So let's start with the basics. What is thoracic outlet syndrome (TOS) and what does it look like in a patient? TOS is a term used to describe a group of symptoms or conditions caused by compression on blood vessels or nerves as they leave your neck and travel down into your arm. Unfortunately, it usually goes undiagnosed and all other symptoms are seen individually, rather than seeing the whole picture. A good example is a patient coming to you for carpal tunnel, cubital tunnel and lateral epicondylitis (tennis elbow) all at the same time. Something is clearly going on proximally causing symptoms all the way down the arm! So you would want to screen the neck and screen for TOS. Actually listening to your patient is crucial- they will tell you everything you need to know to help them. Listen to their symptoms, everything will seem disjointed but use your knowledge of dermatomes, myotomes, the brachial plexus, nerve innervations and distributions, it will all make sense! Patients with TOS will commonly report waking up at the same time every night with burning and numbness in their hand. They will have numbness and tingling when reaching overhead. They typically also have ulnar nerve symptoms into their hand like tingling and numbness of the ring and small fingers. Additionally they may report feeling of a stuffy ear on that side, lateral neck pain or collarbone pain.
What causes TOS?
Thoracic outlet syndrome is caused by compression of nerves and blood vessels as they leave your neck and travel into your arm. There are 3 different types of TOS, neurogenic (nTOS), venous (vTOS), and arterial (aTOS). There are also 3 areas this compression can happen, the scalenes triangle, costoclavicular space (below the clavicle), and subcoracoid space (under the pec muscle). A patient can usually identify where they feel the most pull, pressure or discomfort and guess what, it will probably be one of these areas and now you know where to focus!
Why does it happen?
TOS can happen for a variety of reasons: history of trauma or whiplash causing tightening muscles or compensatory positioning, poor scapular stability and posture resulting in that scap tipping anteriorly and taking up space it shouldn't (less space for all those critical structures to travel!), poor breathing patterns using the scalenes to assist with breath rather than the ribs and diaphragm expanding, an extra rib at the cervical spine again taking up extra space or sometimes it is just anatomy! The person could have been born with a narrow outlet which puts them more at risk of compression. Validating to the patient that what they are feeling makes sense to you can be a game changer for rapport- usually these patients have been told they are "crazy" by the healthcare system and having an explanation for what they are experiencing can give them a huge amount of relief. EDUCATE THEM!
Treatment
OK so now the fun part...actually helping them! Based on where you identified the main problem (or if you can't that's OK, focus on a little of everything) you want to start to mobilize this area. We want to stretch the muscles that are tight and strengthen the surrounding muscles to hold them in a better position. Doing hands on manual work for scalenes trigger point release, joint mobilization to the clavicle at both the acromion and sternal ends, joint mobs and stretching to the shoulder and scapular mobilizations all to help improve positioning and gliding. Below are some of my favorite stretches to give patients. You want to instruct them that they should feel a good stretch but it should never be sharp pain or worsening tingling or numbness. If it does, back out of the stretch slightly.
Scalenes stretching (lengthen the scalenes triangle to make sure a tight muscle isnt causing compression):
Doorway pec stretch (stretch the pec and improve their posture to limit compression):
Self first rib and clavicle mobilization:
So now that you got things moving a little better it's time to strengthen the area so help them maintain that position all the time! Exercises focused on scap stability and posture are always a great starting point. You want to cue them to focus on scapular retraction using the big muscles of their back. You also want to ensure the anterior part of the shoulder is also being pulled back and not just tipping forward. We want to encourage opening of the chest for overexaggerated upright posture. Additionally you want to keep an eye on their core and spine. We do not want a big lordotic curve of their low back because this will cause anterior tipping of the scapula. Cue them to engage their core while they stand up wall and do exercises. Below are some of my favorite exercises to start with to allow them to focus on movement patterns and posture
Prone scap retraction:
Supine scap retraction (instruct patient to push elbows into bench while squeezing shoulder blades back)
Bilateral band external rotation (hello, good posture):
Band rows:
As the patient progresses with better mobility, posture and scapular control start to challenge them more! A foam roller can be a great tool to have them start open chain exercises while cuing them to keep through shoulders back and down.
Foam roller flexion:
Foam roller abduction:
Other things to think about
There is so much more to consider assess and strengthen- how are their lats, thoracic mobility, neck retraction, low trap and serratus activation. Start slow and progress as you can. Always respect their tingling and numbness. Ergonomics assessments and adaptive tools can be helpful to improve their positioning and function during the day. TOS can be a slow recovery since it took their body a long time to get in this positioning, it usually isn't fixed overnight. Encourage them to start exercise or stretching habits, educate them and support them as they navigate this journey! In my experience these patients usually return once a year or so for maybe one or two sessions to have you stretch them back out, reassess their positioning and get them back on track!