooves of the shoulder or on loadingis difficult to demonstrate radiologically. This is dueto technical difficulties in obtaining radiographs ofcomparable quality and of placing markers on thefirst rib. The subluxation of the acromioclavicularjoint may sometimes be seen.
MANAGEMENTA clear explanation of the underlying mechanismfor the symptoms, preferably with the aid of a plasticmodel, is most important. The next step is theelimination of the cause of symptoms. Patients mustbe advised to wear either strapless brassieres or
Fig. 5 Diagram showing shoulder pads in place-threadedthrough broad brassiere straps.
brassieres with broad straps with a pad threadedthrough the strap and placed in position on theshoulders (Fig. 5). These measures help to distributethe downward force exerted by the straps. Thestraps must not be too tight. Patients must avoidcarrying heavy shopping bags. The use of a shoppingtrolley solves this problem. Attention to posturedirected at avoiding stooping and shoulder girdleexercises helps. Weight reduction though seldomresulting in significant reduction in the weight of thebreasts helps, if only to increase the sense of generalwellbeing.
Pain and tenderness in the acromioclavicular jointusually respond to a reduction of the distracting
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forces on the joint produced by the measures aind to Mrs Janice Sharpe of the Department of Medical Illustrat-outlined. Some may need treatment with local ice or tion, University Hospital of Wales. Cardiff. for Figs I and 5.heat and simple analgesics. Occasionally an injec-tion of corticosteroid and local anaesthetic into the Referencesacromioclavicular joint may be required. In extreme 1 Pollak E W. Surgical anatomy of the thoraicic outIct syndromeic.cases surgical reduction of breast size by mammo- Stirg CGvtecol Obstet 198ff; 150: 97-l1)3.plasty produces excellent results. 2 Falconcr M, Wcddel G. Costoclavicular comprcssion of thesubclavicular arterv atnd vein. Lat1cet 1943: ii: 534-44.
My thanks to Mrs Elainc Thomas, secretary, Postgraduatc Ccntrc,Princc Charles Hospital. Mcrthyr Tydfil, for typing the mainuscript
". I I. *..W E*-..
3 Hughes E S R. Collectivc review; venous obstruction in upperextremity (Paget-Schrocttcr's syndrome): review of 320 CasCs.Siurg Gsvnecol Obstet 1949'3 88 (suppl): 89-127.
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