Thoracic Outlet Syndrome (TOS) is a very common diagnosis, affecting approximately 8% of the population. Pain with TOS often presents anywhere between the neck, face, occipital region or into the chest, shoulder, with paresthesia into the upper extremity. Just all other syndromes this diagnosis encompasses a host of signs and symptoms and doesn’t tell us the specific pain generator. TOS can be broken down into neurogenic TOS (95-98% of cases according to Davidovic et al. 2003) vs. vascular TOS. Of Vascular there can be either Arterial TOS or Venous TOS. Despite this vague diagnosis, this article will demonstrate 7 Exercises to beat TOS.
What can Cause TOS?
-Lowering anterior chest wall
-Hypetrophy of scalene muscles
-Forward flexed neck
-Repetitive stress injuries (sitting at keyboard for long hours)
Congenital Abnormalities include:
-Prolonged Transverse process C7
-Enlarged scalene muscles (COPD, Bodybuilders)
-Congenital elevated scapula
Potential sites of compression:
- Interscalene triangle: between the anterior and middle scalene.
- Costoclavicular space: between clavicle and the first rib.
- Subcoracoid or Sub-pectoralis minor space: beneath the coracoid process and under the pectoralis minor tendon. Shown here is an image of all 3 sites of potential compression.
7 Of My Favorite Exercises for TOS
Banded pull apart
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- HOW: Begin this exercise upright. Hold each end of a band of desired resistance, then spread the band. Focus on initiating this motion with your scapula/shoulder blades and following out with the shoulders.
- FEEL: You should feel the shoulders working.
- COMPENSATION: Avoid arching the back and shrugging the shoulder that is lifting up.
- Perform for 2×15 repetitions.
- For This Exercise Begin by Finding a Chin Tuck, this can be achieved by making a double chin.
- When found, apply moderate resistance into your forehead with your hand and hold for five seconds. Follow this up with applying resistance to each side of your head for 5 seconds while maintaining a chin tuck.
- Perform this for a total of 5 rounds
- This may help open up space under the Subcoracoid or sub-pectoralis minor space which is often the culprit of creating TOS symptoms.
- Perform for 2×30 seconds.
Thoracic Spine Foam Rolling
- Place the foam roller perpendicular to your spine. While grabbing onto a stick/pipe, elevate your arms as far back as you can-in an attempt to touch the floor. This movement is very similar to a wall angel.
- Spend a few repetitions on each segment-then move up toward the next. Don’t allow your butt to come off the floor or your ribs from flaring out this is typically due to compensation from your low back!
- A more aggressive way to perform this exercise is by using an external load of a weight as shown here. This will make the stretch more passive and less active. A stiff thoracic spine may contribute to issues up the kinetic chain to the shoulders/neck.
- Self mobilize the thoracic spine for 2 minutes. You can keep your head supported with your hands if you feel like you are straining your neck.
Quadruped Scapula Push-Up
- This will help target muscles on the front of the scapula, primarily referring to the Serratus Anterior.
- Similar to the banded pull-apart, exercises that help strengthen the scapula are very helpful for individuals with TOS as long as your are under the symptom threshold. When scapula muscles are not working in synergy, muscles such as the Scalenes and Pec’s often are overused which may lead to TOS.
- Make sure to keep the neck neutral by maintaining a slight chin tuck for this exercise, Avoid arching your neck.
- Perform for 2×15 repetitions
There are two mobilizations here. One is for your first rib, the second is for the scalene muscles. These may help open up the space in between the Costoclavicular or Subcoracoid space.
The brachial plexus (a network of nerves running from your spine down your arms) is running directly over the 1st rib, thus when elevated you can see how pressure is put on the nerves and vessels passing through this area. This is called TOS and symptoms often consist of limited neck & shoulder range of motion. This syndrome may also be associated with pain in this region that can travel all the way down the arm. When performing the mobilization, be careful, there are a lot of tissues around this area.
- Sit on the back end of the towel and wrap the towel around the top of your shoulder girdle. Bring the other end of the towel down towards opposite hip.
- For the second stretch here, stabilize your scapula by sitting on your hand or holding something like the bottom of the chair shown here. While maintaining a slight chin tuck side bend your head the other direction.
- Perform these for 2×30 seconds each.
Numbness and Tingling?
Often time the Ulnar nerve is the culprit of the numbness and tingling going down the arm into the ring and pinky finger.
- This Ulnar nerve mobilization may help with these symptoms. Be very gentle with this mobilization, as irritation here can lead to a delayed response in pain.
- Perform very slowly for 2×15 repetitions.
With all these exercises, proceed with caution. We recommend to seek advice from a professional when dealing with a diagnosis such as Thoracic Outlet Syndrome. This is a difficult syndrome to diagnose and sometimes may seem a bit ambiguous. Evidence is not great around Thoracic outlet syndrome, most studies cited here are level 3,4, and 5 evidence. Despite this, prognosis is often good with conservative care!
-Lindgren K. Thoracic outlet syndrome. International Musculoskeletal Medicine. March 2010;32(1):17-24. 2011.
-Laulan J, Fouquet B, Rodaix C, Jauffret P, Roquelaure Y, Descatha A. Thoracic Outlet Syndrome: Definition, Aetiological Factors, Diagnosis, Management and Occupational Impact. Journal Of Occupational Rehabilitation [serial online]. September 2011;21(3):366-373. Available from: CINAHL Plus with Full Text, Ipswich, MA. 2011.
-Andrew K Chang, MD et al.; Thoracic Outlet Syndrome in Emergency Medicine; Medscape. 2014.
-Hooper et al. Thoracic outlet syndrome: a controversial clinical condition. Part 2: non-surgical and surgical management. 2010.