Thoracic Outlet Syndrome

What is thoracic outlet syndrome?

Thoracic outlet syndrome (TOS) is a condition that occurs when nerves or blood vessels are compressed (pinched) in the thoracic outlet. The thoracic outlet is the area between your collarbone and your first (top) rib. Nerves and blood vessels run through the thoracic outlet as they go from your chest out to your hands.

What are the types of thoracic outlet syndrome?

Ask your caregiver about these and other types of TOS:

• Neurogenic thoracic outlet syndrome (NTOS): NTOS occurs when your nerves are pinched. This is the most common type of TOS. The exact cause of NTOS may not be known. If the cause is not known, it is called disputed or nonspecific NTOS.
  
  
• Vascular thoracic outlet syndrome: Vascular TOS occurs when your blood vessels are pinched. Vascular TOS may cause blood clots to form. This can lead to complete blocking of the blood vessels. Pieces of clot may break off and cause damage to the hand or lungs. Vascular TOS is broken into two types:
  
  
  • Venous thoracic outlet syndrome (VTOS): VTOS occurs when veins are pinched. Veins are blood vessels that move blood toward the heart.
    
    
  • Arterial thoracic outlet syndrome (ATOS): ATOS is a rare type of TOS that occurs when arteries are pinched. Arteries are blood vessels that move blood away from the heart.

What are the signs and symptoms of thoracic outlet syndrome?

Your signs and symptoms depend on the type of TOS you have. You may feel symptoms on one side of your body or on both sides. Signs and symptoms may come and go. They may get worse when your arm is raised above shoulder level. They may also get worse after activity, such as throwing a ball. You may have one or more of the following:

• Pain, tingling, or both in the head, neck, shoulder, arm, or hand.
  
  
• A loss of feeling in your arm or hand.
  
  
• A weak grip.
  
  
• The muscles in your hand are weak and your hand may look smaller.
  
  
• Swelling and aching in your arm or hand.
  
  
• A cold, pale, or bluish arm or hand.

What causes thoracic outlet syndrome?

• Congenital problems: Congenital problems exist since birth. You may have cervical ribs. A cervical rib is an extra rib at the top of your rib cage, close to your collarbone. You may have bands of muscle fibers near your thoracic outlet. The scalene muscles found on each side of your neck may be larger than normal. All of these problems can narrow the thoracic outlet and cause TOS. If you have any of these congenital problems, you may also be more likely to develop TOS after an injury.
  
  
• Injuries: If you break a bone, extra bone or scar tissue may grow where the bone heals. Growth on your collarbone, top rib, or neck can cause TOS. The extra bone or scar tissue may take time to grow. As a result, symptoms of TOS may not occur right after an injury.
  
  
• Repeated movements: Blood vessels or nerves can be pinched when you do the same activity over and over. Repeated overhead arm movements, such as those done in swimming, tennis, and football, can cause TOS. Repeated movements done at work, such as working on a computer or an assembly line, can also cause TOS.
  
  
• Drooping shoulders: If your shoulders droop, the space around your thoracic outlet may narrow, leading to TOS. Drooping may occur with age. Shoulders may also droop because of poor posture (not standing up straight).

How is thoracic outlet syndrome diagnosed?

Your caregiver will ask about your symptoms and your health history. He will look at your neck, shoulders, ribs, arms, and hands. He will check your posture. He will also check the nerves in your arms and hands, your reflexes, and your sense of touch. Ask your caregiver for more information about these and other tests you may need:

• Tests to check your symptoms: Your caregiver may take your pulse and ask you to move your head, neck, arms, or hands in different positions. He will ask about your symptoms during these movements.
  
  
• Chest x-ray: A chest x-ray takes pictures of the bones and tissues in your chest. This test is used to check for a broken collarbone or to see if you have cervical ribs. These pictures also help caregivers see if you have tissue problems, such as a mass.
  
  
• Magnetic resonance imaging: This test is also called an MRI. During an MRI, pictures are taken of your muscles, bones, or blood vessels. An MRI is used to check for problems and changes in your thoracic outlet. You will need to lie still during an MRI. Never enter the MRI room with any metal objects. This can cause serious injury. Tell your caregiver if you have any metal implants in your body.
  
  
• Scalene muscle injections: Numbing medicine may be injected into the scalene muscle to weaken it. A chemical may be injected to damage nerves near the muscle. If either of these injections decreases your pain, you may have TOS.
  
  
• Electromyography and nerve conduction studies: Electromyography (EMG) is a test that measures the electrical activity of your muscles. Your muscles are tested at rest and while you are using them. An EMG test may also check the nerves that control your muscles. Nerve conduction studies check for problems with how nerve signals are sent near the thoracic outlet.

How is thoracic outlet syndrome treated?

Ask your caregiver for more information about these and other treatments you may need:

• Medicines:
  
  
  • Nonsteroidal anti-inflammatory (NSAID) medicine may decrease swelling and pain or fever. This medicine can be bought with or without a doctor's order. This medicine can cause stomach bleeding or kidney problems in certain people. If you take blood thinner medicine, always ask your primary healthcare provider if NSAIDs are safe for you. Always read the medicine label and follow the directions on it before using this medicine.
    
    
  • Blood thinners: This medicine helps prevent clots from forming in the blood. Clots can cause strokes, heart attacks, and death. Blood thinners make it more likely for you to bleed or bruise. Use an electric razor and soft toothbrush to help prevent bleeding.
  
  
• Physical therapy: A physical therapist helps you with special exercises. These exercises help strengthen the muscles in your neck, shoulders, and back. This can help increase the amount of room in the thoracic outlet. These exercises can also help improve your posture.
  
  
• Surgery: Surgery may relieve pressure on your nerves or blood vessels. Surgery may be done if medicine and exercise do not relieve your symptoms. Caregivers may cut or remove one or more ribs. They may cut or remove your scalene muscles. Caregivers may remove the fibrous bands in the thoracic outlet.

How can I help manage my thoracic outlet syndrome?

• Rest and elevate. If you have vascular TOS, your caregiver may tell you to rest and elevate (raise) your arm. When you are sitting or lying down, prop your arm on 2 to 3 pillows. This will raise your arm above the level of your heart and decrease swelling.
  
  
• Avoid activities that make your symptoms worse. Do not sleep with your arms above your head. Avoid activities that involve repeated overhead movements.

What are the risks of thoracic outlet syndrome?

Ask your caregiver about these and other risks of TOS:

• You may have decreased movement of your arms. Scalene muscle injections may cause nerve damage. This can lead to arm pain and tingling. Surgery may not relieve your symptoms. You may have bleeding problems or an infection after surgery. Nerve and lung damage may occur. Your signs and symptoms may come back after treatment.
  
  
• You may get a blood clot in your arm. This can cause pain and swelling, and it can stop blood from flowing where it needs to go in your body. The blood clot can break loose and travel to your lungs. A blood clot in your lungs can cause chest pain and trouble breathing. This problem can be life-threatening. ATOS can damage arteries, which may block the blood flow to the hand and lead to aneurysms. An aneurysm is swelling of part of a blood vessel. This can lead to chronic (long-term) pain. Aneurysms may cause similar signs and symptoms as TOS.
  
  
• Without treatment, NTOS may cause permanent nerve damage. Without treatment, VTOS may cause chronic problems such as pain, swelling of the arm, and tiredness from exercise. Delayed treatment of ATOS can lead to a chronic pain syndrome.

Where can I find support and more information?

It can be hard to cope with the chronic pain of TOS. You may feel frustrated and sad. These feelings are normal. It may help to learn all you can about TOS. Ask your caregiver for more information. You can also contact the following:

• National Institutes of Health
  9000 Rockville Pike
  Bethesda , MD 20892
  Phone: 1- 301 - 496-4000
  Web Address: www.nih.gov
  

When should I call my caregiver?

Call your caregiver if:

• You have pain, numbness, or tingling in your head, neck, shoulder, arm, or hand.
  
  
• You have a weak grip.
  
  
• One hand looks smaller than the other.

When should I seek immediate help?

Seek care immediately or call 911 if:

• Your arm, hand, or both ache or feel heavy.
  
  
• Your arm, hand, or both feel cold, look pale, or have a bluish color.
  
  
• Your arm feels warm, tender, and painful. It may look swollen and red.
  
  
• You have chest pain or trouble breathing that is getting worse over time.
  
  
• You suddenly feel lightheaded and have trouble breathing.
  
  
• You have new and sudden chest pain. You may have more pain when you take deep breaths or cough. You may cough up blood.

Care Agreement

You have the right to help plan your care. Learn about your health condition and how it may be treated. Discuss treatment options with your caregivers to decide what care you want to receive. You always have the right to refuse treatment.

Learn more about Thoracic Outlet Syndrome