Thoracic outlet syndrome, or TOS, is a varied pattern of signs and symptoms resulting from compression of nerves and/or vessels, which can occur along various anatomical sites from the neck down. Within the thoracic outlet, there is a bundle of major blood vessels and nerves that come from the neck, travel under the collar bone and then feed the muscles and joints in the arm on both sides. Compression of this bundle of vital tissues can happen anywhere from the neck to the hand.

TOS is different from a typical muscle strain or stiff joint. Muscles need strengthening and joints need movement to heal. However, too much strengthening or movement makes the symptoms of TOS worse.

A muscle problem is different from TOS. Muscle problems ache when you overuse them. The best treatment for a muscle problem is initial rest followed by gradual strengthening. Joint problems are also different from TOS. When your joints hurt, you can localize the point of pain quite precisely.

Thoracic outlet syndrome is a problem of compression. Blood vessels and nerves can become “squished” under the collar bone or anywhere along their path. The treatment involves gradually taking pressure off the vessels by changing your posture. It must be done slowly because too extreme or too fast a postural change will aggravate symptoms. Over-correction into a “military posture” results in the blood vessels and nerves becoming tethered, like pulling on a taut rope, and the stretching makes matters a lot worse.

Another tricky thing about TOS is that the walls of the blood vessels and the sheath of the nerves do not have the same type of pain fibers as those of muscles and joints. Nerves that go to muscles and joints send direct impulses to the brain so you know exactly what you did to cause the pain. When you overwork a muscle or joint, it tells you right away.

If you compress, tether, or stretch blood vessels and nerves there’s no immediate path to the brain for you to become aware of the problem. You only discover hours later because there is a diffuse ache, swelling, coldness or numbness. You can’t figure out if it was how you slept, how you hung-up clothes on the clothes line or if that long drive caused your symptoms.

It’s really hard to learn from your mistakes. It’s even harder for well-meaning family members to advise and support you. Often spouses are at a total loss as to what to do to help you. TOS really requires a lot of understanding on you and your family’s part. It is like no other muscle or joint problem.

During physical therapy and occupational therapy sessions at our facility, we will speak of the need to reduce extreme reaching and end-of-range movements of your neck and arms. We will talk about avoiding any posture that might overly stretch or compress the blood vessels and nerves that come from your neck and extend down the length of your arm.

During physical or occupational therapy sessions, we will teach you the technique to ease pressure off the blood vessels and nerves in your neck. It’s called “The Thinker” pose. It’s referred to as “The Thinker” pose because it’s the same posture that the Rodin statue depicts. Perhaps you are aware of Rodin’s “The Thinker” statue created in 1880. If not, google it and you will see what I mean.

In addition to decompressing the blood vessel and nerves, we also want to improve circulation. Walking is really the best way to do this. Walking is best done daily.  Bike riding is great for circulation, but holding the bike handles can extend the arms too much and stretch the irritated tissues of the blood vessels and nerves. A stationary bike is a better option, because you can skip holding the handles.

We will also gradually add specific exercises aimed to take tension off muscles that have become sore due to compression of the vital nutrient system that feeds the muscles. The nutrients are comprised within the blood circulation and nerve conduction.  When the blood vessels and nerves can’t properly support muscles with oxygen, nutrients, and correct messages from the brain, the muscles become very sore.  

Our treatment at the clinic involves hands-on work to restore function to the tissues of the thoracic outlet. We are glad when you get some relief when you come in to see us. Usually sleep is restored first, then a smile or two, and gradually more function will follow. It may feel like a very gradual process, but it is all happening at the rate we would expect for this complex multi-system diagnosis. Ask anyone who has had TOS; they know just how long it takes to heal from this problem. You and your support network need to really understand this condition for you to get back to enjoyable living. We want to help!

Please email me with any questions or concerns you or your family may have. I am very happy to work with you and can address specific concerns in a future newsletter. You can reach me at Cresswell Physical Therapy and Hand Rehabilitation, Inc. Email: