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Thoracic Outlet Syndrome (TOS)

That annoying pain around your neck, shoulder and down your arm that you can’t find the source of! It may be Thoracic Outlet Syndrome!

Image of the Thoracic outlet

Signs and Symptoms:

  1. Pain in the base of the neck/1st rib (Just below the collar bone)

  2. Pain in the arm when lifting the arm above your head

  3. Pins and needles and numbness may be present down the arm – usually into the 4th and 5th finger 

  4. Pain in the shoulder or down the arm when carrying things on your shoulder

  5. Increase symptoms after use of the arm

  6. Fatigue and arm/hand weakness (may be present)

  7. Often pain is worse at night

  8. Discolouration and swelling (If there is vascular compression – This is rare but more serious)

What is it?

Thoracic outlet syndrome is compression of nerves and possibly blood vessels as they pass over the first rib.

Neurogenic Thoracic Outlet Syndrome: The most common, when the Brachial Plexus (bundle of nerves) is compressed.

Venous or Arterial Thoracic Outlet Syndrome: Rare but more serious, this is when the Subclavian Vein or Subclavian Artery is compressed.

What causes it?

There are a number of structures that may be contributing to compression at the first rib, this is why it is difficult to diagnose. What is causing it for one person may be different to what is causing it for another person. Thorough assessment is crucial for effective management.

Potential sites for compression include:

Image of the bones and muscles which can cause compression of the nerves and blood vessels

  1. Muscles: Scalenes and pectorals 

  2. Bones: Some people have a cervical rib (An extra rib attached at the neck which can get in the way of the nerves and blood vessels – This can be seen on X-Ray

  3. Mechanics of the scapula or rib dysfunction: If the scapula is not upwardly rotating correctly, the scapula can be dumping downwards which can put extra pressure on the neural structures. There can also be dysfunction at the ribs which can also increase the pressure.

When the scapula (Shoulder blade) isn’t upward rotating enough, compression of the brachial plexus can occur

*Any one, or a combination of these things can be contributing to the issue.

How can Physiotherapy help?

  1. Assessment and identification of the cause of the problem is key!

  2. Addressing postural habits

  3. Addressing muscle imbalances

  4. Mobilising the neural system 

Written by Ashley Holliday

Physiotherapist

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