Arm and neck pain are very common complaints. These problems are most commonly caused by tension in the neck muscles, neck hernia, tendon compression or tear in the shoulder . However, in some people, the problem may be caused by thoracic outlet syndrome. Thoracic outlet syndrome can be overlooked because it is a relatively rare condition and there is no specific diagnostic test.

Thoracic outlet syndrome (thoracic outlet syndrome = TOS) is a problem characterized by arm pain, numbness and weakness. The reason is the compression of the nerves and blood vessels going to the arm. The thoracic outlet is a region that extends from the pit above the collarbone to the armpit. Compression can occur in three anatomical areas: between the collarbone and the first rib (costoclavicular space), between the neck muscles called the scalene triangle, and the pectoralis minor space (subcoracoid space). There are three types of thoracic outlet syndrome according to the compressed structure:

  • Neurogenic TOS: Nerve compression occurs in 95% of all TOS patients.
  • Venous TOS: Venous entrapment accounts for 4% of patients.
  • Arterial TOS: Compression of the artery occurs in 1% of TOS cases.

Artery or vein entrapment is also sometimes referred to as vascular TOS in general terms.

Signs and Symptoms

Neurogenic TOS: There is compression of the nerve bundle called the brachial plexus. Symptoms such as pain, weakness, numbness and tingling in the hand and arm may be seen. There may be neck pain and pain in the back of the head. If there is nerve damage, thinning of the muscles on the thumb side of the hand (Gilliatt-Sumner hand) may occur.

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Venous TOS: Also known as Paget-Schroetter disease. There may be bruising, swelling and tingling in the arm.

Arterial TOS: Coldness, numbness, tingling, pain and paleness may be seen in the hands and fingers. There may be complaints of cramping and fatigue (claudication) in the hand during work. The pulse may be weak or not felt. The pain is usually in the hand and arm, but can also be felt in the shoulder and neck.


Neurogenic TOS generally occurs due to neck trauma, whiplash injury, and excessive repetition of certain movements during work. Excessive stretching of the muscles leads to injury and the formation of micro-scar tissue. Scar tissue can press on the nerves going to the arm. Poor posture, carrying a heavy backpack for a long time, having a congenital extra rib at neck level or a band extending from the spine to the rib bone are also among the reasons. Rarely, it may develop due to tumor.

Venous TOS usually occurs with forceful movements of the arm that injure the subclavian vein, which is the main vein of the arm. Variations other than normal anatomy can put pressure on the vessel. Repetitive movements that force the arm and shoulder can cause clot formation and congestion in the vein.

Arterial TOS occurs with clot formation in the subclavian artery, the main artery of the arm. Most of the time, although a clot has formed, the person may not have any symptoms. Complaints may occur when the clot breaks into small pieces and impairs circulation in the elbow and hand. Congenital extra ribs (cervical ribs) or differences in the shape of the first rib can trigger clot formation.

Who Is It Seen?

TOS is most common in adults aged 20-40 years. It is more common in women than men.

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A Related Problem: Pectoralis Minor Syndrome

Pectoralis minor syndrome is a condition that causes pain, numbness and tingling in the hand and arm. It can be seen together or alone with TOS. Its symptoms are similar to TOS, but there may be pain and tenderness below the collarbone, on the chest wall, and under the armpit. Pain may also be felt in the collarbone and back. The reason is the tension of the pectoralis minor muscle under the pectoralis major muscle in the front of the chest. Neck trauma or overstretching of the shoulder can lead to this. Professionally performing sports involving swimming and ball throwing in children can also cause pectoralis minor tension. Treatment is primarily physical therapy. If there is no improvement, surgery can be performed in the form of cutting the pectoralis minor tendon where it attaches to the collarbone.

How is Thoracic Outlet Syndrome Diagnosed?

It can be difficult to diagnose because the symptoms seen and the severity of the problem vary greatly from person to person. In order to make a diagnosis, the doctor questions the signs and symptoms and evaluates the patient with a physical examination. The person’s occupation and sports are questioned in terms of risk factors. Findings such as low shoulder, edema or color change in the arm, pulse abnormality, limitation of movement may be guiding. Provocative tests that reproduce or exacerbate complaints are valuable in the examination. The arm, neck and shoulder are brought to certain positions and it is checked whether the complaints occur or not. Adson test, hands-in-air stress test (EAST or Roos test), arm tension test (ULTT or ELVEY) are special tests used for TOS in physical examination.

Various tests are used to diagnose and exclude other possible diseases. If there is a neck rib, it can be seen with X-ray film. With Doppler ultrasound, blood flow in the arm veins and whether there is a clot can be evaluated. CT or MR angiography may be performed for imaging the vessels. With MRI, structural abnormalities and problems that may cause similar complaints such as neck hernia can be detected. Nerve damage can be determined by EMG and nerve conduction study.

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Avoiding excessively compelling arm movements that pave the way for TOS, not carrying heavy items, not carrying heavy bags on the shoulders, losing weight for overweight people, stretching exercises and exercises that strengthen the shoulder muscles, and correcting the posture are the first issues to be considered in the treatment of this problem. If physical therapy exercises are done regularly, the pressure on the vessels and nerves can be reduced and healing can be achieved.

In case of clot formation in the vein, clot-dissolving (thrombolytic) and anticoagulant (anticoagulant) drug treatments can be given.

If there is no improvement with physical therapy and neurological problems progress, surgery may be required. The surgery can be performed by a thoracic surgeon or a cardiovascular surgeon who has experience in this area. There are different surgical approaches. Removing a part of the first rib, loosening or removing the muscles that cause compression, removing the clot if there is a clot in the vein, and repairing the vein are some of the methods applied. Surgery may also have risks, complaints may not improve or may recur after a while, even if they improve. Your doctor will explain the possible benefits and risks to you. Physical therapy may be required to return to normal life after surgery.

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