TOS an uncommon beast
Thoracic outlet syndrome is a rare but interesting problem that we see from time to time at Movement Centre. Thoracic outlet syndrome (TOS) is not a diagnosis on its own; rather it describes a collection of symptoms. These include neurological and vascular conditions that result from irritation and compression of structures in the anterior neck around the collar-bone. All of which can benefit from thoracic outlet syndrome physio management.
What exactly is thoracic outlet syndrome?
TOS is a condition that occurs when a bundle of nerves, veins and arteries become compressed or irritated as they traverse from the neck down into the arm. Patients present to us with a variety of symptoms, and sometimes an unclear history. Most commonly, patients report that they have intermittent pins and needles, or numbness down into the arm. This can also include neck pain, shoulder and arm pain, or headaches. Prolonged cases can result in weakness and muscle wasting – particularly noticeable in muscles of the thumb.
Patients often report that the paraesthesia or pain is strongly related to posture/ positioning
. Patients may find that when they sit in certain positions – at the desk, or on the push bike – the position they hold their neck and arm in can bring on their symptoms. Usually in the case of TOS, a change to positioning can change the patient’s symptoms.
The causes of thoracic outlet syndrome
It is thought that TOS occurs when there is compression or competition for space at several different points where the neurovascular tissue runs from the neck down into the arm
. The three main areas where this can happen are:
- Between the scalene muscles at the front of the neck
- In the costoclavicular space – under the collarbone
- Behind the pec – the retroprectoralis space
The compression and subsequent symptoms that arise can result from soft-tissue changes / abnormalities such as:
- Scalene muscle hypertrophy
- Abnormalities in the normal anatomy of the scalene muscles or ligaments
- Cysts and soft-tissue tumor formation
Less frequently TOS symptoms may result from bone abnormalities, such as:
- Cervical rib
- Prominent C7 transverse process
- Acute or long-term issues relating to rib fracture
- Acromioclavicular (AC) or sternoclavicular (SC) joint injury.
In our experience, there is often some degree of anatomical change as outlined above, coupled with an increase or change in loading – particularly irritating postures.
Movements and activities that can bring on or aggravate symptoms
Prolonged head forward and shoulder slouched positions are an obvious place to start when looking for contributors for TOS. The advent of work-from-home has meant that office workers are now spending more time hunched over a small laptop on the couch or coffee table. Prolonged time spent hunched forward can create tightness and crowding in the muscles of the neck, and under the collarbone and pec. These positions can exacerbate underlying abnormalities as outlined above.
Other activities and positions we see contributing to TOS development:
- Road cycling – prolonged time spent hunched over the handlebars
- Climbing / Bouldering – prolonged time performing overhead activities
- Repetitive over-arm throwing such as cricket, baseball and water polo
Importance of getting the right diagnosis
While a diagnosis of TOS is somewhat vague, it can be important for us to understand the causes, and rule out other potential factors. Similar symptoms can result from acute or chronic nerve irritation in the neck, or peripheral nerve irritations such as carpal tunnel or cubital tunnel irritations. Likewise traumatic injuries to the shoulder, such as dislocations, subluxations, broken collarbones, or burners/stingers can all create similar symptoms, and need to be assessed for.
While these other injuries can create similar symptoms, the history and mechanism of their onset is often different. At Movement Centre, your physio will use clinical tests to identify the causes of your symptoms. We perform a thorough assessment of the neck and shoulder girdle to rule out any other factors.
Thoracic outlet syndrome physio management – some of the steps we take at The Movement Centre
- Posture and position
Once we understand the contributing factors, we can work to correct them. Physio management often commences with trying to get the patient moving out of the irritating positions (obvious, we know). This is important as decreasing the repetitive irritation to the nerve tissue helps to desensitise it to further irritation. We don’t stress the need for a “correct posture”, but we certainly need to move our neck and shoulders, and move them out of the positions of irritation.
Exercises like chin tucks (we love these) and scapular retractions are great ways to perform alleviating movements throughout the day. These exercises serve as great reminders of the movements our bodies crave – especially when we have been sitting immobile in front of a screen for hours.
- Soft-tissue length and mobility
Thoracic outlet syndrome physio will look at the soft-tissue causes, and work to improve them. This may involve soft-tissue massage work for the muscles of the neck, chest and thoracic spine.
- Cervical and thoracic spine mobility work
Improving the overall range of motion of the neck and back is an important step in managing TOS symptoms. This goes hand in hand with the two steps above. We need to stretch and move the muscles, and consciously move into positions away from the slouched forward postures. For this we need the neck and upper back to be willing to extend into these positions. Exercises such as extension over a foam roller, as well as thoracic rotation exercises are important. As well as this, the chin tucks mentioned above are a great way to encourage cervical spine mobility.
- Strengthening work for the upper back
Strength training is an important part of thoracic outlet syndrome physio management. We focus on exercises to strengthen the muscles of the upper back. These muscles – the lats, traps and rhomboids – help us to maintain upright postures, and move into positions to alleviate TOS symptoms. We love exercises such as rowing movements which draw the scapula across the back. These exercises open up through the front of the chest, and can provide space for the crowded neurovascular tissues running through the front of the shoulder.
- Neurodynamic mobilisations
This is a fancy way of saying “nerve movements/stretches”. Thoracic outlet syndrome physio management will often involve stretches and mobilisations for the nerves running from the neck down into the arm. These mobilisations are designed to make the nerve tissue of the brachial plexus less sensitive to mechanical irritation. This can allow the nerve tissue to tolerate changes and challenges in its positioning, without disrupting its usual flow of information.
Thoracic outlet syndrome physio treatment at The Movement Centre
The answer is movement. The difficulty can be finding the right movement for you, and the right movement to solve your problems. If you are experiencing thoracic outlet syndrome symptoms, come and see our team at Movement Centre. Getting an accurate explanation and diagnosis is key to improving. And our team is dedicated to getting you back to the activities you love.