Do you wake up in the middle of the night with pins and needles or pain in one or both of your hands? This is a common experience for many. Physiotherapists can assist you getting the restful, pain free sleep you desire.  

What can cause your hands to go numb at night?

Numbness, pins and needles, or a burning, prickling sensation (also referred to as paresthesia) are symptoms of sustained pressure on a nerve and usually disappears when that pressure is relieved.1 Most people have experienced temporary pins and needles when they have sat on their foot for too long or fallen asleep with their head resting on their arm. The symptoms can also occur when there is a narrowing of the space through which a nerve or blood vessel travels, causing pressure on the structure.1 Some examples of this include carpal tunnel syndrome (pressure on the median nerve as it passes across the wrist), arthritic changes in the neck (creating pressure on the nerves where they exit the spine) and thoracic outlet syndrome (pressure on the bundle of nerves traveling into the arm from the spine).

The remainder of this article will discuss the causes, diagnosis, and physiotherapy treatment of thoracic outlet syndrome (TOS) specifically.

What is TOS?

The thoracic outlet refers to the space created between the first rib, collar bone, and a group of muscles crossing the front of the shoulder. The blood vessels and nerves that supply the arm must pass through the outlet and under or through the muscles before they enter the arm. (See Diagram #1) At any point in this journey, pressure can be placed on the vessels or nerves causing the sensation of pins and needles or pain. Holding the arm overhead, sleeping with an arm under the head or extreme rotation or bending of the neck can narrow the outlet and cause pressure on the structures. TOS is characterized by pain, paresthesia, weakness, and discomfort in the upper limb.1 It is reported that approximately 8% of the population will experience a form of TOS.2

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Diagram #1

TOS is classified as vascular (vTOS) or neurological (nTOS) depending on whether the blood vessels (artery or vein) or nerves are compressed. nTOS can be further divided into true neurological TOS which happens when a bone or muscle compresses the nerve, or symptomatic (sTOS) when sleeping positions, work postures or activities, or sporting activities create temporary compression of the structures involved.2 Evidence identifies that over 90% of TOS cases are neurological with the majority of those classified as sTOS in nature.2,3

How is TOS diagnosed?

It is very important that the true cause of the symptoms be identified to determine the best treatment plan. As noted earlier, there are several causes for pins/needles or pain and numbness in the hand or arm. Each of these must be ruled out as each will be addressed differently to successfully reduce or eliminate the symptoms. There is no one test or investigation that will consistently diagnose TOS, so the diagnosis is based on a collection of symptoms.1 To obtain a clear picture of the source of the problem, a thorough exam must be completed and may include:1

• A history of symptoms including:
  • The location(s) where the pins/needles or painful symptoms occur
  • The presence of stiffness, swelling or loss of muscle control or size in the hand or arm
  • Any postures or activities that aggravate or initiate the symptoms such as overhead activities, sleep positions, prolonged postures (sitting or lying), carrying a backpack or other items, sustained elevation of shoulder(s), or repetitive use of the hand or arm
  • Any history of previous injuries involving the neck, shoulder or arm or chronic diseases such as heart problems or diabetes which can also lead to paresthesia in the hand or arm1
• A physical exam looking for:
  • Changes in skin color, temperature, or hair growth
  • Pain or symptoms reproduced with pressure on the muscles around the neck, shoulder, or shoulder blade
  • The posture of the neck, shoulder, and shoulder blade at rest and during activity
  • The flexibility of the neck, shoulder, shoulder blade, elbow, wrist, or hand
  • The strength of the muscles that move the neck, arm, or shoulder blade or pain when testing muscle strength
  • Instability of the shoulder joint
  • Abnormal or absent reflexes or sensation in the arm or hand
• Tests designed to provoke symptoms by positioning or moving the neck, shoulder, arm, or hand in specific patterns or postures

Physiotherapists are well trained to complete these assessments and design a treatment plan. They also have the skills and knowledge to identify situations where a referral to a medical doctor may be appropriate. Conservative treatment, including physiotherapy, is the universally accepted first step in treatment for TOS.2,3,4 Surgery may be indicated when conservative treatment is unsuccessful,2,3,4 and may be the first option in the presence of vascular TOS due to the presence of a structural abnormality such as a cervical rib; however, the success and appropriateness of surgical intervention is controversial.

How can physiotherapy help?

Based on the assessment findings, a physiotherapist will design a rehabilitation program that focuses on reducing symptoms and correcting muscle or postural imbalances and misalignments.

Many individuals experiencing TOS have had symptoms for a long period of time and require assistance to understand TOS, become aware of what aggravates or relieves their symptoms, and strategies to reduce these symptoms allowing them to manage or prevent issues in the future.3 An individualized rehabilitation plan may include:3

• Posture re-education and exercises to improve both resting and active postures
• A home program of strengthening and stretching exercises to improve the strength and movement at the shoulder and shoulder blade muscles focusing on improving the control and efficiency of the shoulder girdle3,4
• Hands-on therapy to the neck, thoracic spine, shoulder, and other associated structures to address any misalignments or stiffness may be performed by the physiotherapist, with self-mobilization techniques taught as part of a home program3,4
• Recommendations for modification of workplace ergonomics, resting positions and sleep postures and education about strategies to address postures and activities that may bring on symptoms or make them worse.3,4

If you are experiencing frequent episodes of pins/needles, numbness, and/or pain in your arm, hand, obtaining a physiotherapy assessment is a great place to start your journey to manage your symptoms.

1. National Institute of Neurological Disorders and Stroke: Paresthesia Information Page. Available at https://www.ninds.nih.gov/disorders/all-disorders/paresthesia-information-page
2. Watson LA., Pizzari T., Balster S., Thoracic outlet syndrome part 1: Clinical manifestations, differentiation, and treatment pathways. Manual Therapy. Volume 14, Issue 6, 2009. Pages 586-595 ISSN 1356-689X. Available at https://doi.org/10.1016/j.math.2009.08.007
3. Watson LA., Pizzari T., Balster S..  Thoracic outlet syndrome Part 2: Conservative management of thoracic outlet. Manual Therapy, Volume 15, Issue 4, 2010, Pages 305-314, ISSN 1356-689X. Available at  https://doi.org/10.1016/j.math.2010.03.002 .
4. Peek J, Vos CG, Unlu C, van de Pavoordt HDWM, van den Akker PJ, de Vries JPM. Outcome of surgical treatment for thoracic outlet syndrome: systematic review and meta-analysis. Annals of Vascular Surgery, 2017-04-01, Volume 40, Pages 303-326.