Thoracic outlet syndrome

A case of thoracic outlet syndrome is characterised by tingling in the arm and hand when the limb is used above the head. It is also often the underlying cause of carpal tunnel syndrome, tennis elbow and the frozen shoulder.

This page was last updated by Dr Barrie Lewis on 9th July, 2021.

Symptoms of TOS

The symptoms of TOS are varied and complex depending on whether nerves or blood vessels or both, in the neck are involved. Generally only one arm is affected, commonly with pain, tingling in the limb, or just a dull ache.

An ache in the muscles of the lower neck is common.


A central diagnostic question to be faced is whether the pain and tingling in the arm is caused by a nerve root issue, as in a severely compromised intervertebral foramen, or in the thoracic outlet.

One small rule of thumb may be useful; working with the arm above the head worsens the tingling in TOS but generally relieves the pain in a degenerative IVF.

It's not uncommon after a whiplash injury in which there is sudden contraction of the scalene muscles, sometimes subluxating the first rib. Then the inter scalene triangle becomes dysfunctional, affecting the subclavian artery and brachial plexus on their way to the arm.

The classic sign is a reduced pulse in the wrist with certain movements of the head together with breathing.

Very occasionally a tumour in the apex of the lung may cause a thoracic outlet syndrome; smokers beware.

Diagram showing how the thoracic outlet can cause arm pain.

1. NERVES

The C6 dermatome refers to the thumb and forefinger.

The hallmark of TOS is that a broader spectrum of the arm is often affected, as distinct from a dermatomal pattern, where only a part of the arm is affected.

Why? Because the arm is supplied by five nerve roots, called C5, C6, C7, C8 and T1, so, if you have a pinched nerve in the spine, you are likely to have pain limited to a specific part of the arm, rather than generalised arm pain that may occur in what is sometimes called the first rib syndrome.

You may have just lower arm tingling, in the thumb and forefinger, for example; that's the sixth nerve root from the neck, shown above.

Or in the pinkie and ring finger. That's the C8 dermatome.


In the thoracic outlet syndrome however, not the nerve root per se, but a large bundle of nerves called the brachial plexus is affected, so the pain will be in broader aspects of the arm mostly, and also perhaps over the chest and parts of the shoulder and back.

It is caused primarily from a subluxation of the first rib. This syndrome, because it affects several nerves, also makes you vulnerable to tennis elbow and other syndromes of the shoulder and wrist. It's commonly the underlying cause of frozen shoulder and carpal tunnel syndrome for example.

One exception is the eighth cervical nerve root which lies immediately on the first rib. It's affected more than other nerve roots so the ring finger and pinkie may be primarily effected, mimicking a C8 nerve root lesion in the intervertebral foramen.

It's not common, as the vein from the arm only passes through the interscalene triangle in a small percentage of cases, but the venous return from the arm can be affected. Then the arm is likely to swell and it's wise to get a medical opinion; rule out a deep vein thrombosis in the arm.

2. ARTERY

The blood vessel carrying oxygenated blood to the arm may also be affected, in which case the arm may feels cool, and aches with use, a condition called intermittent claudication, more classically felt in the leg.

The arm tends to tire quickly whether from lack of oxygenated blood, or nerve supply, or both. Working above your head, as in using a drill to put in a curtain rail, or hanging the washing, becomes very tiring. More later about why. Mouse arm may also be caused by this condition, if the arm is unsupported.

The vein bringing blood back from the arm is rarely involved as it does not usually pass through the "thoracic outlet". If it is affected, the arm may swell alarmingly. Notice here that the vein (blue) does not pass between the anterior and medial scalene muscles.

The triangle formed by the two scalene muscles and the first rib is called the inter scalene triangle.

Thoracic outlet syndrome

Anatomical diagram showing pain generators in the thoracic outlet syndrome.

Heart Attack


Commonly, at the coalface, we see patients who have thought they were having a heart attack if the pain was in the left arm, and also the chest. Sometimes their doctors thought so too. Not infrequently they have been through a whole gamut of cardiac tests, some of them quite invasive and dangerous in themselves.


Obviously, because of the seriousness of a heart condition, this needs to be ruled out first, but our counsel is that, before expensive and invasive tests are considered, it is wise to consult a chiropractor to evaluate whether the pain in the chest and left arm could be coming from the thoracic outlet, rather than a myocardial infarct; or even a Tietze's syndrome.

For an interesting case of a thoracic outlet syndrome, a man who went through a year of misery, and extensive, and very costly medical tests for a heart condition, visit our chiropractic coalface stories.

I'll be waiting for you, whilst you go down these country website lanes, but remember to come back. Sigh, it's so easy to get sidetracked on the web,  with so many inviting little cul de sacs.

Use the back arrow to return to this page. Meantime, I'll get a few pictures ready that will show you visually how a first rib subluxation can cause so much pain and tingling in the arm and chest.

If you enjoy reading, chiropractor Bernard Preston tells delightful inspiring chiropractic stories that will entertain and educate you. Watch out, expect to be stretched. His hobbies, like soaring with the eagles, are enthralling, but all the stories are in a chiropractic context. For an excerpt chapter, click here.

Big Toe

Cover of Frog in my Throat, a book by Bernard Preston, including a story on the thoracic outlet syndrome.


WHAT IS THE "THORACIC OUTLET"?

aka "Inter Scalene Triangle".

The blood vessels (Subclavian a. and v.) to and from the arm, and a large bundle of nerves (the Brachial Plexus), travel through a narrow passageway that runs in the deep valley just behind and below your collar bone. Run your fingers forward from the large shoulder/ neck muscle forming the nape of the neck. Just before you reach the collar bone you will discover this gully. Deep in it you can feel

  1. something hard (the first rib) and
  2. bundles of muscles (the Scalenes),

both of which may cause the Thoracic Outlet Syndrome as the artery and nerves pass through the Inter Scalene Triangle.

Inter scalene triangle

Boundaries of the inter scalene triangle.

The inter scalene triangle is a passageway made of a triangular gap between the collarbone, the first rib and two large neck muscles (the Scalenes).


Another graphic of the structures involved in TOS.

Spasm of the neck muscles, after a car accident, for example, or even after prolonged computer use if the arm is unsupported are often part of the problem.

Subluxation in the region or a hard fall on the limb, which may jam the clavicle up against the rib may contribute to this syndrome.


If there is pressure on the nerves, or the blood vessels, or both, the arm will be affected, usually with a deep ache, and sometimes tingling, and very rarely with wasting of the muscles.

This is the thoracic outlet syndrome.

See how the plexus of nerves, and especially the lowermost C8 root lie on the first rib?

There are other causes of pressure on these nerves and blood vessels. A Pancoast tumour at top of the lung (yes, caused by smoking) or an anomaly that you were born with and others things, but these are rare conditions that may provoke the thoracic outlet syndrome.

Carpal tunnel syndrome

Carpal tunnel syndrome fairly frequently does not respond complete to surgery in the wrist.

Thoracic outlet syndrome may also be a factor in the so called double crush syndrome, and be the underlying cause of a tennis elbow, for example, or carpal tunnel tingling.

Cervical Rib

Normally only the thoracic vertebrae in the midback have ribs. Twelve pairs. However, at the transition areas to the low back and neck, sometimes ribs form.

These have been implicated in the thoracic outlet syndrome. Surgeons like to remove them, but I fairly regularly treat people who have had the surgery, and still have the tingling and numbness in the arm.

It's quite a gruesome operation - through the armpit (axilla). Certainly I would suggest you consult your chiropractor for an assessment before having this surgery.

Diagram showing how a cervical rib can affect the inter scalene triangle.


How is TOS diagnosed?

The classical orthopaedic test for Thoracic Outlet Syndrome was designed by a Dr Adson. Your chiropractor will turn your head towards the side of pain, ask you to look up, and take in a deep breath, whilst extending the arm and testing the pulse in your wrist.

You can try it for yourself. Does taking up this position cause tingling or an ache in your arm? Testing the pulse is more subtle, and I think it unlikely you could be objective enough.

Adson's Test

The classic way of doing Adson's test with the arm extended, for me, produces too many false positives: a positive test in a perfectly normal person. So I do it with the arm in the neutral position and, vitally, the pulse must grossly decrease as this position is taken up and return when the head returns to neutral and the patient exhales.

Adson's test for tingling in the arms and hands.

Chiropractic Help Treatment

Chiropractic excels in the management of Thoracic Outlet Syndrome, except in its extremest forms which are very rare. Adjustment of the first rib opens the space in the tunnel, and cross friction of the two muscles that form the sides of the triangle helps too.

Sometimes the joints on either side of the collar bone, may be involved too. AcromioClavicular joint ...

Exercises for the neck and shoulder are important.

This is a complex syndrome, but generally patients respond well to chiropractic management.

Tip: Rest the elbow on a small table placed at your side whilst using the mouse. This takes the stretch off the muscles in the neck, and the nerves. Various commercial supports which attach to the computer station may also help.

Tip: Carrying heavy parcels in that hand is likely to aggravate the pain in the arm, as is working above your head.

Tingling in arms and hands

Tingling in an arm and hand is in clinical experience a common complaint; the fixated first rib and associated scalene muscle spasm is often the underlying cause of many of the arm pain syndromes like frozen shoulder and carpal tunnel tingling; every patient with pain and tingling in the arms and hands should have the Adson's test performed; thoracic outlet syndrome is not rare.

Particularly if the tingling is worse when the hand is being used above the head.

IMPORTANT CONSIDERATIONS


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A pancoast tumour can affect the thoracic outlet causing tingling in the arms and hands.

Useful links

These two arm pain case histories will be of interest.

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I receive many questions at Chiropractic Help. It might be help for a spinal condition, but it could also be about a failed Carpal Tunnel operation, or some such thing.

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