Thoracic Outlet Syndrome (TOS)

A condition caused by compression of nerves or blood vessels in the narrow space between the neck and shoulder, resulting in numbness, pain, and weakness in the arm.

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What is this Condition?

Thoracic outlet syndrome occurs when the nerve network and major blood vessels going to the arm are compressed as they pass through the narrow space between the neck and shoulder. Space is limited in this area between the neck muscles, first rib, and clavicle; if it narrows for various reasons, nerves or blood vessels come under pressure. The most common type involves nerve compression and causes numbness, tingling, pain, and weakness in the arm and hand. In much rarer types, an artery or vein is compressed; these can cause symptoms such as cold hands, color changes, or sudden swelling. Symptoms often worsen when raising the arm overhead. The foundation of treatment in most patients is physical therapy and posture correction.

Symptoms

Numbness and tingling in the arm and hand, especially in the ring and little fingers

Pain in the neck, shoulder, and arm radiating distally; particularly worsening at night or when raising the arm overhead

Decreased grip strength in the hand, dropping objects

Rapid fatigue in tasks requiring the arm to be held overhead

Cold hand, pallor in the fingers or color changes

Vascular type: sudden swelling in the arm, bruising, or sudden coldness and pain in one or several fingers

Diagnosis Methods

Diagnosis is largely based on physical examination. The physician moves the arm to specific positions and observes whether symptoms are reproduced and whether the pulse weakens (Adson, Wright, Roos tests). Neck X-ray shows whether there is an extra rib (cervical rib). MRI evaluates soft tissues and nerve compression. Electromyography (EMG) helps differentiate other conditions with similar symptoms. If vascular type is suspected, vascular imaging (angiography, venography) is performed.

Treatment Methods

In the nerve type, treatment almost always starts with physical therapy and is sufficient in most patients. Posture correction, stretching and strengthening exercises for neck and chest muscles, ergonomic adjustment of the work environment, and avoiding movements that require holding the arm overhead are important. Medications or muscle-targeted injections may provide support for pain. Surgical intervention is considered in patients who do not respond adequately to typically 3-6 months of physical therapy, have progressive weakness, or have vascular compression; the most commonly performed procedure is first rib removal. In the vascular type, the situation may be urgent.

Physical therapy: posture correction, stretching and strengthening exercises for neck and shoulder muscles (first and most common treatment)

Work environment adjustment and avoidance of activities requiring arm elevation

Medication for pain or injections targeted at the compressed muscle

Surgery in patients with inadequate response or vascular compression (frequently first rib removal)

References

Greenberg MS. Handbook of Neurosurgery. 10th ed. Thieme; 2023:581-582.
Toussaint CP, Zager EL. Thoracic outlet syndrome. In: Winn HR, ed. Youmans and Winn Neurological Surgery. 6th ed. Elsevier; 2011.
Kim DH, Midha R, Murovic JA, Spinner RJ. Kline and Hudson's Nerve Injuries: Operative Results for Major Nerve Injuries, Entrapments, and Tumors. 2nd ed. Saunders/Elsevier; 2008.

This content is based on academic sources and is for general information only; individual assessment requires a medical examination.

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Thoracic Outlet Syndrome (TOS)

Peripheral Nerve Surgery

1Overview

What is this Condition?

Symptoms

Diagnosis Methods

Treatment Methods

References

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