Thoracic Outlet Syndrome

Thoracic Outlet Syndrome (TOS) is an umbrella term that encompasses three related syndromes that cause pain in the arm, shoulder, and neck:

  • Neurogenic TOS – caused by compression of the brachial plexus
  • Vascular TOS – caused by compression of the subclavian artery or vein
  • Nonspecific or disputed TOS – in which the pain is from unexplained causes

Occasionally, neurogenic TOS and vascular TOS co-exist in the same person.

TOS is more common in women. The onset of symptoms usually occurs between 20 and 50 years of age.

Neurogenic TOS has a characteristic sign, called the Gilliatt-Sumner hand, in which there is severe wasting in the fleshy base of the thumb. There may be numbness along the underside of the hand and forearm, or dull aching pain in the neck, shoulder, and armpit.

Vascular TOS features pallor, a weak or absent pulse in the affected arm, which also may be cool to the touch and appear paler than the unaffected arm. Symptoms may include numbness, tingling, aching, and heaviness.

Non-specific TOS most prominently features a dull, aching pain in the neck, shoulder, and armpit that gets worse with activity. Non-specific TOS is frequently triggered by a traumatic event such as a car accident or a work related injury. It also occurs in athletes, including weight lifters, swimmers, tennis players, and baseball pitchers.

Making the diagnosis of TOS is difficult because a number of disorders feature symptoms similar to those of TOS, including:

Doctors usually recommend nerve conduction studies, electromyography, or imaging studies to confirm or rule out a diagnosis of TOS.

The disorder can sometimes be diagnosed in a physical exam by tenderness in the supraclavicular area, weakness and/or a “pins and needles” feeling when elevating the hands, weakness in the fifth (“little”) finger, and paleness in the palm of one or both hands when the individual raises them above the shoulders, with the fingers pointing to the ceiling. Symptoms of TOS vary depending on the type.

Treatment begins with exercise programs and physical therapy to strengthen chest muscles, restore normal posture, and relieve compression by increasing the space of the area the nerve passes through. Doctors will often prescribe non-steroidal anti-inflammatory drugs (such as naproxen or ibuprofen) for pain. If this doesn’t relieve pain, a doctor may recommend thoracic outlet decompression surgery to release or remove the structures causing compression of the nerve or artery.

The outcome for individuals with TOS varies according to type. The majority of individuals with TOS will improve with exercise and physical therapy. Vascular TOS, and true neurogenic TOS often require surgery to relieve pressure on the affected vessel or nerve.