Thoracic Outlet Syndrome

Thoracic Outlet Syndrome

Thoracic Outlet Syndrome (TOS) is a painful pathology that affects individuals with developed musculature and/or poor posture.  It can present as pain and numbness in the arm, hand, and fingers.


  • Compression or irritation of brachial plexus roots (scalences, costoclavicular equal frequency)
  • Compression of subclavian artery (costoclavicular most frequent)
  • Compression of subclavian vein

3 potential locations of neurovascular compression: between scalene muscles, costoclavicular space (clavicle and 1st rib), pectoralis minor muscle

Causes: trauma, posture, repetitive stresses/overuse, anatomical alignment



Neurogenic: women

Venous: men

Arterial: equal distribution



Neurogenic thoracic outlet syndrome (90%)

  • dermatomal pain (usually in the ulnar region)
  • paresthesias
  • weakness/loss of dexterity
  • neck pain
  • occipital headaches


Arterial thoracic outlet syndrome (1%)

  • pain in hand (but rarely in shoulder or neck)
  • finger ischemia
  • paresthesias
  • coolness/pallor
  • weakness/loss of dexterity
  • early fatigue


Venous thoracic outlet syndrome (3%)

  • pain increases along course of axillary vein
  • feeling of heaviness in the affected extremity
  • arm swelling and cyanosis
  • stiffness in fingers
  • paresthesias


Provocative Maneuvers

Adson Test

Allen Test

Costoclavicular Test

Roos Test

Upper Limb Tension Test (neurogenic)


Physical Therapy

Postural reeducation/ergonomics

Stretching -scalenes, pectoralis minor

Strengthening – scapular muscles

Manual therapy – 1st rib manipulations, joint mobilization, taping

To schedule an appointment for this condition call 208-917-2660 or visit

DynaMed Plus [Internet]. Ipswich (MA): EBSCO Information Services. 1995 – . Record No. 115626, Thoracic outlet syndrome; [updated 2014 Dec 23, cite; [about 7 screens]. Available from Registration and login required.



Surgery: First rib resection and scalenectomy (FRRS)

The most frequent sports conducted by this group were baseball and softball, volleyball, and cheerleading and gymnastics, ranging from high-school to professional levels. The survey results revealed that 96% were improved in pain medication use, 75% would undergo FRRS on the contralateral side if needed, 82% had resolution of symptoms, and 94% were able to perform activities of daily living without limitation; 70% returned to the same or better level of athletic activity after FRRS, and this occurred within 1 year in 50%.


Shutze W, Richardson B, Shutze R, et al. Midterm and long-term follow-up in competitive athletes undergoing thoracic outlet decompression for neurogenic thoracic outlet syndrome. Journal of Vascular Surgery. 2017;66(6):1798-1805. doi:


Drop Shoulder Condition – scapular depression at rest, late insufficient upward rotation, general weakness upper and middle trapezius seen in people with TOS.  Physical therapy includes retraining of scapular muscles for proper recruitment with upper extremity motions

Watson LA, Pizzari T, Balster S. Thoracic outlet syndrome part 2: Conservative management of thoracic outlet. Manual Therapy. 2010;15(4):305-314. doi:


Nichols AW. Diagnosis and management of thoracic outlet syndrome. Current Sports Medicine Reports (American College of Sports Medicine). 2009;8(5):240-249.,url,uid,cookie&db=sph&AN=44304683&site=ehost-live.

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