Thoracic outlet syndrome (TOS) is a diagnosis that doesn't get the recognition it deserves. This is a diagnosis that causes significant problems and pain within the upper extremity. It can cause numbness, swelling and pain from your neck all the way to your hand. Pain can be diffuse, throughout the whole arm and come and go. It can present as other problems such as carpal tunnel or cubital tunnel but will not improve after surgery. It can cause pain both at night or during the day. It can cause you to drop things and having limited use of your arm. So as you can imagine, or are experiencing, this can have a huge impact on your sleep and daily life. As an Occupational Therapist (OT) and Certified Hand Therapist (CHT) I truly understand the impact this can have on life. My goal is to resolve these symptoms, educate and empower you, and all my patients back to living their life to the fullest.
Let’s step back, being an Occupational Therapist I specially focus on function. I want to ensure my patients are able to do what they want and need. Maybe that means caring for a baby, or crushing a workout at the gym, or cooking a meal for their family. Whatever their specific goal, it is my job to help get them there. TOS can get in the way of almost every component of peoples day- treatment is focused on reversing that. When I first see a patient, regardless of their diagnosis, we start with just chatting. I want to know the history of what they have been experiencing and for how long. Does it effect their sleep? Are they able to get dressed? Have they had any testing, surgery or treatment? How much pain are they in? Based on answered to these questions I ask even more. By truly listening to my patients, those with TOS (even if they don’t come to me with this diagnosis) usually guide me right to it. They frequently complain of heaviness in their arm, rapid fatigue with use, pain or coolness when working overhead or numbness in their fingers. They complain of a “stuffy” ear, jaw pain or clavicular (collarbone) pain and pain/numbness that is worse at night. If a patient says any of these “triggers” we screen for TOS. Screens are special tests that can be done in just minutes. These are completed by placing the arm in a variety of positions that are used every day life such as reaching overhead or behind your back. These movements should not cause problems typically, but will reproduce symptoms if you have limited space for your nerves and blood vessels to travel, as do people with TOS. Additionally, I look at positioning and posture. Having proper, upright posture ensures that these crucial structures have space to travel from your neck, into your arm without being pinched. Poor posture or anatomical changes can result in less space for things to move and therefore cause symptoms.
So maybe you think you have TOS? Let’s talk about what we do in therapy to help you improve your symptoms and make them stay away. Shoulder and head positioning is critical to be sure that everything is properly aligned, and therefore, will is enough space in your thoracic outlet for all the important structures to travel with no obstruction. Factors such as an elevated first rib, a tight pec muscle, a poorly positioned shoulder blade and all jeopardize this space. So, first we look at muscle balance and positioning. What muscles are too tight and what ones are underdeveloped? Is the shoulder blade sitting flat against their rid cage? Do they have a hunched upper back? How does their first rib feel and move? How is their thoracic mobility? What is their range of motion like on both sides? From here we find what we need to focus on.
Then we move to treatment. Initially I find it helpful to start with manual work. Massage is used on the tight muscles with both trigger point release and myofascial techniques. This is especially useful on the scalenes and pecs. Cupping can also be an effective method to manage the myofascial restriction and improve blood flow. Joint mobs can be completed by a therapist to improve capsular patterns (i.e your joint and how it sits and moves). Next, the focus turns to teaching the patient how to appropriate fire muscles to hold their shoulder blade back and open their chest. Although it sounds simple, this can be a huge challenge for people. We are so used to working in the forward position all day; reaching to our computer, reaching forward for the steering wheel, pushing a grocery cart. Pulling these shoulders back can be like teaching someone how to walk. They truly don’t know how to fire these muscles. By using tactile cuing and visualization cues I teach the patient how to use these crucial muscles that have just been relaxing. Core weakness can make it even harder to control our shoulder blades. A custom exercise plan is made for each patient to target their weak spots and stretch the tight ones. Home exercises are important to ensure the patient keeps up with the progress we have made in session. Initially that might look like self massage or stretching or even gentle exercises. These can be update every week or two to continue to challenge the patient as they progress. By the end of treatment I want every patient to have a book of exercise ideas that they can reference in the future to help manage their symptoms independently.
Next, adaptation and ergonomics assessment is critical. How a patient spends their time each and every day affects what muscles are or are not used. By using activity analysis I start by talking to the patient about their job. What does a typical day look like for them? Do they have poor posture at a computer all day? Is there an activity that always causes symptoms? These are things we need to change! Doing exercises and stretching several times a day will certainly help but changing activity that irritates them is what makes the lasting difference. I have them take a picture of their work set up or even better go look at it. From here I can offer suggestions of chair and arm rest height, computer monitor positioning to improve posture, keyboard placement to limit distal nerve compression, special phones or a head set to limit lateral neck flexion. Doing something like reaching for the mouse 100x a day can reek havoc on your body if not done in an ergonomic way. Being an OT I love adaptive tools. Some of my favorite recommendations include an ergonomic mouse, a laptop riser paired with a blue tooth keyboard and a phone head set.
As a OT and CHT I place significant importance on looking at the patient holistically. How does this diagnosis and their symptoms impact their daily life and how can we work to eliminate these limitations. Using a combination of skills and assessments I work to get the patient back to doing what they love. I heavily educate all of my patient on what they're experiencing, why they are having these problems and how we will fix them, together. I want help every person to be empowered and motivated to care for their bodies even when I am not present. I personally am more likely to do something if I know why I’m doing it, I follow this same mind set with my patients and frequently reference their own personal goals. TOS can be a long, challenging and daunting road- ask for the help and support you deserve.
Living your life to the fullest is of the utmost importance, do not let thoracic outlet syndrome hold you back!
Are you a therapist needing exercise ideas for TOS treatment? Check out our blog post made just for you!