Thoracic outlet syndrome (TOS) is a group of conditions caused by compression of nerves, arteries, or veins in the space between the collarbone and first rib. This often-misdiagnosed condition can cause significant pain, numbness, and weakness in the arm and hand. At M.O. Therapy in Markham, we help patients with TOS through comprehensive conservative treatment.
Understanding Thoracic Outlet Syndrome
Anatomy of the Thoracic Outlet
The thoracic outlet is a narrow space through which major blood vessels and nerves pass from the neck and chest to the arm. Key structures include:
Nerves:
- Brachial plexus (network of nerves to the arm)
- Provides sensation and motor function to the arm
Blood Vessels:
- Subclavian artery (brings blood to the arm)
- Subclavian vein (returns blood from the arm)
Surrounding Structures:
- Scalene muscles (front and middle)
- First rib
- Clavicle (collarbone)
- Pectoralis minor muscle
Types of Thoracic Outlet Syndrome
Neurogenic TOS (Most Common - 95%):
- Compression of brachial plexus nerves
- Causes pain, numbness, tingling, weakness
- Often involves scalene muscles
- Responds well to conservative treatment
Venous TOS (Paget-Schroetter Syndrome):
- Compression of subclavian vein
- Causes arm swelling, discoloration
- May lead to blood clots
- Requires medical management
Arterial TOS (Rare but Serious):
- Compression of subclavian artery
- Can cause cold, pale arm
- Risk of blood clots
- May require surgical intervention
Causes and Risk Factors
Anatomical Causes
Congenital:
- Cervical rib (extra rib above first rib)
- Abnormal first rib
- Tight fibrous bands
- Anatomical variations
Acquired:
- Postural changes
- Muscle imbalances
- Scar tissue from injury
- Hypertrophy of scalene muscles
Contributing Factors
Occupation:
- Repetitive overhead work
- Prolonged computer use
- Heavy carrying or lifting
- Vibrating tool use
Postural:
- Forward head posture
- Rounded shoulders
- Poor ergonomics
- Carrying heavy bags on shoulder
Trauma:
- Whiplash injuries
- Clavicle fractures
- Repetitive strain
- Direct trauma to shoulder
Other:
- Pregnancy
- Weight gain
- Large breasts
- Muscular individuals with overdeveloped chest/shoulders
Symptoms of Neurogenic TOS
Upper Plexus Compression (C5-C7)
- Pain in neck, face, ear, upper chest
- Pain in outer arm and thumb/index fingers
- Headaches
- May mimic cervical disc problems
Lower Plexus Compression (C8-T1) - More Common
- Pain in inner arm and hand
- Numbness in ring and small fingers
- Hand weakness (grip strength affected)
- Cold sensitivity
- May mimic ulnar nerve problems
Common Symptom Patterns
Pain:
- Aching in neck, shoulder, and arm
- Often worse with arm elevation
- May radiate to chest
- Night pain common
Numbness and Tingling:
- Usually in hand and fingers
- Pattern depends on nerves affected
- Often worse with arm use
- May be constant or intermittent
Weakness:
- Hand clumsiness
- Dropping objects
- Difficulty with fine motor tasks
- May affect grip strength
Other:
- Arm fatigue with activity
- Cold intolerance
- Pallor or discoloration (vascular TOS)
- Swelling (venous TOS)
Diagnosis
Clinical Examination
Postural Assessment:
- Forward head posture
- Rounded shoulders
- Elevated first rib
- Muscle tension patterns
Provocative Tests:
- EAST (elevated arm stress test)
- Roos test (3-minute elevated arm exercise)
- Adson's test (scalene tension)
- Wright's test (hyperabduction)
- Costoclavicular test
Neurological Examination:
- Sensation testing
- Strength testing
- Reflexes
- Nerve tension tests
Imaging Studies
X-Ray:
- Cervical rib identification
- First rib abnormalities
- Clavicle position
- Spine alignment
MRI:
- Soft tissue visualization
- Rule out other conditions
- Cervical disc problems
- Tumor exclusion
MRA/MRV:
- Vascular TOS evaluation
- Blood flow assessment
- Clot detection
Ultrasound:
- Dynamic vascular assessment
- Compression visualization
- Clot detection
EMG/Nerve Conduction Studies:
- Assess nerve function
- Rule out other nerve conditions
- Document severity
Conservative Treatment
Physiotherapy
Physiotherapy is the primary treatment for neurogenic TOS at M.O. Therapy.
Goals:
- Reduce nerve compression
- Improve posture
- Strengthen supporting muscles
- Restore normal movement
Treatment Components:
Postural Correction:
- Address forward head posture
- Correct rounded shoulders
- Improve thoracic spine mobility
- Ergonomic modifications
Stretching:
- Scalene muscle stretches
- Pectoralis minor stretches
- Upper trapezius stretches
- Nerve gliding exercises
Strengthening:
- Scapular stabilizers
- Deep neck flexors
- Rhomboids and middle trapezius
- Core stability
Manual Therapy:
- Soft tissue mobilization
- First rib mobilization
- Nerve mobilization
- Joint mobilization
Nerve Glides:
- Gentle nerve mobilization
- Reduce neural tension
- Improve nerve mobility
- Decrease symptoms
Activity Modification
Avoid Aggravating Activities:
- Prolonged overhead work
- Heavy carrying
- Sleeping positions that compress area
- Repetitive reaching
Ergonomic Changes:
- Proper workstation setup
- Supportive seating
- Regular position changes
- Avoid prolonged arm elevation
Massage Therapy
Our RMTs help with:
- Scalene muscle release
- Pectoralis minor tension
- Upper trapezius tightness
- General muscle relaxation
Chiropractic Care
Chiropractic treatment may include:
- First rib mobilization
- Cervical spine assessment
- Thoracic spine mobility
- Postural correction
Exercise Program for TOS
Stretching Exercises
Scalene Stretch:
- Sit or stand with good posture
- Tilt head away from affected side
- Add slight rotation toward affected side
- Hold 30 seconds, repeat 3 times
Pectoralis Minor Stretch:
- Stand in doorway
- Arm at 90 degrees against frame
- Step through doorway
- Hold 30 seconds, repeat 3 times
Upper Trapezius Stretch:
- Tilt head away from tight side
- Gently assist with hand
- Hold 30 seconds, repeat 3 times
Strengthening Exercises
Chin Tucks:
- Sit or stand tall
- Tuck chin back (make "double chin")
- Hold 5 seconds
- Repeat 10-15 times
Scapular Squeezes:
- Sit or stand with arms at sides
- Squeeze shoulder blades together
- Hold 5 seconds
- Repeat 10-15 times
Rows:
- With resistance band or weights
- Pull elbows back, squeezing shoulder blades
- Keep shoulders down
- 3 sets of 12-15 repetitions
Wall Angels:
- Back against wall
- Arms in "goalpost" position
- Slide arms up and down
- Maintain contact with wall
- 10-15 repetitions
Nerve Glides
Median Nerve Glide:
- Arm out to side, palm up
- Extend wrist and fingers
- Tilt head away then toward arm
- Gentle oscillations
- 10-15 repetitions
Ulnar Nerve Glide:
- Arm out to side
- Flex wrist and elbow
- Gently extend and flex
- 10-15 repetitions
When Surgery Is Considered
Surgery may be needed for:
- Vascular TOS with compression
- Failure of conservative treatment (6+ months)
- Significant weakness or atrophy
- Arterial complications
- Cervical rib causing clear compression
Surgical Options:
- First rib resection
- Scalenectomy
- Cervical rib removal
- Decompression procedures
Prognosis
With appropriate treatment:
- Most patients with neurogenic TOS improve with conservative care
- 60-70% good to excellent results with physiotherapy
- Treatment may take several months
- Recurrence possible without ongoing management
- Postural awareness important for long-term success
Frequently Asked Questions
How long does TOS take to improve? Improvement typically occurs over 6-12 weeks of consistent conservative treatment. Some patients improve faster, while others require longer treatment. Chronic cases may take several months.
Can TOS be cured? While TOS can be effectively managed, ongoing attention to posture, ergonomics, and exercise is usually necessary. Many patients experience significant improvement and can return to normal activities.
What activities should I avoid with TOS? Avoid prolonged overhead activities, heavy carrying, sleeping on the affected side, and any positions that reproduce symptoms. Modifications are usually temporary as symptoms improve.
Is TOS serious? Neurogenic TOS, while uncomfortable, is usually not dangerous and responds well to conservative treatment. Vascular TOS (venous or arterial) can be more serious and requires prompt medical attention.
Book Your Assessment
If you're experiencing arm pain, numbness, or weakness that might be TOS, M.O. Therapy in Markham can help. Our team provides comprehensive assessment and treatment for this challenging condition.
Call (905) 201-5827 or book online for your assessment. We offer direct billing and same-day appointments.