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Thoracic outlet syndrome can result from:

• An injury
• A disease
• A congenital problem (something you are born with), such as an abnormal first rib

The condition is more common in women than in men, and poor posture and obesity can aggravate the condition.

Psychological changes are often seen in patients with thoracic outlet syndrome. It is not clear whether these changes are a cause or result of the syndrome.

Patients with thoracic outlet syndrome often experience a variety of symptoms. Which symptoms you have often depends on which nerves or blood vessels are compressed. Symptoms from nerve compression are much more common than symptoms from blood vessel compression; they are also easier to diagnose.

The following are common signs of thoracic outlet syndrome:

• Pressure on the nerves (brachial plexus) may cause:
  • A vague, aching pain in the neck, shoulder, arm, or hand
  • Pain, numbness, or tingling on the inside of the forearm and the fourth and fifth fingers of the hand
  • Weakness that may make your hand clumsy
• Pressure on the blood vessels can reduce the flow of blood out of your arm, resulting in swelling, redness, or other discoloration of your arm. Less commonly, pressure can reduce the blood flow into your arm and hand, making them feel cool and easily fatigued (tired).
• Overhead activities are particularly difficult because they worsen both types of compression as the rib, collarbone, and/or shoulder blade compress the nerves and blood vessels.
• Your range of motion may be limited.

Diagnosis of this condition can be more complicated than diagnosis of other more common shoulder conditions because there may be many symptoms to explain. Your doctor's evaluation will include an extensive medical history, physical examination, and diagnostic testing.

Tests

Elevated arm stress test. Doctors often use the elevated arm stress test to help them identify thoracic outlet syndrome. Your doctor will have you raise your arms over your head, then open and close your fists for approximately 3 minutes. If this reproduces your symptoms, it is possible that you have thoracic outlet syndrome. However, people who do not have thoracic outlet syndrome may sometimes have a positive test. 

Elevated arm stress test.

Reproduced from JF Sarwark, ed: Essentials of Musculoskeletal Care, ed 4. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2010. 

Imaging tests. To better see and evaluate the bones, muscles, tendons, and blood vessels, your doctor may order imaging tests. These may include:

• X-rays
• Computed tomography (CT) scans
• Magnetic resonance imaging (MRI) scans
• Ultrasound

Additional tests. Your doctor may order special blood circulation tests and nerve conduction tests to help make the diagnosis.

Often, there is not a clear and obvious way to diagnose thoracic outlet syndrome. In some cases, your doctor will perform many tests to rule out other conditions with similar symptoms, such as pinched nerves in your neck or blood clots. 

In some health care institutions, thoracic outlet syndrome is diagnosed and treated by a multidisciplinary team that includes an orthopaedic surgeon, a physical medicine and rehabilitation specialist (PM&R specialist, or physiatrist), physical therapists, a peripheral nerve surgeon, and/or a vascular surgeon.

Treatment for thoracic outlet syndrome usually does not include surgery.

If you have symptoms of thoracic outlet syndrome, avoid carrying heavy bags over your shoulder because this depresses (pushes down on) the collarbone and increases pressure on the important structures in the thoracic outlet.

You should also do some simple exercises to keep your shoulder muscles strong. Here are four that you can try — do 10 repetitions of each exercise twice (2 times) daily:

• Corner Stretch - Stand in a corner (about 1 foot from the corner) with your hands at shoulder height, one on each wall. Lean into the corner until you feel a gentle stretch across your chest. Hold for 5 seconds.

Corner stretch. You should feel this stretch in the front of your shoulder, your chest, and upper back.

• Neck Stretch - Put your left hand on your head, and your right hand behind your back. Pull your head toward your left shoulder until you feel a gentle stretch on the right side of your neck. Hold for 5 seconds. Switch hand positions and repeat the exercise in the opposite direction.

Neck stretch.  You should feel a gentle stretch in your neck as you pull.

• Shoulder Rolls - Shrug your shoulders up, back, and then down in a circular motion.

Shoulder rolls. Make sure you are standing or sitting up straight when you do this exercise (no slouching). 

• Neck Retraction - Pull your head straight back, keeping your jaw level (straight). Hold for 5 seconds.

Neck retraction. Make sure to keep your jaw straight as you pull your head back (do not drop or raise your jaw).

As with all exercise programs, if any of these movements cause pain, stop immediately.