Thoracic Outlet Syndrome

Thoracic Outlet Syndrome, more common in females, is comprised of a number of disorders that may occur when blood vessels or nerves are compressed in the thoracic cavity. This is located between the collarbone and first rib. A number of sensitive structures run through the thoracic cavity, including the brachial plexus, a group of nerves connected to the neck and arms, the subclavian vein, which delivers blood to our jugular, and the subclavian arteries which provide blood to the arms. Pressure on any of these body parts can cause an array of painful, and sometimes dangerous, symptoms.

• Neurogenic TOS occurs when pressure is applied to any brachial plexus nerves. 95% of Thoracic Outlet Syndrome cases are neurogenic.
• Venous TOS occurs when pressure is applied to subclavian vein.
• Arterial TOS occurs when pressure is applied to subclavian arteries. Less than 1% of Thoracic Outlet Syndrome cases are arterial.

SYMPTOMS

Thoracic Outlet Syndrome almost always causes chronic sharp or dull pain. It is most often present in the lower arm and hand, but can also be felt in the neck, armpit region, upper arm, and upper back. TOS can be recognized by a number of symptoms. These include:

• Numbness or tingling in arms and fingers
• Weakening grip
• Discoloration of the hand
• Arm pain and swelling (due to blood clots)
• Blot clots in upper body
• Weak or no pulse in the arm
• Cold fingers, hands or arms
• Weakness of arm or neck
• Throbbing lump near your collarbone

CAUSES

Thoracic Outlet Syndrome is often a repetitive stress injury (RSI), commonly found in those who hold desk jobs for many years, occupations that require heavy lifting, and athletes. Thoracic Outlet Syndrome is especially common in athletes and laborers that have their arms lifted above their heads for long periods of time.

• Physical Abnormalities – This may include a cervical rib (extra rib).
• Poor Posture – Drooping shoulders compresses the thoracic cavity.
• Trauma – Injury and accidents often lead to pressure on nerves.
• Repetitive Activity – Those in occupations that require repetitive motion like typing, lifting, or athletics wear away at tissue, leading to TOS.
• Joint Pressure – Obesity or carrying heavy objects can compress the joints connected to the thoracic cavity.
• Pregnancy – Joints often loosen during pregnancy.

DIAGNOSIS

Diagnosing Thoracic Outlet Syndrome is difficult because the pain and causes can vary so greatly from patient to patient.
A doctor will first give a physical examination, where he will test for physical symptoms like depression of the shoulder, range of motion of the arm, and coloration of hands and fingers.
Medical history will be important in determining whether further tests are needed. The patient will be asked various questions about how long the pain has endured, occupation, and lifestyle.
Other tests are often given to make sure that Thoracic Outlet Syndrome is the cause of the pain. These include:

• EMG
• X-rays of the rib and shoulder
• MRI
• Ultrasounds
• Arteriography or Venography

CONSERVATIVE TREATMENTS

• Physical Therapy – This is the first method used to treat Thoracic Outlet Syndrome. Physical Therapy will strengthen and stretch shoulder muscles, opening the thoracic cavity. This will improve posture, range of motion, and take pressure off of the cavity over time.
• Medications – Anti-inflammatory medications like ibuprofen, and muscle relaxers may aid in relaxing muscles enough to take pressure off of the thoracic cavity.
• Blood Clot Medications – Arterial or venal TOS will usually require thrombolytics to dissolve blood clots, followed by further medications to prevent them.
• Cortisone – Cortisone injections can relieve inflammation and pain.
• Botox Injections – These injections bind nerve endings that activate muscles. This means that the muscles prone to spasms are paralyzed for up to 3-4 months, relieving pain.

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Thoracic Outlet Syndrome: FAQs

What is thoracic outlet syndrome (TOS), and what are its types?

Thoracic outlet syndrome is a group of conditions caused by compression of the nerves or blood vessels between the collarbone (clavicle) and the first rib (the thoracic outlet). There are three main types:

• • Neurogenic (most common) — compression of the brachial plexus causing numbness, tingling, or weakness.

  • Venous — compression of a vein, which can lead to swelling, discoloration, or blood clots.

  • Arterial — compression of an artery, rarer, and may cause coldness, color change, or risk of clots/aneurysm.

What symptoms should I look out for, and when do they occur?

Symptoms vary with the type of TOS but commonly include neck, shoulder, or arm pain; numbness, tingling, or weakness in the arm or hand; swelling or heaviness of the arm (especially in venous TOS); color changes, coldness, or pallor in the hand (especially in arterial TOS). Symptoms often worsen with overhead arm use, carrying heavy loads, or with certain postures.

How is thoracic outlet syndrome diagnosed?

Diagnosis involves a combination of:

• Medical history & physical exam, including provocative tests that reproduce symptoms.

• Imaging: X-rays (to detect cervical ribs or bone abnormalities), MRI/CT scans, vascular imaging when needed.

• Other studies: nerve conduction / EMG studies to distinguish nerve vs other compression; ultrasound for vascular flow.

What treatments are effective and when is surgery considered?

• • Conservative treatments often first: physical therapy to improve posture, stretch tight muscles, strengthen shoulder/neck/upper back, activity modification, pain meds.

  • Injections may be used in neurogenic types (e.g. local anesthetic, botulinum toxin) to relieve symptoms.

  • Surgery (thoracic outlet decompression) is considered when conservative treatments fail or vascular involvement is present; surgery may involve removing the first rib, anomalous rib, or releasing compressive muscles/tissues.

  • Recovery depends on the type and severity; earlier intervention tends to lead to better outcomes.