Physical Therapy for Thoracic Outlet Syndrome
Thoracic outlet syndrome occurs when the nerves, arteries, or veins that run between your collarbone and the highest, first rib are pinched or compressed. The most common type is neurogenic thoracic outlet syndrome (TOS), in which weak or tight muscles cause the brachial plexus, the nerves that control arm muscle movement and sensation, to be pinched and inflamed, often caused by repetitive overhead activities and heavy lifting. Physical therapy is the first line of treatment for neurogenic TOS, utilizing manual therapy, postural retraining, and targeted strengthening of the scapular muscles to relieve symptoms and improve function.
What is Thoracic Outlet Syndrome?
Thoracic outlet syndrome occurs when the nerves, arteries, or veins that run between your collarbone and the highest, first rib are pinched or compressed. Thoracic outlet syndrome (TOS) is named for the pathway, the thoracic outlet, through which the blood vessels and nerves travel en route to the arms and hands. For TOS, the brachial neural plexus, the subclavian artery, and the subclavian vein are most often compressed.
Thoracic outlet syndrome is typically diagnosed in early adulthood, between ages 20 to 40 and women are three times more likely than men to experience TOS.
There are three types of thoracic outlet syndrome:
Neurogenic TOS: Neurogenic TOS is the most common and treatable form of the syndrome at 95% of cases. It generally occurs when weak or tight muscles cause the brachial plexus to become pinched or inflamed. [The brachial plexus is a nerve bundle that controls arm muscles and sensation.] This type of TOS is more common in younger individuals who are involved in repetitive overhead activity and heavy lifting.
Arterial TOS: Arterial TOS is the rarest, most dangerous form of the syndrome and occurs when the arteries under the collarbone are compressed. It can occur when a boney abnormality in the thoracic outlet compresses arteries and limits blood flow. It accounts for 1-2% of cases.
Venous TOS: Venous TOS can occur when new or tiring movements cause damage to veins in the lower neck or upper chest, such as the subclavian vein and axillary vein. It accounts for 3-5% of cases.
Thoracic Outlet Area
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Common symptoms of TOS can include:
Neurogenic symptoms: pain, numbness, and tingling in the hand, arms, shoulders, and neck; headaches; numbness and tingling in the arm; hand clumsiness; intolerance to the cold; hand coldness and discoloration; and symptoms that worsen when the involved arm and hand over the head.
Venous symptoms: pain and swelling in the arm or hands; change in arm color to a bluish discoloration; feeling of heaviness in the arm; and numbness and tingling in the fingers and hands.
Arterial symptoms: pain in the hand, rarely in the shoulder and neck; coldness or intolerance to the cold; and numbness and tingling in the arm.
Thoracic outlet syndrome can result from an acute injury, disease, chronic abnormal posture, repetitive injury, or an anatomical abnormality. Causes of TOS can be due to anatomical abnormalities, a traumatic event, or functional (work or sport). Anatomical abnormalities can include an extra rib located above the first rib (cervical rib) or an abnormally tight fibrous band connecting the spine to the rib. Traumatic causes can include a fall or a car accident that causes a whiplash injury. Functional causes include vigorous, repetitive activity associated with sports or work or poor posture, such as drooping the shoulders or holding the head in a forward position that can compress the thoracic outlet area. Neurogenic TOS can be successfully treated with physical therapy, whereas arterial or venous TOS generally involves consultation with your physician and possibly surgery in severe cases followed by post-surgical physical therapy.
Physical Therapy for Thoracic Outlet Syndrome
Physical therapy is the first line of treatment for neurogenic thoracic outlet syndrome. Exercise therapy under the supervision of a physical therapist has been shown to be a useful, effective approach in the majority of neurogenic thoracic outlet syndrome cases with symptoms improving after exercise and manual therapy interventions. The goal of the physical therapist is to strengthen the upper back and shoulder muscles and postural stabilizers while retraining the patient’s posture and minimizing pain.
The physical therapist conducts a comprehensive evaluation, reviewing medical history leading up to the symptoms and assessing strength, mobility, and strength in the upper extremity, specifically the affected arm and hand.
Physical therapy treatment for neurogenic TOS can include:
Pain management by icing the affected area and modifying activities to minimize pain.
Range of motion exercises: Gentle self-stretching techniques to decrease tension and help restore normal motion in the arm, shoulder, and neck.
Manual therapy: hands-on treatment to gently move your muscles and joints to improve mobility in the neck, shoulder, and arm. The therapist knows how to provide the right amount of manual resistance to improve tension in the thoracic outlet area.
Targeted muscle strengthening: Muscle weaknesses or imbalances can contribute to thoracic outlet syndrome. The physical therapist designs a progressive resistance program, specifically targeting the muscles in the shoulder and shoulder blade, or scapular, region in the upper and mid-back to support posture and relieve pressure on the thoracic outlet area. Exercise also targets deep neck flexor strength, thoracic spine mobility, and functional stabilization movements.
Nerve compression reduction: The therapist works to reduce the amount of compression on the nerves of the brachial plexus through soft tissue massage on the neck and chest muscles to relax the structures, gentle stretching, and the use of nerve gliding movements. These movements attempt to free a nerve from any restriction or compression by gently flossing or gliding the structure back and forth.
Functional training: The therapist teaches the patient correct posture techniques and biomechanics when engaging in daily activities and sports and work-related movements to reduce stress on the neck, shoulder, arm, and thoracic outlet region.
Are you experiencing thoracic outlet syndrome? Work with a physical therapist to relieve thoracic outlet syndrome-related pain and restore function in the upper extremity!
