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Integrated Pain Management


Thoracic outlet syndrome (TOS)…

Thoracic Outlet Syndrome is a term use in describing a group of disorders resulting from the compression, irritation or injury of the blood vessels and/or nerves in the upper chest and lower neck area.

Thoracic Outlet Syndrome

The name is derived from the thoracic outlet, which is the space between the upper chest and the lower neck where the affected grouping of blood vessels and nerves is found.

Signs and Symptoms

The signs and symptoms of thoracic outlet syndrome will include pain in the shoulder, arm, or neck, numbness, and in some cases the impaired circulation of blood in the affected area.

There is a common confusion of the pain experienced in thoracic outlet syndrome and the pain for angina which is pain in the chest as a result of lack of enough oxygen in the muscles of the heart.

The two conditions are distinguished because pain associated with thoracic outlet syndrome will not worsen with walking; it increases when an individual raises the affected arm.

The signs and symptoms the patient is experiencing will assist in the determination of the disorder they are suffering from.

Thoracic outlet syndrome disorders will vary according to the body part or parts affected. In most cases, the syndrome will affect the nerves but there are other cases that involve blood vessels; but this type of thoracic outlet syndrome is not as common as the nerve related one.



This is a thoracic outlet syndrome type that is associated with soft and bony tissues in the lower part of the neck.

The condition is caused by the irritation and compression of the brachial plexus nerves which are the nerves supporting movement and sensory functions to the arm all the way to the fingers.

The symptoms will include numbness, weakness experienced in the hand, hand muscle size decrease (occurs in one side of the body) pain, tingling, numbness and weakness of the neck, arms and chest.


This is another thoracic outlet syndrome type that occurs as a result of damaged major veins in the upper part of the chest and lower neck region.

This condition will mostly appear suddenly after tiring or unusual arm exercise. Symptoms will include swelled arm, hands and fingers, weakness and heaviness of the neck and arms.

The veins in the front of the chest will appear swollen or dilated.


This type of thoracic outlet syndrome is the least common but the most serious of the three.

This type is caused by congenital abnormalities of bony tissues in the upper chest and lower neck region. Symptoms associated with this type include coldness in the hands and fingers, sore fingers, numbness, and inadequate blood circulation in the fingers, hands and arms.


The disorders resulting from thoracic outlet syndrome are not clearly understood.

What is known is that the compression of verves and/or blood vessels in the thoracic outlet passage ways will lead to their irritation and this is what leads to thoracic outlet syndrome.

This syndrome can arise as a result of an extra first rib or because of an old fracture of the collarbone which will be responsible for the reduction of the space normally occupied by the nerves and the blood vessels.

There are many causes of thoracic outlet syndrome but soft and bony tissues are among the most common.

Risk Factors

The following are some of the factors that will increase the risk thoracic outlet syndrome development.


Primary Headache

> Tumors or large lymph nodes located in the underarm or in the upper part of the chest

> Sleep related disorders

> Poor posture

> Back or neck injury

> Depression or stress

> Repetitive injuries resulting from carrying heavy loads on the shoulder

> Participation in sports or games that involve repetitive moving of the shoulder or arm such as swimming, basket ball, handball, volleyball, golfing, baseball, cricket among many others.

> Weight lifting


The success in the treatment of thoracic outlet syndrome starts with the right diagnosis.

Medical experts who can treat this condition include vascular medicine physicians, thoracic/chest surgeons, and vascular surgeons.

The medical practitioner will carry out a physical examination and also look at the diagnostic history of the patient.

Some physicians will carry out evaluations that are aimed at eliminating neurological conditions such as cervical spine disease which might have similar symptoms as thoracic outlet syndrome.

Some of the additional test that might be included in the diagnostic process includes nerve conduction studies for the evaluation of the motor and sensory nerve functionality.

Vascular studies which include the assessment of veins and arteries. Others may include chest x-ray, cervical spine x-ray, CT scan or MRI of the chest and spine, MRI of the blood vessels, blood tests and venogram or arteriogram which is x-ray that used dye to observe the blood flow.


The evidence of the treatment of thoracic outlet syndrome is still poor but there are cases that have been reported where the patients responded well to conservative treatments such as rest, physical therapy and medications. It is only in rare cases that surgery is used, or needed.

Physical Therapy

Physical therapy and stretching are the most common non-invasive treatment approached used in managing thoracic outlet syndrome.

The stretching is aimed at reducing the impingement of nerves and blood vessels, decompression of the thoracic cavity and realigning of the ligaments, muscles, tendons and bones that might be causing the problem.


Cortisone injections into the muscle or joint involved will assist in decreasing the inflammation. Botox injections might be used but will not do better tan placebo.

Surgery has also been used in successfully managing thoracic outlet syndrome especially in cases where the 1strib is behind the nerve, vein or artery compression and involves removal of this rib.

The same technique can also be used in the removal of a cervical or rudimentary rib causing the compression.

Physical therapy is used before the surgery to improve the outcome and after the procedure to improve the recovery process.he outcome and after the procedure to improve the recovery process.