Thoracic Outlet Syndrome

What is thoracic outlet syndrome?

  • Thoracic outlet syndrome is a condition where you can get pain in the arm as a result of compression of the nerves and blood supply around the neck/shoulder.

How common is thoracic outlet syndrome?

  • Thoracic outlet syndrome (TOS) is an uncommon condition that can create pain in the neck and arm.
  • It concerns compression of either nerve or blood supply in the thoracic outlet (the area of the body between the neck and the shoulder) region (1).
  • Thoracic outlet syndrome can be categorised into neurogenic (involving nerves) and vascular (involving blood vessels) (1).

Should I worry?

  • Only slightly.
  • Venous thoracic outlet syndrome requires medical investigation but this only makes up 4% of what is already a rare condition.
  • Neurogenic thoracic outlet syndrome, which makes up 96% of cases, is normally resolved with conservative management (4).

Who is most likely to suffer from thoracic outlet syndrome?

  • Males and females between 20 and 50 years of age (2).
  • It is 3-4 times more likely to present in women than in men (2).

What are the common symptoms?

  • Pain or discomfort may present itself in several locations between the neck and shoulder, the upper limb (including the arm) and hand and/or the chest (1).
  • You may experience an altered sensation, weakness, pins and needles or heaviness in the arm and hand (1).
  • You may experience discolouration or a blotchy appearance to the arm and/or hand (5).

What can I do?

  • Modify your activity by avoiding daily activities that aggravate your symptoms.
  • Manual treatment to increase the movement and reduce muscular tightness.
  • Rehabilitation to improve the movement and stability of the area.

How long will it take to recover?

  • This will depend upon several factors including but not limited to medical/lifestyle factors, stage of injury, your ability to follow your rehabilitation and the type of thoracic outlet syndrome you are suffering with.
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1. Introduction

The term ‘thoracic outlet syndrome’ describes compression of the neurovascular (neural and/or blood vessels) structures that pass through the thoracic outlet (1). This condition commonly presents with upper limb symptoms. Thoracic outlet syndrome is usually neurogenic (involving nerves) which occurs in 95%-99% of all cases (2).

When neural symptoms are present, an assessment by a musculoskeletal physiotherapist will establish if the symptoms are a result of cervical nerve root compression (nerve roots exiting your cervical spine) or compression in the thoracic outlet. In some cases, thoracic outlet syndrome can be vascular (involving blood vessels) but both types of thoracic outlet syndrome can occur simultaneously. Neurogenic thoracic outlet syndrome is often referred to as nTOS. On the other hand, vascular thoracic outlet syndrome can be further divided into two categories: venous (vTOS)  and arterial (aTOS). Signs and symptoms will be dependent on the type of thoracic outlet syndrome you have.

Thoracic outlet syndrome is a complex pathology that, if suspected, requires a thorough assessment to establish where the cause of neurovascular compression is. In thoracic outlet syndrome, there are three potential areas of compression (5):

  1. The interscalene triangle (between the first rib and two scalene muscles of the neck).
  2. The costoclavicular triangle (between the first rib and clavicle (collar bone).
  3. The sub-coracoid space underneath the coracoid process (a muscular attachment site for the pectoralis minor muscle on the front of your chest).

The compression element of thoracic outlet syndrome as previously described refers to either neural or vascular or both simultaneously, known as neurovascular thoracic outlet syndrome (8).

Neural compression refers to compression of the brachial plexus (a nerve bundle formed from the exiting nerves of your cervical spine that further divides into peripheral nerves that innervate specific muscles and areas of skin in your upper body) that passes through the thoracic outlet (9). Vascular thoracic outlet syndrome compression refers to two specific blood vessels within the thoracic outlet known as the subclavian (underneath the clavicle) vein and artery (2).

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2. Signs & Symptoms

This condition commonly presents with upper limb neural symptoms such as paraesthesia (pins and needles) in certain parts of the arm and hand (10). You may experience an altered sensation in certain parts of the arm or the hand (11). Signs and symptoms are typically worse when the arm is overhead or reaching for an object. As a result, activities such as overhead throwing, serving a tennis ball, painting a ceiling, driving or typing may exacerbate symptoms (12). The part of the brachial plexus that is affected will determine the specific signs and symptoms you experience.

3. Causes

There are a number of causes of thoracic outlet syndrome which can be divided into intrinsic (within the body) and extrinsic (outside of the body) factors (16).

Intrinsic:

  • A cervical rib (an extra rib above the collar bone).
  • Cervical spine anatomical changes.
  • Spinal changes such as scoliosis.
  • Changes to the anatomical location of the neurovascular structures.
  • Enlargement or shortening of some of the muscles involved in thoracic outlet syndrome.

Extrinsic:

  • Trauma (fracture(s) to the clavicle and/or high ribs).
  • Whiplash.
  • Postural adaptive changes.
  • Repetitive stress injuries (the most common form of sitting at a keyboard for long hours).
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4. Risk Factors

This is not an exhaustive list. These factors could increase the likelihood of someone developing thoracic outlet syndrome. It does not mean everyone with these risk factors will develop symptoms.

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5. Prevalence

In the general population, thoracic outlet syndrome occurs in less than 0.05% of people (4). Thoracic outlet syndrome is the neurogenic form of the condition in 95%-99% of all cases.

6. Assessment & Diagnosis

A musculoskeletal physiotherapist can provide you with an accurate and timely diagnosis by obtaining a detailed history of your symptoms. A series of physical tests may be performed as part of your assessment to rule out other potential causes for such symptoms and to identify the most likely area of neurovascular compression. It is important to establish the location of compression in order to formulate a specific rehabilitation plan to directly address the compromised structures at fault (9). Your musculoskeletal physiotherapist will want to know how your condition affects your day-to-day so that treatment can be tailored to your needs and personalised goals can be established. Radiographic imaging like X-ray and magnetic resonance imaging (MRI) may sometimes be required in those patients that do not respond well to conservative management (14).

7. Self-Management

As part of the sessions with your physiotherapist, they will help you to understand your condition and what you need to do to help the recovery from your patellar tendinopathy. This may include reducing the amount or type of activity, as well as other advice aimed at reducing your pain. It is important that you try and complete the exercises you are provided as regularly as possible to help with your recovery. Rehabilitation exercises are not always a quick fix, but if done consistently over weeks and months then they will, in most cases, make a significant difference.

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8. Rehabilitation

Research is very clear that avoiding compromising positions that promote compression of these neurovascular structures is important to manage your symptoms, in conjunction with a specific exercise protocol to address the structures at fault (9). Conservative treatment appears to be more effective at reducing symptoms, improving function and facilitating return to work when compared to surgery (10).

Below are three rehabilitation programmes created by our specialist musculoskeletal physiotherapists targeted at addressing thoracic outlet syndrome. In most instances, a one-to-one assessment is appropriate to individually tailor targeted rehabilitation, to establish the exact cause of your symptoms and to rule out other conditions. However, these programmes provide an excellent starting point to self-manage your symptoms as well as clearly highlighting exercise progression.

9. Thoracic Outlet Syndrome Rehabilitation Plans

Early Plan

This programme focuses on maintaining a range of movement within the shoulder and neck and appropriate stretches for specific muscles. Advice will be provided in order to help you decrease your symptoms. We suggest you carry this out once a day for approximately 2-4 weeks as pain allows. We can work into pain during these exercises but ideally, it should not exceed any more than 5/10 on your self-perceived pain scale (3).

Early Plan  - Rating

Intermediate Plan

This is the next progression. More focus is given to the neural system with specific neural and muscular strengthening exercises. As with the early programme, some pain is to be expected but ideally, we do not want this to be any more than 5/10 on your pain scale.

Intermediate Plan  - Rating

Advanced Plan

This programme is a further progression with challenging, provocative, compressive positions (i.e. overhead activities). Again, some pain is acceptable but ideally, we do not want it to exceed 5/10 on your pain scale.

Advanced Plan  - Rating
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10. Return to Sport/Normal Life

For patients wanting to achieve a high level of function or return to sport, we would encourage a consultation with a physiotherapist as you will likely require further progression beyond the advanced rehabilitation stage.

As part of a multi-modal treatment approach, your physiotherapist may also use a variety of other pain-relieving treatments to support symptom relief and recovery. Whilst recovering, you might benefit from a further assessment to ensure you are making progress and establish the appropriate progression of treatment. Ongoing support and advice will allow you to self-manage and prevent future reoccurrence.

11. Other Treatment Options

If conservative management fails, imaging may be required to establish the exact cause of neurovascular compression. As such, in some cases, surgery may be required. However, this requirement happens very rarely and should be used as a last resort.

References

  1. Laulan J, Fouquet B, Rodaix C, Jauffret P, Roquelaure Y, Descatha A.(2011). Thoracic outlet syndrome: Definition, aetiological factors, diagnosis, management and occupational impact. J Occup Rehabil.
  2. Smith FC, Winterborn RJ. (2019). Thoracic outlet syndrome. Surgery.
  3. Illig KA, Doyle AJ. (2010). A comprehensive review of Paget-Schroetter syndrome. Journal of Vascular Surgery.
  4. Jones MR, Prabhakar A, Viswanath O, Urits I, Green JB, Kendrick JB, et al. (2019). Thoracic Outlet Syndrome: A Comprehensive Review of Pathophysiology, Diagnosis, and Treatment. Pain Ther.
  5. Freischlag J, Orion K. Understanding Thoracic Outlet Syndrome. Scientifica.
  6. Crosby CA, Wehbé MA. (2004). Conservative treatment for thoracic outlet syndrome. Hand Clinics.
  7. Klaassen Z, Sorenson E, Tubbs RS, Arya R, Meloy P, Shah R, et al. (2014). Thoracic outlet syndrome: A neurological and vascular disorder. Clinical Anatomy.
  8. Hussain MA, Aljabri B, Al-Omran M. (2016). Vascular Thoracic Outlet Syndrome. Semin Thorac Cardiovasc Surg.
  9. Vanti C, Natalini L, Romeo A, Tosarelli D, Pillastrini P. (2007). Conservative treatment of thoracic outlet syndrome: A review of the literature. Europa Medicophysica.
  10. Hooper TL, Denton J, McGalliard MK, Brismée JM, Sizer PS. (2010). Thoracic outlet syndrome: A controversial clinical condition. Part 2: Non-surgical and surgical management. Journal of Manual and Manipulative Therapy.
  11. Ferrante MA. (2012). The thoracic outlet syndromes. Muscle and Nerve.
  12. Chandra V, Little C, Lee JT. (2014). Thoracic outlet syndrome in high-performance athletes. J Vasc Surg.
  13. Kuhn JE, Lebus V GF, Bible JE. (2015). Thoracic outlet syndrome. Journal of the American Academy of Orthopaedic Surgeons.
  14. Watson LA, Pizzari T, Balster S. (2009). Thoracic outlet syndrome part 1: Clinical manifestations, differentiation and treatment pathways. Man Ther.
  15.  Howard L. (2019). Acute pulmonary embolism. Clin Med J R Coll Physicians London.
  16. Sanders RJ, Hammond SL, Rao NM. (2007). Diagnosis of thoracic outlet syndrome. Journal of Vascular Surgery.
Other Conditions in Neck, Shoulders, Upper Arms

Cervical Disc Dysfunction

Disk/joint-related issues that can cause pain, weakness and altered sensation in the neck and arms.

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Cervical Spinal Stenosis

Narrowing of the spaces through which the neck spinal nerves travel which can result in weakness, pain and reduced function.

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Cervical Radiculopathy

Nerve pain originating from the neck and causing pain, altered sensation or weakness in the arm.

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Neck Pain

Pain or discomfort in the neck and/or shoulder girdle, with or without pain referred to the arms.

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