Thoracic Outlet

Overview

Thoracic outlet syndrome (TOS) is a group of disorders that occur when blood vessels or nerves in the space between your collarbone and your first rib (thoracic outlet) are compressed. This can cause pain in your shoulders and neck and numbness in your fingers.

Common causes of thoracic outlet syndrome include physical trauma from a car accident, repetitive injuries from job- or sports-related activities, certain anatomical defects (such as having an extra rib), and pregnancy. Sometimes doctors can’t determine the cause of thoracic outlet syndrome.

Treatment for thoracic outlet syndrome usually involves physical therapy and pain relief measures. Most people improve with these approaches. In some cases, however, your doctor may recommend surgery.

Symptoms

There are a number of types of thoracic outlet syndrome, including:

  • Neurogenic (neurological) thoracic outlet syndrome. This most common type of thoracic outlet syndrome is characterized 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.
  • Vascular thoracic outlet syndrome. This type of thoracic outlet syndrome occurs when one or more of the veins (venous thoracic outlet syndrome) or arteries (arterial thoracic outlet syndrome) under the collarbone (clavicle) are compressed.
  • Nonspecific-type thoracic outlet syndrome. This type is also called disputed thoracic outlet syndrome. Some doctors don’t believe it exists, while others say it’s a common disorder. People with nonspecific-type thoracic outlet syndrome have chronic pain in the area of the thoracic outlet that worsens with activity, but a specific cause of the pain can’t be determined.

Thoracic outlet syndrome symptoms can vary, depending on which structures are compressed. When nerves are compressed, signs and symptoms of neurological thoracic outlet syndrome include:

  • Muscle wasting in the fleshy base of your thumb
  • Numbness or tingling in your arm or fingers
  • Pain or aches in your neck, shoulder or hand
  • Weakening grip

Signs and symptoms of vascular thoracic outlet syndrome can include:

  • Discoloration of your hand (bluish color)
  • Arm pain and swelling, possibly due to blood clots
  • Blood clot in veins or arteries in the upper area of your body
  • Lack of color (pallor) in one or more of your fingers or your entire hand
  • Weak or no pulse in the affected arm
  • Cold fingers, hands or arms
  • Arm fatigue with activity
  • Numbness or tingling in your fingers
  • Weakness of arm or neck

Causes

In general, the cause of thoracic outlet syndrome is compression of the nerves or blood vessels in the thoracic outlet, just under your collarbone (clavicle). The cause of the compression varies and can include:

  • Anatomical defects. Inherited defects that are present at birth (congenital) may include an extra rib located above the first rib (cervical rib) or an abnormally tight fibrous band connecting your spine to your rib.
  • Poor posture. Drooping your shoulders or holding your head in a forward position can cause compression in the thoracic outlet area.
  • Trauma. A traumatic event, such as a car accident, can cause internal changes that then compress the nerves in the thoracic outlet. The onset of symptoms related to a traumatic accident often is delayed.
  • Repetitive activity. Doing the same thing repeatedly can, over time, wear on your body’s tissue. You may notice symptoms of thoracic outlet syndrome if your job requires you to repeat a movement continuously, such as typing on a computer, working on an assembly line or lifting things above your head, as you would if you were stocking shelves. Athletes, such as baseball pitchers and swimmers, also can develop thoracic outlet syndrome from years of repetitive movements.
  • Pressure on your joints. Obesity can put an undue amount of stress on your joints, as can carrying around an oversized bag or backpack.
  • Pregnancy. Because joints loosen during pregnancy, signs of thoracic outlet syndrome may first appear while you’re pregnant.

How is thoracic outlet syndrome treated?

Early identification of TOS can help improve the success of treatment. Thoracic outlet syndrome treatments vary, depending on the type of TOS you have and your symptoms. The goals of treatment are to reduce symptoms and pain. Your health care provider will recommend the treatment option that is right for you.

Before choosing any treatment, it is important to talk to your health care provider about the potential benefits, risks and side effects of your treatment options.

  • Occupational/physical therapy: The most common initial treatment for thoracic outlet syndrome is occupational/physical therapy. 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 therapy.
  • Medications: For pain relief, over-the-counter pain medications, such as aspirin, acetaminophen (Tylenol), or ibuprofen (Motrin), may be recommended. Your doctor may prescribe a muscle relaxant for additional pain relief.
  • Surgery: In some cases, surgery may be needed to treat thoracic outlet syndrome if symptoms continue, despite an optimal course of occupational/physical therapy.