Friday, December 13, 2019

PT Pathologies: Thoracic Outlet Syndrome

Thoracic Outlet Syndrome (TOS) is a condition that is caused by the compression of nerves and blood vessels in the area between the clavicle and first rib.  The space between the collar bone and rib is more specifically known as the thoracic outlet.  This narrow space is the home to nerves, blood vessels and muscles.  There are three types of TOS:  neurogenic, vascular and disputed.  Neurogenic TOS is caused by compression of the brachial plexus.  The brachial plexus is a network of nerves that come from your spinal cord and control muscle movements and sensation in your shoulder, arm and hand.  In the majority of thoracic outlet syndrome cases, the symptoms are neurogenic.  Vascular TOS is described as compression of the artery or vein in the thoracic outlet.  The final type, disputed TOS, contains no neurological deficits, however, the patients have TOS symptoms and pain.

        When the tissue in the thoracic outlet is changed or enlarged, TOS is often times the outcome.  There are several causes of TOS, some of the main being trauma, pregnancy, repetitve injuries, weight lifting, weight gain, tumor growth, and birth defects such as having an extra rib.  Some symptoms common in TOS are pain of the neck, shoulder and arm, numbness in the hnd, arm and fingers, decreased circulation to limbs, weakness in arms shoulders and hands.

        Clinical presentation in TOS patients can differ depending on the type of TOS.  With venous obstruction, patients may present with upper extremity swelling.  With arterial obstruction, patients may report color changes of their affected upper extremity, or arm or hand pain.  Patients may have painless atrophy of the intrinsic muscles of the hand, and patients may report difficulty grasping objects as a result of intrinsic muscle weakness.  They may also report sensory loss.  In order to diagnose TOS, one will need to visit a nerve specialist and an experienced neurologist.  A comprehensive medical exam, including neurological exams, complete medical history, imaging studies such as X Rays and or MRI, electro diagnostic studies (EMG) will need to be performed.

         Physical therapists play a large role in the recovery of TOS patients.  The main goal of therapists assisting patients with TOS is to educate them about and improve their postural abnormalities, and decrease muscle imbalances in order to relieve unwanted pressure in the thoracic outlet.  It is the therapists job to explain postural positioning that are high risk and low risk positions for compression  Pain control and range of motion are also areas in which the therapist works with patients.  Stretching muscles such as the upper trapezius, levator scapula, and pecs are important in TOS recovery.  Once motion is regained and pain levels are decreased, strengthening exercises should be incorporated.  Other options include injections including nerve blocking agents and acupuncture.  If the above techniques do not improve a patient's symptoms the surgical route to recovery is an option.  Many doctors only recommend surgery as a last resort choice due to the complications associated with TOS surgery.


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