Thoracic Outlet Syndrome

Written by Dr. Jason Ngan, DC

What is Thoracic Outlet Syndrome?

Thoracic outlet syndrome (TOS) occurs when nerves and blood vessels are compressed at the thoracic outlet. The thoracic outlet is an area between the neck and the chest. It is a ring formed by the clavicle (collar bone), top rib, and neck muscles. There are three types of thoracic outlet syndromes, arterial, venous, and neurogenic.

  • In arterial TOS, the axillary and/or subclavian arteries are compressed. These arteries are the main blood supply to the arms.

  • In venous TOS, the axillary and/or subclavian veins are compressed. These veins are the main blood drainage of the arms.

  • In neurogenic TOS, the brachial plexus are being compressed. The brachial plexus are a bundle of nerves that comes from the cervical and thoracic spine (C5-T1). These nerves split up and travel down to the fingers and controls movement and sensation.

What Causes Thoracic Outlet Syndrome?

Thoracic outlet syndrome is caused by compression of the thoracic outlet. Some common reasons include:

  • Overuse and sports injuries

  • Poor posture

  • Upper cross syndrome: muscle imbalance of the neck and upper back.

  • Trauma such as whiplash from car accidents and during delivering of an infant

  • Carrying heavy backpacks

  • Overweight/obesity

  • Cervical rib: an extra rib that forms on C7 (the last neck bone)

  • Pregnancy

  • Tumors

What are the Signs and Symptoms?

  • Pain, numbness, and tingling sensation that runs down to the fingers

  • Weakness of the arm and hand

  • Arms are easily fatigue

  • Discoloration of the hand

  • Swelling of the hand

  • Gilliatt-Sumner hand sign in severe cases. Weakness and muscle loss in the hand.

How is Thoracic Outlet Syndrome Diagnosed?

The diagnostic criteria for TOS is created by the Consortium for Outcomes Research & Education of Thoracic Outlet Syndrome. Thoracic outlet syndrome is diagnosed with a thorough medical history, physical examination, and orthopedic testing. Thorough assessments can narrow down to the structure being affected. Some common structures include the anterior or middle scalene, pectoris minor, subclavius muscles, and axillary artery and vein.

Diagnostic imaging and other special studies can be used to look for signs of TOS and help differentiate the types.

  • X-ray, ultrasound, CT scan, MRI can look for signs of thoracic outlet narrowing

  • Angiograpy, anteriography, venography can visualize blood vessel disruption

  • EMG/NCV check for muscle and nerve function

What are the Treatment Options?

At Ngan Chiropractic, we properly diagnose the cause of the TOS and we treat the source. Some options we provide are:

  • Chiropractic manipulation and mobilization

  • Soft tissue therapies

  • Gua-sha

  • Nerve flossing and gliding

  • E-stim

  • Ultrasound

  • Ergonomic/postural counseling

  • Nutritional counseling for weight management and decreasing inflammation

  • Rehabilitative exercises and stretching

Other treatments that patients may seek (not provided at Ngan Chiropractic) include acupuncture, and surgery if severe.  

References

  1. Pajaj, E., Alimehmeti, R., Dashi, F., Stoja, A., & Aeferi, A. (2020). Neurogenic Thoracic Outlet Syndrome Reviewed. Albanian Journal of Trauma and Emergency Surgery, 4(2), 709-714. https://doi.org/10.32391/ajtes.v4i2.119

  2. DynaMed [Internet]. Ipswich (MA): EBSCO Information Services. 1995 - . Record No. T115626, Thoracic Outlet Syndrome; [updated 2018 Nov 30, cited 2021/2/21]. Available from https://www.dynamed.com/topics/dmp~AN~T115626. Registration and login required.

  3. Kuwayama DP, Lund JR, Brantigan CO, Glebova NO. Choosing Surgery for Neurogenic TOS: The Roles of Physical Exam, Physical Therapy, and Imaging. Diagnostics. 2017; 7(2):37. https://doi.org/10.3390/diagnostics7020037

  4. Weaver, M. L., & Lum, Y. W. (2017). New Diagnostic and Treatment Modalities for Neurogenic Thoracic Outlet Syndrome. Diagnostics (Basel, Switzerland), 7(2), 28. https://doi.org/10.3390/diagnostics7020028

  5. Kaplan J, Kanwal A. Thoracic Outlet Syndrome. [Updated 2020 Nov 17]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK557450/

  6. Levine NA, Rigby BR. Thoracic Outlet Syndrome: Biomechanical and Exercise Considerations. Healthcare (Basel). 2018 Jun 19;6(2):68. doi: 10.3390/healthcare6020068. PMID: 29921751; PMCID: PMC6023437.

  7. Balderman J, Abuirqeba AA, Eichaker L, Pate C, Earley JA, Bottros MM, Jayarajan SN, Thompson RW. Physical therapy management, surgical treatment, and patient-reported outcomes measures in a prospective observational cohort of patients with neurogenic thoracic outlet syndrome. J Vasc Surg. 2019 Sep;70(3):832-841. doi: 10.1016/j.jvs.2018.12.027. Epub 2019 Mar 7. PMID: 30852035.

  8. Ferrante MA, Ferrante ND. The thoracic outlet syndromes: Part 1. Overview of the thoracic outlet syndromes and review of true neurogenic thoracic outlet syndrome. Muscle Nerve. 2017 Jun;55(6):782-793. doi: 10.1002/mus.25536. Epub 2017 Mar 21. PMID: 28006844.