Thoracic Outlet Syndrome
Do you experience tingling or pain in your arm or hand? It is possible that the culprit may be Thoracic outlet syndrome (TOS). This condition is caused by compression of nerves or blood vessels (or both) through the area between the base of the neck and the armpit (the thoracic outlet). This area is surrounded by muscle, bone and other tissue and anything that results in enlargement or movement of these structures can cause thoracic outlet syndrome. These causes might include:
- Head forward and shoulder forward posture (the most common factor)
- Muscle enlargement (such as from weight lifting)
- Weight gain
- An extra rib from the neck at birth (cervical rib)
- Tumours at the top of the lung (very rare)
- Sometimes no specific cause is found.
Symptoms of thoracic outlet syndrome include:
- Neck, shoulder, and arm pain
- Arm, hand or finger numbness
- Arm and hand weakness
- Impaired circulation to the extremities (causing discoloration)
- Symptoms may be bilateral (both sides) but is more typically unilateral (one side only)
Diagnosis: There is currently no single clinical sign that makes the diagnosis of TOS with “certainty”, however there are several accepted methods used. These include:
- Electromyography or EMG (nerve conduction study)
- Arm Elevation Tests – Adson’s Maneuver, EAST test, Costoclavicular Maneuver, Allan’s Test (these test can be performed by your physician or your therapist).
- Scalene Blocks/Injections
- Computed Tomography (CT) Scan
- Magnetic Resonance Imaging (MRI)
- Doppler Arteriography (tests the force of the arterial flow through the radial arteries)
- Ultrasound Imaging
Treatment of the thoracic outlet syndrome is typically successful with conservative measures involving massage and manual therapy on the musculature surrounding the chest and shoulder. The patient is then given specific exercises to perform at home with the goal of opening up the chest cavity and lengthening shortened muscles in the chest (thoracic) region.
Patients should avoid prolonged positions with their arms held out or overhead. For example, it is best to avoid sleeping with the arm extended up behind the head. It is also helpful to take short stretch breaks at work to minimize muscle fatigue and tension and. Patients should avoid sleeping on their stomach with their arms above the head. They should also not do repetitive lifting.
Some patients with severe, resistant symptoms can require surgical operations to open the thoracic outlet, but this happens in only a small minority of patients. These procedures include removal (resection) of the first rib in order to spare injury to the affected nerve and blood vessels from ongoing compression.
The following exercises are all helpful in management of TOS. The information below can be found in it’s complete form at The Summit Medical Group’s TOS page.
- Scalene stretch: This stretches the neck muscles that attach to your ribs. Sitting in an upright position, clasp both hands behind your back, lower your left shoulder, and tilt your head toward the right. Hold this position for 15 to 30 seconds and then come back to the starting position. Lower your right shoulder and tilt your head toward the left until you feel a stretch. Hold for 15 to 30 seconds. Repeat 3 times on each side.
- Pectoralis stretch: Stand in a doorway or corner with both arms on the wall slightly above your head. Slowly lean forward until you feel a stretch in the front of your shoulders. Hold 15 to 30 seconds. Repeat 3 times.
- Scapular squeeze: While sitting or standing with your arms by your sides, squeeze your shoulder blades together and hold for 5 seconds. Do 3 sets of 10.
- Arm slide on wall: Sit or stand with your back against a wall and your elbows and wrists against the wall. Slowly slide your arms upward as high as you can while keeping your elbows and wrists against the wall. Do 3 sets of 10.
- Thoracic extension: While sitting in a chair, clasp both arms behind your head. Gently arch backward and look up toward the ceiling. Repeat 10 times. Do this several times per day.
- Rowing exercise: Tie a piece of elastic tubing around an immovable object and grasp the ends in each hand. Keep your forearms vertical and your elbows at shoulder level and bent to 90 degrees. Pull backward on the band and squeeze your shoulder blades together. Repeat 10 times. Do 3 sets.
- Mid-trap exercise: Lie on your stomach on a firm surface and place a folded pillow underneath your chest. Place your arms out straight to your sides with your elbows straight and thumbs toward the ceiling. Slowly raise your arms toward the ceiling as you squeeze your shoulder blades together. Lower slowly. Do 3 sets of 15. Progress to holding soup cans or small weights in your hands.
For more on information on Thoracic outlet syndrome you can also go to Nicholas Institute of Sports Medicine and Athletic Trauma’s page.