Thoracic Outlet Syndrome (TOS) is a complex and controversial condition in which the nerves and/or blood vessels in the thoracic outlet are compressed. The thoracic outlet is the area between the base of the neck and the armpit, including the front of the shoulders and chest.
The term ‘thoracic outlet syndrome’ was originally coined in 1956, to indicate compression of the neurovascular structures in the interscalene triangle. Since then, the condition has emerged as one of the most controversial topics in musculoskeletal medicine and rehabilitation. This controversy extends to almost every aspect of the condition, including the definition, the incidence, the pathoanatomical contributions, diagnosis and treatment.
TOS affects mainly the upper limbs, with signs and symptoms manifesting in the shoulders, neck, arms, hands and sometimes fingers. In rare cases, the condition can lead to eye and vision problems.
Symptoms of TOS
Due to the many variations in cause and symptoms, TOS is a clinical controversy.
The National Center for Biotechnology Information reports that TOS is a frequently overlooked peripheral nerve compression that creates difficulties for the clinician regarding diagnosis and management.
The symptoms of TOS range from an aching pain in the neck, shoulder, arm, or hand, as well as pain, numbness, or tingling in the forearm and the fourth and fifth fingers of the hand. The pressure can limit blood flow to and from the arm, causing swelling, redness, and fatigue. Many sufferers of thoracic outlet syndrome have trouble performing overhead activities. Some experience swelling or discoloration of the arm as well as a depression in the shoulder.
Pain can be present on an intermittent or permanent basis. It can be sharp/stabbing, burning, or aching. Pain can also be in the side of the neck, the pectoral area below the clavicle, the armpit/axillary area, and the upper back (i.e., the trapezius and rhomboid area). Discoloration of the hands, one hand colder than the other hand, weakness of the hand and arm muscles, and tingling are commonly present.
Types of TOS
Currently, TOS is classified into three main categories, named according to the cause of the symptoms; however, these classifications are part of the condition’s controversial status because TOS can involve all three types of compression to various degrees.
The compression can occur in three anatomical structures: arteries, veins and nerves; it can be isolated, or, more commonly, two or three of the structures are compressed to greater or lesser degrees. In addition, the compressive forces can be of different magnitude in each affected structure. Therefore, symptoms can be variable.
- Neurogenic thoracic outlet syndrome: This condition is related to abnormalities of bony and soft tissue in the lower neck region (which may include the cervical rib area) that compress and irritate the nerves of the brachial plexus, the complex of nerves that supply motor (movement) and sensory (feeling) function to the arm and hand. Symptoms include weakness or numbness of the hand; decreased size of hand muscles, which usually occurs on one side of the body; and/or pain, tingling, prickling, numbness and weakness of the neck, chest, and arms.
- Venous thoracic outlet syndrome: This condition is caused by damage to the major veins in the lower neck and upper chest. The condition develops suddenly, often after unusual and tiring exercise of the arms. Symptoms include swelling of the hands, fingers and arms, as well as heaviness and weakness of the neck and arms. The veins in the anterior (front) chest wall veins also may appear dilated (swollen).
- Arterial Thoracic Outlet Syndrome: The least common, but most serious, type of TOS is caused by congenital (present at birth) bony abnormalities in the lower neck and upper chest. Symptoms include cold sensitivity in the hands and fingers; numbness, pain or sores of the fingers; and poor blood circulation to the arms, hands and fingers.
Causes of TOS
According to clinical evidence, the disorders caused by TOS are not well understood. When the shoulder muscles are too weak to properly stabilize the collarbone, the bone can slip down and forward into the thoracic outlet. The bone puts pressure on the nerves and blood vessels in this small passageway, creating the various symptoms. Poor posture rapidly aggravates TOS.
The following may increase the risk of developing thoracic outlet syndrome:
- Participating in sports that involve repetitive arm or shoulder movement, such as baseball, swimming, golfing, volleyball and others
- Repetitive motion injuries from carrying heavy shoulder loads
- Trauma to the neck or back (whiplash injury)
- Poor posture
- Weightlifting
- Pregnancy
- Anatomical abnormality causing an extra first rib
- Tumors or large lymph nodes in the upper chest or underarm area
- Stress or depression
- Sleep disorders
Often, there is no direct cause found in patients suffering from TOS, which leads to one of the controversial points on the condition.
Chicken or egg?
Since TOS is often the underlying cause of conditions such as frozen shoulder, carpal tunnel syndrome or forward head posture, it is difficult to pinpoint true cause or to determine which came first, TOS or a related condition.
Another clinical puzzle is that the symptoms of TOS mimick other conditions that can produce similar symptoms, such as rotator cuff tear, cervical disc disorders, fibromyalgia, multiple sclerosis and complex regional pain syndrome.
Who is affected by TOS?
Thoracic outlet syndrome can occur in people of all ages and gender, though recent studies have shown that TOS is more common in women, particularly middle-aged women, and those with poor muscular development, poor posture, or both. Clinical evidence suggests that TOS affects less than 2% of the population.
The condition is common among athletes who participate in sports that require repetitive motions of the arm and shoulder, such as baseball (especially pitchers), swimming, volleyball, and weightlifting. It’s not uncommon to see musicians and electricians with TOS, as they work long hours with their hands above their heads.
Several major league baseball players have been diagnosed with TOS. In July this year, Mets starting pitcher Matt Harvey, announced that he is opting to have surgery for TOS after saying “his shoulder was dead, his arm was dead, that there was no energy there and that he couldn’t feel the ball” after his last start.
Musician Isaac Hanson suffered a potentially life-threatening pulmonary embolism as a consequence of thoracic outlet syndrome.
UFC fighter Matt Serra had a rib removed to alleviate TOS, as did singer Tamar Braxton.
Diagnosing TOS
NCBI reports that the disagreement regarding the definition of TOS makes the overall incidence of the condition difficult to track. Complicating matters, the recognized prevalence of the diagnosis varies between disciplines. For example, it is estimated that surgeons diagnose TOS 100 times more frequently than neurologists.
In some cases, a thorough evaluation by a neurologist may be recommended to rule out cervical spine disease or other neurological conditions that may be mimicking or causing TOS symptoms.
Additional tests performed to diagnose thoracic outlet syndrome include:
- Nerve conduction studies (to evaluate the function of the motor and sensory nerves)
- Vascular studies (of the arteries or veins)
- Chest X-ray, to rule out cervical rib abnormalities
- Cervical spine X-rays to rule out a cervical rib (extra rib) or cervical (neck) spine abnormalities
- CT scan and (MRI) of the chest
- CT scan or MRI of the spine to rule out cervical spine impingement (pressure), which can mimic neurogenic thoracic outlet syndrome
- Magnetic resonance imaging with angiography (MRA) to view blood vessels
- Arteriogram/venogram (X-ray that uses dye to look at blood flow)
- Blood tests
How to treat TOS
Early identification of TOS can help improve the success of treatment. Thoracic outlet syndrome treatments vary, depending on the type of TOS and symptoms. The goals of treatment are to reduce symptoms and pain.
Start with simple therapy like the doorway stretch:
Treatment of neurogenic thoracic outlet syndrome include:
- Physical therapy / bodywork: The most common initial treatment for neurogenic thoracic outlet syndrome is physical therapy. Physical therapy increases the range of motion of the neck and shoulders, strengthens muscles and promotes better posture. Most patients experience an improvement in symptoms after undergoing physical therapy including deep tissue massage, myofascial release and other bodywork. Of course it makes sense that restoring the posture, flexibility and good biomechanics we’re born with, might be helpful! Watch our how to videos for upper / lower back and chest / shoulders.
- Microcurrent: electromedical devices are an effective, non-invasive pain therapy that can be used as often as needed and provide considerable relief. Using electrical stimulation to treat pain dates back to Ancient Rome, when they would stand on electrical fish at the seashore; thankfully, the method has greatly improved, but even Benjamin Franklin endorsed the use of electrical stimulation to treat pain. It’s the future of medicine (and yes I use it too). Watch Benedick Howard getting neck pain relief with his Denas PCM-6 SCENAR device in the video below:
- Medications: For pain relief, over-the-counter pain medications, such as aspirin, acetaminophen, or ibuprofen may be recommended. A muscle relaxant or cortisone may be recommended for additional pain relief. Just remember that pharmaceuticals are processed by your liver and may cause unforeseen complications. Please try yoga, physical therapy and bodywork first!
- Surgery: In some cases, surgery may be considered if the symptoms continue after all other efforts fail.
Additionally, stretching, acupuncture, breathing exercises, ergonomic desk set-up, motion and posture practices and chiropractic or osteopathic adjustments, are common non-invasive approaches used in the treatment of TOS.
Ice can be used to decrease inflammation of sore or injured muscles. Heat can also aid in relieving sore muscles by improving blood circulation to them. While the whole arm generally feels painful in TOS, some relief can be seen when ice or heat is intermittently applied to the thoracic region (collar bone, armpit, or shoulder blades).
I was diagnosed with thoracic outlet in 2013, I was 25 years old. I have a full cervical rib on my left and a partial on my right. I have bilateral severe compression of my brachial plexus. The specialist I saw wouldn’t do surgery on me because he claimed that I wasn’t troubled enough by it. Fast forward 5 years and I’m still in pain, have moved and changed dr’s 4 times with nothing but, “I don’t think you have TOS.” “Let’s try physical therapy for the 10th time, I’m sure it’ll work now.” I’ve also changed my job and am now going to school for ultrasound… which can cause, you guessed it… TOS!! FML… WILL SOMEONE JUST TAKE THESE THINGS OUT OF MY NECK
Sounds like you could use something more effective than physical therapy. Have you tried chiropractic or any other forms of bodywork?
Hi my name is megan im just browsing threw reading everything. I have a one year old so im pretty active always picking him up putting him down today out of nowhere my left side of chest and pack and part of my arm are hurting so bad like something is pinched the pain is under my left breast all the way threw to my back and in my shoulder but most pain is the back and under breast could this be something like these things?
Hard to say virtually like this. Is it still bothering you? Sounds a little bit like a muscle pull too.
I had an upper extremity arterial bypass 3 years ago due to clotting in my upper left arm. My vascular surgeon was stumped as to why a 47 yr old active woman developed a blood clot. I went undiagnosed. Stayed on eliquis for 3 years. Went through a 10 hour bypass surgery, and multiple wound infections.
Lost all feeling on inner arm, but blood flowed well.
Fast forward 3 yrs later.
I was a passenger in my husbands truck, traveling at about 10 mph, when a women with no headlights rear ended us while traveling about 50 mph. She never put on her brakes.
I waled away but developed symptoms rapidly, post concussion syndrome, and whiplash. Began physical therapy. About a month later, i develop shooting pains in my left arm, gradually symptoms became so bad, lost pulse again in my left arm, i had 2 blood clots again in my left arm. Total occlusion of bypass and a long clot in my lower left arm. Angiograms, 5 days of meds to break up the clots in cicu. New vascular surgeon. Discovers thoracic outlet syndrome. I have an extra rib on my left side. The cause of the blood clots! Arterial deterioration. My artery has an anuerism and clotting likely can gather there. Then release into my left arm. I will have surgery in 2 weeks to remove the rib and repair the artery.
There are other symptoms related to this congenital condition. By the way, have since learned, my daughter has the extra rib, n 2 sons as well have an extra rib.
My question is, i went 3 years with out a clot and then a month after my car accident, i develop 2 clots in left arm. Could the automobile accident that gave me whiplash and post concussion syndrome, triggered these other two blood clots that I developed after the accident?
I think in the artery that has the aneurysm, the blood clots they are in order to try and repair the artery, and a sudden Shar, such as whiplash, could trigger the clock to break off and travel on down my arm. Do you think something like this is possible? Thanks for your advice.
Hi Georgeanne, thanks for sharing your remarkable story! I do know that physical trauma and especially whiplash can destroy a person’s health by triggering fibromyalgia, so what you describe does not sound implausible to me. I would try to get FSM treatment for your concussion. You can read about it in this book https://www.amazon.com/Resonance-Effect-Frequency-Specific-Microcurrent/dp/1623171105
Hi Eric,
For the past 18 months I’ve had a strange issue, that kind of came out of nowhere. When doing weighted bench press in the gym, and only when I finished my reps and would go to re-rack the weight and effectively breaking the tension, I would get a fleeting sharp pain along my clavicle. Essentially once the tension was let go, the sharp pain would occur and last about 1 second, and be fine after. I have no problems or pain pressing the weight itself nor lingering pain afterwards. In that in this area of my chest I would get a _little_ red/flushed skin appearance also, I noticed this when I finished my sessions and headed to the showers and looked in the mirror. This has persisted for the past 18 months, fast forwarding to now I have had the following other symptoms which have cropped up in that time. These can come and go, appear at the same time or sometimes in isolation, but have been experienced largely chronically and have persisted.
– Dull, tight, ache in my right pec (only), possibly my pec minor muscle. Minor in terms of pain but an annoying tight/dullness.
– Dull ache in a spot around my right shoulder blade, possibly my middle/lower trapezius muscle.
– At rare times, and not experienced recently, very slight numbness/feeling in my pinky and outside part of hand. Potentially ulnar nerve or similar entrapment symptomatically.
– Recently, in the past two weeks a rather tight feeling on the right side of my neck down to the upper right side of my trap. Feels like I need to constantly stretch or massage it. Otherwise not painful.
– Two weeks ago I had what felt like a slightly pulled upper right trap that also seemed to radiate around my right shoulder/upper chest, strangely enough if I pressed on my sternoclavicular joint I felt a bit of pain, when doing this I could also feel the same on, or around, my AC joint. Has since healed.
I really don’t know if I’m dealing with isolated injuries or if this is one whole big problem. I did see a sports doctor back in January who commented I had a chest dominate posture and that my upper chest muscles were super tight and needed stretching every day, particularly before bench pressing. He also said I need to gain more strength in my upper back presumably to fix my posture. I also work on a computer all day which does not help my posture/weakness issue at all.
Vinnie, your issues sound ideally suited to massage ball therapy. Stretching may help some – I do a little yoga for that reason every day, but massage balls are far more targeted and in my experience effective. I’d look at the 4 inch balls for your chest and armpit area in addition to our smaller size (2.75 inch) for your traps and back…
I have TOS on the right side could this effect tingling in my left arm as well
I don’t believe TOS is a binary diagnosis. It’s not necessarily that you either have it or don’t have it, as anyone can have a bit of it or a lot of it. So I would guess you may have a bit of it on the left side and more of it on the right side…
Great article! Actually I have been diagnosed myself with vascular TOS in my left hand. I am 35 years old I am right handed. For most of my life I have been going rather regularly to gym or swim….now I am wondering should i continue that sports or stop it?
Thanks,
Tomas
Tomas, check out the microcurrent section I just added for you above. I’ve been doing the shoulder lifts you see in the video now for several weeks and it is very effective therapy…
Oh and swimming could be good therapy because it involves good range of motion movement which will naturally loosen you. Weightlifting at the gym on the other hand causes tightening and probably aggravation of your condition.
Hi! I was curious if a c-spine mri would catch TOS or does it have to be a chest mri. Thanks!
Hi Joanna, that sounds like a question for your doctor. Hypothetically speaking, if I suspected my daughter had TOS, I would have her do massage and physical therapy to release the muscles and tendons around the chest, neck and shoulders to open up the area. Seeing an MD would be my last resort.
I’m suffering from TOS…found out my cervical spine and ribs are shifted…I would strongly advise anyone suffering from TOS see an Upper Cervical Chriopractor…it is helping me tremendously…accompanied with PT modalities it should help
Osteopaths also do this sort of work.
Hi, I have no diagnosis 7months in from having what looked like stroke symptoms(face drop, loss off muscle tone) and numerous syncope episodes. I couldn’t sit in an upright position for 20 days without passing out. I would experience lots of tingling down my arms and in the left side of my face. I had numerous test and all were clear. I have a bulged l5/6 and c6/7 disks. I’ve been to numerous specialists and none can make out what’s wrong. My symptoms now are visual disturbances, raynauds issues, heart palpitations, blue/purple coloured arms when hanging down by my side and white/blanched when above shoulders. My legs are also doing the same thing in certain positions. My right side temple has been swollen and pressure feeling headaches. I’m clear autoimmune disease and ecg all clear. Do you think I could have tos? I’m pursuing my own health ATM as I’m falling on deaf sears other wise. Thanks heaps, Shirleah.
Certainly there are an extraordinary number of symptoms they can develop from structural imbalances that affect the spine and nerves including the important Vagus nerve which passes close to C7… What have you tried? Can you do any exercise or yoga? Tibetan Rites?
Hi Eric,
Can you please recommend a good sleeping position and a pillow for TOS patient, as they toss and turn a lot. They never get a good night’s sleep. Tos combined with a low back stiffness.
Thank you
This is a difficult question to answer – when I had my own neck shoulder problems I purchased a memory foam mattress (and pillow) and it really helped tremendously. Even now 15 years later I still depend on foam to allow me to sleep on my side. However, I think I made a terrible mistake in buying my mattress new, because they are very toxic. Now I only buy used…
One of the hand gets colder than other,this symptom comes in which type of Thoracic Outlet Syndrome ?
I believe it’s likely that one hand would be affected with any of the three types of TOS…
Yeah Eric Jeffrey,this problem obviously comes in following three but could this be solved by bodywork or one has to urdergo some serious medical treatment
I’m a big fan of bodywork and just finished three sessions with an osteopath for neck alignment and found it very helpful. Certainly a great place to start.
Thank you for all this..If you could possibly tell effective exercises to reduce this illness I’ll be more thankful then
I’ve updated the post with 2 videos showing a number of stretching routines that should get you started…
I was diagnosed with tos, I had my rib removed and a scalenotomy. The problems is I still have very tight shoulder blade pain and it hurts to breathe. Any idea what it could be.
In my opinion, these problems are often best resolved through bodywork, not surgery. Try seeing an osteopath, rolfer or chiropractor…
Hi
My wife is in massive pain across her collarbone and behind her shoulder blade. We are mid-diagnosis and have a scan next week. Could this be TOS and what can we do for immediate pain relief….over the counter meds’ are doing nothing
Has she done any massage, rolling or yoga? What’s her posture, flexibility and physical fitness like?
Hi.
None of the above because 4 weeks prior she has slipped a disc in her lumber. It was lying in bed recuperating that has brought on this huge pain in her collarbone and behind her shoulder blade.
Her posture isn’t great but never had problems like this prior to it suddenly coming on
Chris, the fact that lying in bed seems to have induced the pain is a good sign that myofascial release should resolve it. When you stop moving, your connective tissues tighten as they no longer are pushed through their full range of motion. If it were my wife or daughter, I be focusing less on diagnosis and more on therapy, getting her on massage balls. Just make sure not to roll the slipped disc directly.
Hello,
I was officially diagnosed with Neurogenic TOS about 18 months ago. Since then, I have undergone PT for strengthening of my arms/back/chest muscles and I have also changed my diet; drastically reducing sugar and caffeine as they seem to be the most obvious triggers of inflammation and TOS symptoms. Over the past month or so I have slacked in the diet department and I am having more flare ups than I’ve had leading up to falling off the wagon. I’m in the middle of a 4-day episode and am making a move to get back to eating better and starting some kind of PT/exercise.
I know it’s hard work Hannah! How much sun do you get? I follow Dr. Kruse who believes that almost all illness traces back to lack of sunshine exposure, not diet. I also follow a very strict diet in an effort to get everything right…
Can or shoulds you use hear or cold packs at home for TOS? The shoulder that has the troubles is the should of the arm I use a cane with. I already take Muscle relaxers and pain pills. I am looking for an at home treatment between PT/chiropractic visits.
I would venture to guess that heat may aggravate your condition. Cold reduces inflammation and increases circulation which are both good things, but do check with your specialists. Muscle relaxers and pain pills may help you in the short term, but they may also aggravate whatever underlying health issues may have triggered your problem. Most medications tend to deplete magnesium in the body for example.
Just diagnosednafter mri etc etc .59 yr old female
Was told by vascular surgeon thatmy artery is narrowed by a cervical rib but as there is still blood getting through.
Years ago I was diagnosed with Costochondritis but I now think the chest and shoulder soreness is because of TOS. It is very sore after I lift anything heavy or do work in the garden.Can the two conditions be confused by GPS?
What can you suggest to help with the pain?
hi Ann, you might find that extensive myofascial release work resolves either or both conditions. Even if it doesn’t get you to one hundred percent, you would probably experience quite a bit of relief.