If you ever feel an aching pain where your neck meets your collarbone or tingling and numbness in your fingers, you may be suffering from thoracic outlet syndrome. Luckily, you can do PT exercises to treat this rare condition and relieve TOS pain.
What is Thoracic Outlet Syndrome?
The thoracic outlet is a diamond-shaped space located behind the clavicle (collarbone) and on top of the first rib. It spans from the base of your neck to your shoulder joint in the upper chest. Several nerves and blood vessels run through this area on their way to service the arm and hand.
When these sensitive fibers become compressed or irritated, it can result in a group of rare disorders called thoracic outlet syndrome. Problems in this area can result in big-time pain and even life-threatening vascular issues if not treated promptly.
Types of Thoracic Outlet Syndrome
Diagnosing TOS is not always easy and may require the intervention of a neurologist, vascular or thoracic specialist. Physical examinations, nerve conduction studies, and other additional tests can pinpoint the type, like a CT scan, X-ray, or MRI.
There are three types of TOS.
Arterial thoracic outlet syndrome is caused by a compression of the axillary artery and/or subclavian artery, the main vessels that carry blood to the arm. The reduction is often the result of a congenital abnormality- one present at birth- that reduces the size of the thoracic outlet.
Arterial is the least common type, affecting only 1% of TOS patients, but the most serious. It can cause an aneurysm or blood clot that could be life-threatening. This type of TOS can happen abruptly and requires immediate medical attention. Surgical treatment is a common treatment option for this type of TOS.
The compression of axillary and/or subclavian veins under the collarbone, the ones that carry blood away from the arm, is the cause of venous thoracic outlet syndrome. This can create blood clots that may be life-threatening if they break loose and make their way to the lungs.
It can develop abruptly, often after intense arm exercise or activity, and only comprises about five percent of TOS cases. When venous and arterial thoracic outlet syndromes occur in tandem, it’s called vascular TOS.
Neurogenic, also called neurologically, is the most common type of TOS, affecting around 95% of all people suffering from the condition. It is caused by compression of the brachial plexus, a network of nerves that comes from your spinal cord and controls muscle movement and sensation in your upper extremity. Neck trauma is often the source.
Neurogenic TOS symptoms often develop gradually and are more pronounced with activity or when the arm is elevated. Neurogenic TOS does not usually require surgery and can be managed, though it can become painfully disabling if not properly treated.
What Causes Thoracic Outlet Syndrome
This is most commonly diagnosed in adults between the ages of 20-50, and females are three times more likely to get it than males. Athletes are also at a higher risk of developing TOS, depending on the sport they participate in.
Components of the Thoracic Outlet
There are three components of the thoracic outlet. Compression or an abnormality in any of these spaces- like a muscle abnormality or extra rib- can irritate the neurovascular bundle and blood vessels.
- Interscalene triangle: The area surrounded by the anterior scalene muscle anteriorly, middle scalene muscle posteriorly, and the first rib inferiorly where the brachial nerves pass through.
- Costoclavicular space: The area between the clavicle and the first rib. The brachial nerve plexus, subclavian vein, and subclavian artery pass through here.
- Sub-pectoralis minor space: The area between the rib cage and the pectoralis minor tendon and pec minor muscle. This is a relatively tight space where the nerves and vessels can become compressed.
Common Causes of TOS
The thoracic outlet space can become reduced due to physical trauma, repetitive strain, or an anatomical defect. Sometimes the cause is unknown, but common reasons are listed below.
- A car accident, fall, or other impact that causes a whiplash injury or damages the clavicle and shoulder area
- A surgery or accident that results in scar tissue around the brachial plexus and subclavian vessels
- Jobs that require carrying heavy shoulder loads, lifting items overhead, or repetitive activities like typing on a computer or working on an assembly line
- Sports that require repetitive arm motions, like baseball, volleyball, golf, swimming, and weightlifting
- Congenital anatomical defects such as bony or soft tissue abnormalities or an extra rib (called a cervical rib)
- Habits like poor posture, sedentary behaviors resulting in poor muscle development, or always carrying a heavy shoulder bag
- Weight gain such as in pregnancy, or obesity
- Tumor on the neck (rare)
While neurogenic is the most common type, it is possible to have all three types of TOS if the thoracic outlet is compressed in multiple places. This often happens as the result of a traumatic injury.
Symptoms of Thoracic Outlet Syndrome
The most common symptom of TOS is the neck, shoulder, trapezius muscle, or chest pain that may feel similar to angina or a heart attack. It is also indicated by impaired circulation, numbness, tingling, and weakness in the hand and fingers on the affected side.
However, specific symptoms will differ depending on the type of TOS you suffer from and the level of nerve compression.
Symptoms of Arterial TOS
- Pain or aching in the arm and hand, especially during exertion
- Coldness in the arms, hands, or fingers
- Pallor or a bluish tinge in the fingers or hand
- Easy fatigability
- A weak pulse in the affected arm or no pulse at all indicates poor circulation
- Sores on the fingers
Symptoms of Venous TOS
- Arm pain
- Arm swelling
- Fatigue in the arm and neck muscles during activity
- Discoloration or paleness of the hand and/or fingers
- A throbbing feeling at the collar bone
- Blood clots
Symptoms of Neurogenic TOS
- Pain or aches in the neck, shoulder, arm, or hand
- Numbness, prickling, or tingling sensations on the affected side
- Weakened grip
- Decrease in size of hand muscles
How to Treat Thoracic Outlet Syndrome
Conservative treatment of TOS includes PT and pain relief medications. When beginning treatment, take a break from the activity that aggravates the issue, like a particular sport or typing at a computer.
If all else fails, surgery may be an option, but often therapeutic measures can improve the condition and manage pain. However, surgery may be required to assuage the effects of venous or arterial TOS.
The goal of a TOS PT plan is to:
- Strengthen the muscles in your shoulder, neck, and arm
- Increase range of motion in the thoracic spine
- Improve nerve health
- Relieve pain
Postural correction exercises can also counteract habits that close down the thoracic outlet.
Some complex PT exercises and manual therapy techniques are best done with a physical therapist or other health care providers. They can give you advice on proper form and suggest some exercises that will be best for your specific situation. Most exercises can be easily done at home or anytime you’re hit with a bout of pain.
Stretching Before Exercise
Even if you’re not suffering from TOS, stretching daily can prevent this and many other health conditions. Performing stretches and exercises that keep your chest, neck, and shoulder muscles strong can avoid a problem in the future.
Stretching before a workout or PT session warms up and loosens your muscles, making them less likely to tear, twist, or strain.
Especially if you are working at a computer for most of your day, get up to stretch at least once an hour. This will get your body back into alignment and release some of that pressure on your thoracic outlet.
Like many painful conditions and injuries, the discomfort from TOS can be managed with over-the-counter medications. NSAIDs like ibuprofen, naproxen, and aspirin or acetaminophen can help reduce pain and inflammation.
If the pain is severe, a doctor-prescribed muscle relaxant can help to reduce tension and improve mobility. If you have vascular TOS, your health care professional may prescribe thrombolytics and/or anticoagulants to treat blood clots.
Exercises for Thoracic Outlet Syndrome Pain Relief
Thoracic outlet syndrome exercises address the three compression sites to relieve pressure and, in turn, pain. They target the scalene muscles- three pairs of muscles on the side of the neck- cervical spine, pectoral, and trapezius muscles.
Conservative management through TOS exercise will help you to reduce symptoms, improve posture, and return to more normal mobility.
TOS strengthening exercises and stretches should never hurt. You may feel some discomfort as you put a strain on the muscles, and that’s normal, but never push yourself to the point of pain.
When performing these exercises, focus on keeping it slow and steady. Jerking or bouncing movements can exacerbate the injury or cause problems elsewhere. And as always, consult your physician before starting a new exercise routine.
Below are eight of my favorite exercises that can relieve TOS pain. You can find a more extensive list of exercises for shoulder pain here.
- Sit straight with your upper spine against a wall.
- Pull your head straight back, chin tucked, so that your head touches the wall.
- Hold for five seconds.
- Repeat 10-12 times.
Neck/ Scalene Stretch
- Stand with your feet shoulder-width apart, arms hanging freely, and looking straight ahead.
- Slowly tilt your head to the right as fit, trying to touch your ear to your shoulder. You may use your hand to apply light pressure.
- Hold for 10 seconds.
- Repeat in the other direction.
- Perform three reps on each side.
- Stand slightly bent at the waist with your feet shoulder-width apart.
- With elbows straight, raise your arms in front of you so that they are parallel with your shoulder blades.
- Slowly raise your arms out to the sides, making a T shape.
- Slowly bring your arms back to the starting position.
- Repeat for 12-15 reps.
- This exercise can also be done while holding dumbbells.
Shoulder External Rotation with Bands
- Attach a resistance band at shoulder level.
- Standing straight, grasp the band in an overhand grip.
- Bend your elbow 90 degrees so that your forearm runs parallel to the ground.
- Externally rotate your forearm away from your body, keeping your elbow at your side.
- Slowly return to the starting position.
- Repeat for five to ten reps.
Prone Trapezius Raise
- Lie facedown on a table or bench with your affected arm hanging down and head resting comfortably on the other forearm.
- With your arm straight, elbow slightly bent, and thumb up, raise your arm outward toward the ceiling.
- Hold for a few seconds before slowly lowering.
- Repeat for 12-15 reps.
Shoulder Blade Squeeze
- Standing straight with arms at your sides, squeeze your shoulder blades together.
- Hold for 10 seconds.
- Repeat for ten sets, increasing the number of sets as you feel comfortable.
Supine Foam Rolling/ Supine Pec Stretch
- Lie on a foam roller with it running parallel to your spine, between your shoulder blades.
- Bend at the knees so your feet are flat on the floor.
- With elbows bent and palms facing up, slowly allow your arms to fall to the floor, creating a stretch in your chest.
- Hold the stretch for 30 seconds.
- This stretch can also be done lying on a table or weight bench.
Ulnar Nerve Gliding Stretches
With this stretch, you will move the arm through a series of six positions to relieve pressure on the ulnar nerve and help it to glide normally.
- Extend the arm in front of you with the elbow straight and fingers flexed.
- Extend the wrist and fingers.
- Bend the elbow, keeping wrist and fingers extended.
- Move arm out to the side, gently flexing the wrist.
- Rotate the arm toward the back.
- Gently tilt your head to the opposite shoulder.
- Hold for 15 seconds. Repeat three times.
Living with TOS
Complications from arterial or venous TOS can lead to more severe problems, so it’s essential to see your doctor immediately if you think you may have one of these conditions. Most people with these types of TOS will require vascular surgery. Neurogenic TOS also sometimes involves surgery to remove the source of compression.
Unfortunately, TOS is not something that is healed overnight. It takes a lot of patience and persistence to manage the condition. But if identified early and treated appropriately with TOS exercises, you can see a radical reduction in symptoms and continue to enjoy sports and everyday life as usual.