What is Thoracic Outlet Syndrome?
In thoracic outlet syndrome (TOS), patients have symptoms that result from the compression of blood vessels or nerves in the upper chest. In that region, there is a passageway where blood vessels and nerves exit from the chest and provide a supply to the upper extremities. That passageway is called the thoracic outlet. The thoracic outlet is located between the armpit and base of the neck. Symptoms include shoulder, arm, clavicle, collarbone, and neck pain. Patients may also have impaired circulation, leading to discoloration in the extremities and tingling and numbness in the fingers. Bordering the thoracic outlet are “muscle, bone, and other tissues”. Symptoms occur due to “enlargement or movement of these tissues of or near the thoracic outlet”. Weight lifting, which leads to muscle enlargement, as well as injuries, weight gain, lung tumors, or even “an extra rib extending from the neck (cervical rib)” can cause thoracic outlet syndrome, although sometimes the cause is not found. The passageway becomes inadequate for the blood vessels and nerves, as a result of this condition, and the symptoms can be intermittent or constant. People most at risk of thoracic outlet syndrome are those who make heavy use of upper extremities such as dental hygienists, jackhammer operators, the pregnant, the obese, and weightlifters. Another symptoms of this disorder includes weak upper extremities, especially if the arm is extended or above the
shoulder.1 As noted before, TOS can be a result of positional causes or static causes (spasm, enlargement, or abnormalities of the surrounding muscles, a tumor, or a cervical rib). However, the most common causes of TOS are trauma (car accident), repetitive strain injury (non-ergonomic keyboard usage, sports activities), and anatomical defects (extra rib). Typically, symptoms show in the hands, with burning, aching, or sharp pain. Part or all of the hand can be involved, as well as the upper arm and forearm. There may also be neck and pectoral pain, armpit pain, or upper back pain. Tingling and weakness of the hands is possible, and one hand may be colder than the other. In fact, TOS could be the underlying reason behind frozen shoulder, carpal tunnel syndrome, or forward head posture. If the subclavian artery is affected, TOS may be related to a condition called cerebrovascular arterial insufficiency, and it could impact the vertebral artery, which may lead to vision disturbances, including transient blindness, and embolic cerebral infarction. If it is not treated, “TOS can lead to neurological deficits”.2
Thoracic Outlet Syndrome Tests and Types
Healthcare professionals can detect thoracic outlet syndrome during examination, and “certain maneuvers of the arm and neck can produce symptoms and blood vessel “pinching,” causing a loss of pulse”. Adson’s maneuver, for example, is when the healthcare provider moves the shoulder in ways that can result in pinching the artery and nerves to the arm being tested. Other thoracic outlet syndrome tests include EMG and X-ray tests.3 Aside from the Adson’s test, there are other tests such as the “Costoclavicular Manoeuvre, and the “Hands-Up” test or “EAST” test”. There have historically been three types of TOS: neurogenic, arterial, and venous; however, “TOS can involve all three types of compression”. Most cases are neurogenic (compression of brachial plexus nerves). Arterial and venous involve compression of the subclavian artery and vein respectively.4 Doctors perform physical exams, and sometimes a neurologist will be recommended in order to “rule out cervical spine disease or other neurological conditions”. Some other tests that might performed are nerve conduction and vascular studies, chest and cervical spine X-rays, CT or MRI, venogram/arteriogram, and blood tests.5
Thoracic Outlet Syndrome Exercises and Treatments
Conservative treatments include thoracic outlet syndrome exercises that stretch open the thoracic outlet tissues. The exercises are done with weight and without weight in the hands to pull open the outlet into a “relaxed” position. Shoulder-shrug exercises may also be prescribed by the physical therapist or other healthcare professional. These can be done at work or at home. Patients should avoid positions where the arms are held overhead or held out, for long periods of time. The patient should incorporate rest periods into work and should not lift heavy items repetitively. Some patients may need to lose weight. Healthcare providers may prescribe anti-inflammatory medicines (NSAIDs) or muscle relaxants to patients. Sometimes, patients may be recommended for surgery, such as “interruption of the scalene muscle (scalenotomy) and removal (resection) of the first rib in order to spare injury to the affected nerve and blood vessels from ongoing compression”. If the thoracic outlet syndrome impacts the vascular system, surgery is most likely required, but it is rare that surgery is necessary.6 Physical therapy and stretching are common treatments for TOS. One type of stretch is the “hunching” stretch (moving the shoulders forward), and the another is “arching” (moving the shoulder back). Another stretch is to tilt and extend the neck to the opposite side of the injury while the arm is kept down or “wrapped around the back”. Physical therapy includes range of motion exercises that are active and passive, “working up to weighted or restricted sets”. Some of the techniques used in PT (or chiropractic) may include myofascial release or Active Release Technique (ART). Nerve gliding may also be performed; this is done “by extending the injured arm with fingers directly outwards to the side and tilting the head to both sides”. Poor posture and ergonomics aggravate the condition. Ice and heat could also provide relief to patients.7 Venous thoracic outlet syndrome may be treated by thrombolytic medications, anticoagulant medications, or surgery, in order to reduce the risk of clots and pulmonary embolism. To treat arterial thoracic outlet syndrome, patients may undergo surgery, after taking thrombolytic medications (“if necessary, to dissolve blood clots”).8
Massage therapy is one of the treatment options for TOS. Different methods are used, depending on the type of thoracic outlet syndrome. For the anterior scalene syndrome, it is important to loosen the scalenes with stretching and massage. With pectoralis minor syndrome, therapy is designed to loosen the pectoralis minor with stretching and massage, but the therapist will also recommended special exercises to “strengthen the antagonistic musculature of retraction of the scapula”. For patients with costoclavicular syndrome, therapy is meant to loosen tight muscles that are leading to poor posture and slumped or rounded shoulders (subclavius and pectoralis major). The muscles that “resist this postural pattern are strengthened”.9 Chiropractors are also healthcare professionals that can help patients with TOS. Therapy may include a mixture of methods, such as “joint mobilization/manipulation, physical therapy modalities, home stretching exercises, and soft-tissue therapy”. It is important that patients also avoid aggravating positions and that they perform any prescribed home exercises carefully and slowly. A stretch is good, but bouncing the stretches should be avoided, and the exercises should not be done to the point of pain.10 Some common, specific stretches are the ulnar, radial, and median nerve stretches, held for 30 seconds. Patients may even lie down on a vertical foam roller or rolled towel to assist with posture.11 There are also suggested sleeping positions, such as sleeping with the arms at the side when on the back, or holding the arm a particular way when sleeping on the side so that the arm is not tucked up under the pillow and the hand is not higher than face level. Pillows can be used to provide proper support in the correct sleeping positions. Sleeping on the stomach is to be avoided.12
Learn more about frozen shoulder.