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Thoracic Outlet Syndrome

The thoracic outlet is the area of the shoulder/neck where the nerves (brachial plexus) and blood vessels (subclavian vessels) pass from the cervical area toward the axilla.  Thoracic outlet syndrome (TOS) is a set of symptoms due to compression and/or irritation of these vessels and nerves.  There is much controversy among physicians and diagnosing this syndrome is very difficult.  It is often confused with carpal tunnel syndrome, brachial plexus syndrome, rotator cuff syndrome and bursitis.


  1. Disc protrusion, herniation or degeneration causing nerve impingement
  2. Brachial plexus entrapment or subclavian artery compression in the interscalene triangle (usually between anterior and medial scalene)
  3. Impingement at the cervico-axillary canal or the costo-clavicular space (1st rib) -could be from carrying a heavy shoulder bag or bad posture
  4. Fibrositis of the cervical and shoulder area (pectoralis major and minor, the posterior cervical triangle)
  5. Cervical spondylosis -irritation or compression of the C3-C8 spinal nerves causing increased tension and spasm in anterior scalene muscles.
  6. Extra first rib (cervical rib)
  7. Bone spurs on cervical vertebrae (may be called extra first rib)
  8. Trauma such as whiplash (hyperextension) or other injury to the neck that results in scar tissue formation in scalenes which lead to compression
  9. Trauma to the shoulder
  10. Old fractures of the clavicle that limit space for vessels.
  11. Postural distortions caused by pec minor and minor, SCM, scalenes, trapezius, levator scapulae; forward head, rounded shoulders, scoliosis (psoas imbalance), kyphosis
  12. Loss of curvature in the neck due to Longus coli shortening
  13. Excessive exercise leading to shortening of the shoulder and neck muscles
  14. Shallow breathing -hypertrophy of scalene muscles
  15. Postural changes due to pregnancy
  16. Anterior scalene tightness
  17. Pectoralis minor tightness





  1. Chills
  2. Paresthesia of the hand most commonly little finger, medial forearm and arm; Pins and needle feeling
  3. Weakness in trapezius
  4. Swelling or puffiness in arm or hand
  5. Bluish color in hand, coldness in hand and fingers due to loss of circulation: insufficient blood supply due to compression of subclavian artery
  6. Muscles in hand atrophy in chronic conditions
  7. Edema/swelling in hand caused by compression of subclavian vein
  8. Raynaud's phenomenon
  9. Pain in neck
  10. Weakness in hands and arms especially when raising overhead
  11. Dull shooting pain down the arm
  12. Feeling of heaviness in arms
  13. difficulties with fine motor skills of hands
The following test may help to locate the areas of impingement.  These test may not be reliable and conclusive. Palpation of the area may prove to be more helpful in finding the source of impingement.
  1. East Test or hands up test -client brings hands up above head, with elbows slightly back and opens and closes hands slowly for 3 minutes.  Pain, heaviness or weakness and numbness are positive signs
  2. Adson or Scalene Maneuver- Find the radial pulse.  Have the client look to the side and up toward the ceiling while holding the pulse. Check for diminishing pulse.  Hold the same wrist and have client rotate head to opposite side and up toward the ceiling.  A positive sign indicates neurovascular impingement between the anterior and medial scalene or the presence of a cervical rib.
  3. Costoclavicular Maneuver - Find the radial pulse. Have the client pinch their shoulder blades together and tuck the chin in towards the chest.  Check for diminishing pulse.  A positive sign is an absence of pulse and indicates compression of the neurovascular bundle between the first rib and the clavicle. This may be due to scalene and subclavius tightness.
  4. Wright's Test - Find the radial pulse.  Passively raise arm out to the side and above the head      (abduction of shoulder ) holding for several seconds. Check for diminishing pulse. A positive sign indicates pectoralis minor or coracoid process compression.
  5. Traction Test - Find the radial pulse.  Apply firm traction on the arm for several seconds checking for diminishing pulse.  A positive sign indicates cervical rib pressure on the tested side.

see the tests online:

Neck muscles-  view 1         view 2
Neck Nerves
Neck Nerve Plexus
Shoulder and upper arm Nerves
Brachial Plexus Nerves
Neck arteries
Neck veins
Shoulder arteries
Shoulder veins
Lyphatic System in Neck/Axilla

Treatment Goals: Release adhesions causing nerve entrapment, reduce muscle spasming or contractures causing nerve entrapment.

  1. Work all muscles of the shoulder, neck and upper back; Scalenes, trapezius, SCM, pectoralis major and minor, subclavius, rhomboids.  Use Trigger Point therapy.
  2. Correct postural deviations.  Look at the whole body and see how the shoulders and neck are influenced by the lower body.
  3. Re-educate and increase awareness of posture.

Online resources:


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