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. Always see your MD or an MD specialist for
diagnosing this syndrome and getting the OK for deep tissue massage first.

Massage Treatment Goals: Release adhesion’s causing nerve entrapment, reduce muscle spasming or contractures causing nerve entrapment.

  1. Work all muscles of the shoulder, neck, and upper back; Scalenes, Trapezius, Sternocleidomastoid (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.


Nicola of Riktr Deep Tissue Massage is a Licensed Massage Therapists, Body Worker, Santa Barbara, Ca.

If there was one repetitive strain injury that was most dependent on good posture, then Thoracic Outlet Syndrome would be it.  It is important that you correct any posture imbalances that you may have, whether in a sitting posture or in a standing position. This provides a more open pathway for the passage of the brachial plexus and should significantly reduce your symptoms. It is almost impossible, however, to correct poor posture without also releasing adhesion’s that are affecting the muscles and interfering with their work.

Thoracic Outlet Syndrome

Radiating pain along the arm, tingling in the fingers, hot sensations on the skin, or ‘prickly heat’ are all signs that there is a nerve involvement going on in your upper spine. Nerve pain is persistent and aggravating. You aren’t exactly sure what is making the pain present and you can begin to look like something out of a horror film as you try to twist your head and shoulders in various contortions to attempt to relieve the symptoms.

The other issue of nerve pain in these areas is that it can be a couple of different causes. Wryneck, Rotator Cuff Impingement, even disc herniation all have similar pain patterns and it can be frustrating trying to figure out exactly which one it is. Often practitioners play a bit of ‘hide and seek’ in an initial consult trying to ascertain which of the top 3 choices is the real culprit. In instances where it is eliminated down to one or two options and the pain keeps persisting after treatment, it usually indicates the time for an ultrasound or MRI which is the definitive way to determine exactly what is going on.

So – you’re getting tingling down your arm, you may even have some sensation in your fingers and along your shoulder. You could also be presenting with coldness in the arm and fingers and even some discoloration in the arm after or during exercise – one of the elements to consider is a condition called Thoracic Outlet Syndrome (TOS). This is the presentation of symptoms that involves the entrapment of the brachial plexus – the main nerve bundle that exits the cervical spine and travels as a group through the anterior scalenes (muscle in the neck), between the clavicle (collar bone) and first rib, under the pectoralis minor and around the arm bone before splitting and becoming the various arm nerves that control the functions of the arm, forearm, and hands.

thoracic outlet.png

The other aspect associated with TOS is the entrapment not only of nerves but also of blood vessels. TOS is considered a ‘neurovascular entrapment’ meaning that the subclavian vein and axillary artery are at risk of being compressed and can contribute to pain, loss of blood flow, discoloration, and motor issues involved in the limb. Impingement can occur anywhere along the path of this brachial plexus and that involves anything from the head to the shoulder – quite a broad area of referral.

The THORACIC OUTLET itself is the space between the Clavicle and the First Rib. This space is subject to a lot of movement and influences from muscles, particularly the pectoralis minor and biceps brachii and to a lesser extent, the scalenes and sternocleidomastoid muscles. Tension in the scalenes or scar tissue from the damage to the muscle can shorten the muscle and create a compression of the brachial plexus. Likewise, tightness in the pectoralis minor can close the space underneath the clavicle (via its insertion on the coracoid process) and create pinching of the brachial plexus in the space between the 1st rib and clavicle.

Chronic tightness here is also an issue with clients who may have had injuries in these muscles and not had them treated or rectified. In particular, this can be an issue for those involved in heavy lifting or the aging person. This can create muscle atrophy, where the muscle fails to be able to perform, and that relates directly to the posture and alignment of the upper thoracic. This is particularly of note with shoulder stabilizers and the posture of the upper body. We have talked at length about this in the article on Scapula Stabilisation and here is a classic case of one issue contributing to another.

There are numerous other factors that can also contribute to the symptoms of TOS and mimic the same symptoms. These involve bone growths and spurs on the cervical spine that occlude the pathways of nerves and blood vessels, cervical subluxation (partial dislocation) and misalignment of the ribs that all contribute to the alignment of the body in this area, and genetic issues such as growth spurs on the transverse process’ of the cervical spine. The articulations of the ribs against the cervical spine are important as these ‘joints’ can have a tendency to misalign. A subluxation can be as simple as the joint not being in its true alignment and this creates issues in the thoracic outlet space as well as the coracoid process AND the anterior scalene. This is all very technical information but it basically results in a misalignment of the bones in and around the spine and the neck.

Symptoms tend to be worse at night for sufferers as well as when they raise their arms overhead. Its the combination of nerve symptoms and vascular symptoms that is the trigger for TOS. The usual pain patterns and type of prickly, hot pain of nerve impingement is combined with a ‘fullness’ of the arm, discoloration as well as fluid issues. Unfortunately, the tests in place for TOS are inconclusive on some clients owing to the particular location of the occlusion which varies from case to case. The standard tests (which include Wright Hyperabduction Test, the Adson’s test) are not always definitive and MRI or radiographs can give information about the bone spurs but not the muscular tightness. Even Nerve conduction tests are inconclusive.

Other conditions that may be mistaken for true TOS are:

  1. arthritis in the shoulders
  2. elbow tendinitis
  3. disc herniation
  4. Cervical ligament injury
  5. rotator cuff injury
  6. Spondylosis
  7. wrist tendinitis or sprain

It’s the combination of factors all together that include both muscular and vascular issues that present true TOS and these can only be determined by a practitioner who understands the multiplicity of these symptoms combined and the indications that they trigger.

TOS treatment comes in many forms and some cases respond exceptionally well to massage and muscular release through the affected muscles in the neck and pectoral area. Some more severe cases need surgical intervention to alter affected nerves and release pressure created by bone abnormalities. The essence is to create space where space has been occluded so in this case, ensuring efficient movement patterns, posture, and exercise with any soft tissue work that can help reinforce these patterns can be ultimately most effective in keeping TOS at bay.

Good links for information on Thoracic Outlet Syndrome:

Thoracic Outlet Syndrome Self Care Tips

Thoracic Outlet Syndrome 1

Thoracic outlet syndrome (TOS)
Brachial Plexus
PRO Massage by Nicola. LMT
PRO Massage by Nicola. LMT
*Disclaimer: This information is not intended to be a substitute for professional medical advice. You should not use this information to diagnose or treat a health problem or disease without consulting with a qualified healthcare provider.
Please consult your healthcare provider with any questions or concerns you may have regarding your condition.
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