Thoracic Outlet Syndrome

The condition ‘thoracic outlet syndrome’ (TOS), relates to a compression of the area in which nerves and blood vessels that supply the upper limb are located. This ‘thoracic outlet’ region is where the neck and upper back meet. Specific structures create this outlet which is triangular in shape and is formed by the highest rib from below and two neck muscles – the anterior scalene which creates the frontal boarder and the middle scalene that makes the posterior boarder.

Symptoms of TOS can vary significantly however it is generally characterised by pain and change in sensation in the upper back (thoracic spine) shoulder, arm and hand. Depending on which structures are affected, it may also produce symptoms in the face, ear, chest and base of the skull. It is also common for patients with a suspected TOS to reported changes in sensation such as pins and needles, numbness and temperature alterations in the arm and hand. Alongside this, the arm may be described as feeling heavy. Symptoms are typically provoked when turning the head and when the affected limb is held in an overhead position such as painting a ceiling, throwing or cleaning windows as several examples.

There are 2 main types of TOS:

• Neurogenic – compression and inflammation of the nerves.

• Vascular – compression of the arteries or veins.

• Repetitive arm movement.

• Extreme arm positions.

• Sports injury.

• Road traffic accident.

• Anomalies in the neck muscles.

• Abnormalities in the first rib.

• Defects in the vertebrae in the neck.

• Abnormalities in the chest muscles.

It affects those between 20 and 50 years old generally. More women than men statistically are affected by TOS. Commonly, it starts gradually without known reason but other causes of this problem are trauma, including road traffic accident or sporting injury. Long standing muscle imbalance or weakness in a particular muscle group can also lead to this problem.

It is helpful to see a Physiotherapist to get an accurate and quick diagnosis. Approximately 90% of the diagnosis comes from the subjective assessment where aggravating and easing factors alongside the characteristics of your problem are discussed. Specific and neurological tests are done in the physical exam to test the physiological structures and rule out other musculoskeletal problems.

By receiving a timely diagnosis, a bespoke plan can be devised a plan to best combat this condition and prevent re-occurrence, specific to your lifestyle and goals. It is most effective when diagnosed within 6 weeks of when the problem started. With any condition a subjective assessment and a physical assessment is done by the Physiotherapist.

Sometimes but not often, further investigations may be necessary to help with this diagnosis. If this is required, the Physiotherapist can refer you to your doctor or specialist to arrange an X-ray or MRI scan.

Your Physiotherapist will provide you with the skills and knowledge to effectively manage your symptoms and work towards recovery. You will be given individualised strategies to modify any aggravating activities, tips on avoiding any postures that may cause irritation and ways in which you can continue to manage your condition to prevent re-occurrence. Regular re-assessment will make certain that you are progressing well and will allow any adaptations in your current treatment to be made so that your recovery remains optimal.

At Pure Physiotherapy, TOS is a condition that is seen regularly and treated effectively and quickly. We feel it is important to cater a treatment plan to get the best results for the patient and use the grade of treatment appropriate for you. The following treatment approaches are normally used for this problem:

• A specific progressive exercise program

• Joint mobilisations

• Trigger point therapy

• Massage

• Nerve mobilisation

• Acupuncture

Through the anticipated injury healing time, specific exercises will help to change pain generation and restore the health of the injured structures. Movement and strengthening promotes healthy blood flow and nutrient supply, as well as addressing any muscle weakness. You can have muscle weakness and/or imbalances due to this problem. One of the roles of Physiotherapy is to identify any strength or movement problems and address these in order to reduce the chance of it happening again.

Please find the patient resources section of our website where we have created a series of recommended exercise programmes for his condition. We advise consulting with your Physiotherapist prior to trying any of these exercises.

Patient.info page dedicated to TOS – click here.