Thoracic Outlet Syndrome

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Thoracic Outlet Syndrome and You

Thoracic outlet syndrome (TOS) represents a broad spectrum of clinical issues that result from compression of blood vessels and nerves exiting the chest and neck area and going into the arm. The thoracic outlet is a narrow space between the collarbone and first rib where three scalene muscles are located. Through this space the subclavian vein, artery and brachial plexus pass and any of these structures can get compressed to give rise to venous, arterial or neurogenic thoracic outlet syndrome.


*Photo courtesy of Dr. Sidhu


Vascular Thoracic Outlet Syndrome

This type of TOS occurs when one or more of the veins or arteries under the collarbone are compressed. In venous TOS, patients present with sudden onset of arm swelling and pain. An ultrasound will show a clot in the subclavian vein. Arterial TOS presents with diminished blood flow to the arm and hand, sometimes combined with painful fingertips from thrombus emboli. An ultrasound can elicit compression and irregularity of the subclavian artery. Vascular TOS is most commonly present in young adults and athletes, such as baseball players and swimmers, who are involved in repetitive overhead motion.

Neurogenic Thoracic Outlet Syndrome

This form of TOS is characterized by compression of the brachial plexus, which is a network of nerves that come from the spinal cord and control muscle movements and sensation in your shoulder, arm and hand. Neurogenic TOS is complex and can present with varied symptoms, including neck pain, arm pain, headaches, tingling numbness in arm and hand, sharp pain starting in the collar bone area and radiating to the arm that gets worse with repetitive activities.

Nonspecific-Type Thoracic Outlet Syndrome

Also known as disputed thoracic outlet syndrome, patients with this form have chronic pain in the area of the thoracic outlet that intensifies with activity, but a specific cause of the pain cannot be determined.


TOS symptoms can vary widely, depending on which structures are compressed. Symptoms of neurological TOS include:

  • Muscle wasting in the fleshy base of your thumb, also called Gilliatt-Sumner hand
  • Numbness or tingling in the arms or fingers
  • Neck, shoulder or hand aches and pain
  • Weakening grip

Signs and symptoms of vascular TOS can include:

  • Bluish discoloration of the hand
  • Arm pain and swelling
  • Blot clot in veins or arteries in the upper part of your body
  • Lack of color in one or more of your fingers or your entire hand
  • Weak or no pulse in the affected arm
  • Cold fingers, hands or arms
  • Arm fatigue with activity
  • Numbness or tingling in your fingers
  • Weakness of the neck or arm
  • Throbbing lump near your collarbone


Compression of the nerves or blood vessels in the thoracic outlet is the cause of TOS, but some conditions can make you more prone to developing it, including:

  • Anatomical defects that are inherited, such as an extra rib above the first rib or an abnormally tight fibrous band connecting your spine to your ribs
  • Poor posture, involving dropping your shoulders or holding your head forward can cause compression
  • Trauma, including vehicular accidents, can cause internal changes that compress the nerves. The onset of symptoms after a traumatic accident is often delayed
  • Repetitive activity can, over time, wear on your body. Movements such as typing on a computer, working on an assembly line of lifting things above your head can cause compression. Athletes such as swimmers and baseball pitchers can develop TOS from years of repetitive movements

Women are far more likely to be diagnosed with TOS than men. It’s also more common in young adults between 20 and 40 years old.

Occupational Factors

Patients involved in some occupations also appear to be more prone to TOS. Work activities that involve maintaining restrictive postures over a long period of time appear to be involved. Examples of occupations where workers are at higher risk include dental hygienists, anyone typing on a computer, assembly line workers or warehouse workers and others who carry heavy shoulder loads or frequently reach for items above shoulder level are at risk. These motions can cause inflammation and swelling of muscles and tendons in the shoulders and upper arms. Contributing factors include weak shoulder muscles, sloped shoulders, poor posture and obesity.


Dr. Sidhu can evaluate and diagnose all three kinds of TOS and will discuss treatment options. For venous TOS, Dr. Sidhu will use clot-busting medication to dissolve the clot first, and then decompress the thoracic outlet space by removing part of the first rib and freeing the muscles. For arterial TOS, the thoracic outlet space is decompressed. Sometimes the subclavian artery will need reconstruction to restore flow to the arm. For neurogenic TOS, Dr. Sidhu will work very closely with your physiatrist to rule out any neck or shoulder issues, because the symptoms from neck and shoulder problems can mimic neurogenic TOS. The initial management for neurogenic TOS involves specific physical therapy.

During the same period, depending upon the symptoms, patients may need an MRI of the neck and brachial plexus, nerve conduction studies and even scalene muscle block. If the conservative management fails, then surgical decompression of the thoracic outlet space is recommended along with freeing the nerve bundle to manage the complex nature of TOS.

When you need comprehensive care for thoracic outlet syndrome, come to Vein, Vascular, Primary Care & Aesthetic Associates. We serve the communities of Serving the communities of Everett, Issaquah, Kirkland, Newcastle, Seattle and Sammamish.

When you need vascular and endovascular procedures or vascular ultrasound, choose the double board-certified surgeon at Vein Vascular, Primary care & Aesthetic Services. For more information or to make an appointment, call us today at 425-250-9999. For your convenience, you can use our online Request an Appointment form.


Dr. Sidhu
Dr. Ramandeep Sidhu

Author - Dr. Ramandeep Sidhu

SPECIALTIES: Percutaneous aneurysm repair, endovascular treatment of peripheral arterial disease, treatment for varicose veins, open vascular surgical procedures, deep vein thrombosis/pulmonary embolism treatment and aesthetic services.


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