Thoracic Outlet Syndrome
Are you experiencing pain as well as numbness, tingling, and weakness in the hand and fingers?
Do your fingers or hands feel like they’re “falling asleep” while you type at a keyboard, grip a
steering wheel, work out at the gym, or pick up groceries or even your child?
There are several conditions of the head, neck, shoulder, elbow, and wrist that cause sensations
of tingling, numbness, pain, and weakness with grip strength. More common conditions include
carpal tunnel syndrome1, tennis elbow (lateral epicondylitis)2, compression of the nerves exiting
the neck spine (cervical radiculopathy)3, and pinched nerve (impingement syndromes) of the
shoulder. Less common injuries involve brachial plexus injuries, such as Thoracic Outlet
Syndrome, or TOS for short.
What is Thoracic Outlet Syndrome?
The thoracic outlet is a space in the body that sits between the lower part of the neck and the
collar bone (cervicothoracobrachial region), close to the first rib of our ribcage. This region
stretches to the upper part of the arm and contains a network of nerves and blood vessels
supplying the arm.
Thoracic Outlet Syndrome describes a series of conditions that cause compression of the major
nerves and/or blood vessels that run through that thoracic outlet space. However, the term
“TOS” does not specify the structure being compressed.
There are three different types of thoracic outlet syndrome4, and all of these are named after
the type of vessel or structure being compressed. Categories include:
Compression of the brachial nerve plexus
Slower onset of symptoms
Decreased sensation along the arm
Possible weakness with grip strength and hand muscles
About 90% of all TOS cases
Compression of the axillary or subclavian vein
Symptoms are more abrupt in onset
Includes venous distention in the neck
Pain ranges from the arm to the forearm
Less than 10% of all TOS cases
Compression of the axillary or subclavian artery
Symptoms are also more abrupt in onset
May cause color changes in the fingers
May cause diminished pulses in the upper extremity
Less than 10% of all TOS cases
What structures can compress the neurovascular bundle in the thoracic outlet?
The compression of the neurovascular bundle in TOS can have multiple causes, ranging from
anatomic anomalies to poor posture.
Cervical ribs and the fibromuscular bands connected to them are identified as the most
common cause of neurovascular compression in TOS. Cervical ribs are not like the first rib of
our ribcage, which is the uppermost rib and projects off the first thoracic vertebrae. Instead,
cervical ribs are an anatomic anomaly where an extra rib branches off the lowest cervical
vertebrae. It is known that about 1 in 500 people present with a cervical rib, making it a
common genetic occurrence. Not everyone with a cervical rib will develop TOS; it is simply a
Another major cause of TOS is muscle tightness in the thoracic outlet. Affected muscles include
pectoralis minor and scalene muscles.
Alterations in posture can be another cause of TOS. Slouched posture with forward rounding of
the shoulder narrows down the thoracic outlet, which can compress any neurovascular
structures. This can occur with prolonged poor posture or in individuals with additional breast
Finally, TOS can be seen in athletes who engage in repetitive extreme shoulder motions such as
competitive swimming or baseball pitchers identified to narrow the thoracic outlet.
How do we treat thoracic outlet syndrome?
In our Woodbury, MN sports and rehab practice we perform a detailed history of your injury,
followed by a functional movement assessment and examination.
Mechanical causes of TOS such as poor posture or tightness of certain muscles respond well to
conservative chiropractic treatment. Often, TOS will be caused due to a combination of tight
muscles and poor posture. Tight muscles would be treated with a manual therapy technique
muscle release technique called Active Release Technique and Graston Technique. Poor posture
will be addressed with sports rehabilitation exercises to strengthen the mid-back and deep neck
Frequently Asked Questions (FAQ)
How do I know if a chiropractor is right for me? Do I need surgery?
At our chiropractic office, we take ample time to perform a detailed history and physical
examination to find the cause of your pain. Once we have found the cause of your pain, we will
develop a specific treatment plan that will suit your care. In abrupt vascular symptoms, such as
diminished pulses, severe discoloration of the fingers, and cold hands, the patient will be sent
out for an orthopedic consult to discuss surgical treatment.
With the absence of vascular symptoms, we would consider a conservative trial of care that
includes releasing tight muscles, strengthening weak muscles to improve posture, and
mobilizing/manipulating any restricted joints.
If a patient does not respond to a conservative management plan, the patient will also be sent
out for an orthopedic consult to discuss possible surgical treatment. Please note that after a
few weeks of care, we will re-examine your condition and determine next steps. While you
may feel relief after a few visits, complete resolution after a few visits is not likely.
A conservative treatment approach has fewer side effects than surgery and a faster return to
normalcy than the extensive rehabilitation required after surgery.
How long will it take to recover from Thoracic Outlet Syndrome?
Unfortunately, this depends. According to the most recent research, an average conservative
trial of care will take about eight visits, after which the symptoms will be re-assessed.
Recovery can be dependent on many things, including the body’s response to healing, lifestyle,
ergonomics, and compliance to rehabilitation exercises. Depending on the severity of your
symptoms, you may also need collaboration with other healthcare providers.
When should I see a chiropractor for my pain?
If you are dealing with any of the above-mentioned symptoms, we are here for you. If you want
a same-day examination and treatment for your injury, call us at 651-459-3171. We are your
Woodbury, MN premier practice for all your musculoskeletal needs!
1. Wainner, R., Fritz, J., et al. (2005). Development of a clinical prediction rule for the diagnosis of
carpal tunnel syndrome. Arch Phys Med; 86: 609-618.
2. Walz, D.M., Newman, J.S., Konin, G.P., and Ross, G. (2010). Epicondylitis: pathogenesis, imaging, and
treatment. RadioGraphics; 30(1): 167-184.
3. Eubanks, J.D. (2010). Cervical radiculopathy: Nonoperative management of neck pain and radicular
symptoms. American Family Physician; 81: 33-40.
4. Laulan, J., Fouquet, B., et al. (2011). Thoracic outlet syndrome: definition, aetiological factors,
diagnosis, management and occupational impact. Journal of Occupational Rehabilitation; Sep