Have you ever been frustrated with still having symptoms in your neck and arms or not progressing with treatment due to significant symptoms in your upper body? Then you may be dealing with Thoracic Outlet Syndrome (TOS). TOS is a narrow space between your collarbone and first rib, and is characterized by different neurovascular signs and symptoms involving your neck and upper limb and involves compression of the neurovascular bundle as it exits the thoracic girdle (aka upper back and space between neck and shoulder). More specifically the compression is thought to occur at one or more of these three regions: the interscalene triangle (front of your neck to collar bone), the costoclavicular space (collar bone, shoulder blade, and first rib), and the retropectoralis minor spaces (pecs, anterior chest wall, and subscapularis muscle).
Per WebMD, there are three types of TOS: neurogenic (affects nerves leading from the spinal cord to the neck to the arm, venous (affects veins), and arterial (affects arteries). But about 95% of TOS cases involve nerves, so we will focus on neurogenic TOS.
Most cases involve middle-aged women and the male to female ratio is 1:3. More than 80% of patients are between the ages of 25 and 40 years. It’s often seen in athletes and workers who make repeated arm motions. The typical symptoms per WebMD:
- Pain in the neck, shoulder, or arm
- Numbness (most often reported in all fingers, but worse in the ring and pinky fingers and medial forearm)
- Tingling
- Tenderness (over scalene muscles)
- Swelling
- Weakness
- Discoloration — blue, red, or pale
- Cold hands
There are several causes of TOS, but most frequently the cause occurs after a single episode of neck trauma (ex. motor vehicle accident). It can also be caused by a combination of neck trauma (including microtrauma secondary to repetitive activities) plus an anatomic predisposition. Overhead work activities may lead to this repetitive activity (ex. assembly line work, hair dressing, and cash register operations). The predisposition of someone’s anatomy may cause compression of the brachial plexus. This compression causes an impingement of the neurovascular bundle supplying the upper limb and mainly occurs at the scalene triangle (between the anterior and middle scalene muscles). Additionally, cervical ribs may be more superior or fused with the second rib and cause the area of the thoracic outlet to be smaller. This region is also dynamic; the area or volume changes with breathing and any activity of the neck, ribs, or arm. Per WebMD there are several causes:
- Injuries: Whiplash, a broken collarbone, or other injury can leave scar tissue and inflammation.
- Poor posture: When your shoulders slump, your collarbones can move out of place and press on your nerves. Weak shoulder muscles can cause bad posture.
- Repetitive stress: It can affect people who move their arms in a certain way, like swimmers, volleyball players, and baseball pitchers.
- Physical defects: Some people are born with an extra rib or a thoracic outlet that’s smaller than normal.
- Obesity: Extra weight can put stress on the muscles that support your collarbones.
There are many diagnostic tests for TOS, but most often it is a diagnosis of exclusion. There are many other causes of these symptoms that may mimic TOS, such as herniated cervical disks, rotator cuff injuries, peripheral nerve entrapment, and chronic pain syndromes. The most objective examination is the lidocaine scalene block test, but a MRI, Elvey’s Test, Upper Limp Tension Test (ULTT), Adson Test, and Roos Test or Elvated Arm Stress Test (EAST), may be used to assist with diagnosis.
Management of neurogenic TOS is mainly non-operative. Approximately 60–70% of patients with neurogenic TOS can be successfully treated with conservative treatment. Conservative treatments involve avoidance of activities that make symptoms worse, physical therapy, ergonomic modifications to the workplace, and medication ease pain/swelling and relax muscles. Physical therapy will include stretching (to maintain normal muscle length, decrease stiffness, and improve posture) and extension strengthening exercises (to gain regular muscle length and decrease functional deficits required for ideal posture). Other modalities that may help with pain management of TOS are yoga, massage, meditation, and acupuncture. WebMD recommends conservative management for 8–12 weeks before considering surgery or other interventions.
So, if you are frustrated with still having significant symptoms like pain (in the neck, shoulder, or arm, numbness down arm into your fingers, tingling, tenderness and swelling in the front of your neck, and upper limb weakness, please discuss with your physical therapist and/or MD. There are things that can help you feel better.