Thoracic Outlet Syndrome (TOS) and Neck, Shoulder, and Arm Pain


American Academy of Orthopaedic Surgeons,
(AAOS)

A syndrome is a combination of signs and symptoms that characterizes an abnormal condition. A physician must review all of these signs and symptoms in order to make a diagnosis. That's certainly the case with thoracic outlet syndrome, or TOS.

TOS gets its name from the space (the thoracic outlet) between your collarbone (clavicle) and your first rib. This narrow passageway is crowded with blood vessels, muscles, and nerves. If the shoulder muscles in your chest are not strong enough to hold the collarbone in place, it can slip down and forward, putting pressure on the nerves and blood vessels that lie under it.

Symptoms vary, depending on which structures (nerves or blood vessels) are being compressed. Pressure on the blood vessels can reduce the flow of blood to your arms and hands, making them feel cool and tire easily. Pressure on the nerves can leave you with a vague, aching pain in your neck, shoulder, arm or hand. Overhead activities are particularly difficult.

TOS can result from injury, disease, or a congenital abnormality. Poor posture and obesity can obesity can aggravate the condition, which is more common in women than in men. Psychological changes are often seen in patients with thoracic outlet syndrome. It is not clear whether these precede the onset of the syndrome or are the result of dealing with the pain and frustration of diagnosing and treating this condition.

Diagnosis

When you visit your doctor, he or she will ask you about the history of your symptoms, give you a physical examination and try to reproduce your symptoms through a series of tests to diagnose TOS. There may be a depression in the shoulder, or a swelling or discoloration in the arm. Range of motion may also be limited.

X-rays may be recommended; an MRI (magnetic resonance imaging), nerve conduction tests, or ultrasound may be used to rule out other possible causes for your symptoms. Your doctor may order special blood circulation tests and elecrodiagnostic tests to aid in making the diagnosis of TOS.

Treatment

The treatment for TOS is conservative, and does not usually involve surgery.

  • Physical therapy can help strengthen the muscles surrounding the shoulder so that they are better able to support the collarbone.

  • Postural exercises can help you stand and sit straighter, which lessens the pressure on the nerves and blood vessels.

  • Nonsteroidal anti-inflammatory drugs, like aspirin or ibuprofen, can ease the pain.

  • If you are overweight, your physician may recommend that you go on a diet.

  • You may need to change your workstation and avoid strenuous activities.

  • In rare cases, surgery may be recommended if conservative treatment fails. The surgery involves dividing a muscle in the neck and removing a portion of the first rib.
Avoiding TOS

If you have symptoms of TOS, avoid carrying heavy bags over your shoulder because this depresses the collarbone and increases pressure on the thoracic outlet. You could also do some simple exercises to keep your shoulder muscles strong. Here are four that you can try; do 10 repetitions of each exercise twice daily.

  1. Corner Stretch: Stand in a corner (about one foot away from the corner) with your hands at shoulder height, one on each wall. Lean into the corner until you feel a gentle stretch across your chest. Hold for 5 seconds.

  2. Neck Stretch: Put your left hand on your head, and your right hand behind your back. Pull your head toward your left shoulder until you feel a gentle stretch on the right side of your neck. Hold for 5 seconds. Switch hand positions and repeat the exercise in the opposite direction.

  3. Shoulder Rolls: Shrug your shoulders up, back, and then down in a circular motion.

  4. Neck Retraction: Pull your head straight back, keeping your jaw level. Hold for 5 seconds.
As with any exercise program, if you start to hurt…stop!

posted 9/1/2000

Your Orthopaedic Connection, Patient Education Web Site of the American Academy of Orthopaedic Surgeons, © 2002




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