How to Know if you Have Thoracic Outlet Syndrome
Hey everybody, my name is Elliot, I'm a doctor of physical therapist with 1-hp.org and we specialize in helping gamers, desk workers, musicians, artists, and anybody that does repetitive movements in a seated position fix their pain.
8% of the cases of RSI in the arm actually end up being thoracic outlet syndrome, so I wanted to put this megathread together to help people know what to look out for.
Think of your thoracic outlet as a busy highway system where important nerves and blood vessels travel from your neck to your arm. This highway has three major "tunnels" where traffic jams (compression) can occur:
The Three \"Tunnels\" of the Thoracic Outlet
The Scalene Triangle represents the first potential compression point. This space is formed by two neck muscles (the anterior and middle scalenes) and your first rib, creating a tunnel where a traffic jam can occur. When these muscles become tight from prolonged forward head posture, they can compress the important nerves and blood vessels passing through this space.
The Costoclavicular Space forms the second potential compression point. This area lies between your collarbone and first rib, creating a tight corridor that neurovascular structures must navigate. Poor posture, especially rounded shoulders and tight pecs, can narrow this space further and increase compression on these vital structures.
The Subcoracoid Space represents the final checkpoint. This passage runs beneath your pectoralis minor muscle, which often becomes tight in gamers and desk workers due to prolonged internal rotation of the shoulders. When this muscle shortens, it can create a pressing force on the neurovascular bundle passing underneath it.
The Posture Problem
Here's where your gaming or work setup comes into play. That forward head position you slip into during intense sessions? That’s caused by low endurance of your deep neck flexor muscles which are responsible for keeping your neck in an upright posture. This causes your scalene muscles to work overtime to try to pick up the slack to keep your head up. The scalene muscles are primarily movement muscles and aren’t designed to hold your neck upright all the time and they get tired and irritated which causes them to tighten down as a protective response.
Deep Neck Flexors Responsible for Keeping Your Neck In An Upright Posture
And those rounded shoulders from hours of sitting? That’s due to weak upper back muscles between your shoulderblades not being able to keep your uppper back straight due to low endurance which causes your chest muscles (especially the pectoralis minor) get increasingly tight.
Parascapular Musculature Responsible For Keeping Shoulders Back
Pec Major And Pec Minor Tighten Down With Rounded Shoulder Posture
If you have the double whammy of forward head and rounded shoulders, it’s called upper crossed syndrome and is the biggest predisposing factor for developing TOS in people that play or work in a seated position.
The Three Flavors of TOS
Thoracic outlet comes in three major flavors and much like ice cream you can have just one kind or a combination of all three. Unlike ice cream, none of them are delicious.
Recognizing Neurogenic TOS
Neurogenic TOS is the most common form, accounting for 90-95% of all cases. Patients typically experience tingling sensations and pain that radiates down the arm, most commonly effecting the nerves that go to pinky and ring fingers, but can effect any of the nerves in the arm so your symptoms may be anywhere below the shoulder. This occurs when the brachial plexus, which is essentially your arm's nerve superhighway, becomes compressed at one or more of the thoracic outlet tunnels. Think of it like bad wire management.
The Brachial Plexus Your Arm's Nerve Super Highway
The nerves are the wires that connect your skin and your muscles to your brain and vise versa. If those are pinched you are going to start feeling weird sensations linke numbness, tingling, and pain. The symptoms often worsen during gaming sessions or prolonged computer use. If the compression goes on for long enough you can also experience weakness in any of the muscle groups in the arm, which can also lead to overuse injuries.
Sensory Innervation of the Arm
Understanding Venous TOS
Venous TOS manifests through visible changes in your arm's appearance and sensation. The affected arm may become swollen and take on a bluish-purple tint due to compromised blood return through the compressed veins. You might experience a persistent feeling of heaviness in the arm, as if you've just completed an intense workout. This form of TOS is particularly concerning for competitive gamers who maintain static arm positions for extended periods.
Discoloration From Impinged Veins
Identifying Arterial TOS
Arterial TOS, while the least common, can be the most severe form. Your hand might feel unusually cold and appear pale due to reduced blood flow through the compressed arteries. You may notice weakness during gaming or work sessions and experience cramping with continued activity. You can also experience numbness and tingling due to nerves losing their blood supply. These symptoms tend to be more pronounced during intense work or play sessions when blood flow demands to the hands are higher.
Pale Skin From Impinged Arteries
Self-Assessment: Understanding Your Symptoms
While only a healthcare professional can provide a definitive diagnosis, there are several self-assessment techniques you can use to better understand your symptoms. Remember: these tests should never cause significant pain or discomfort - if they do, stop immediately and consult a healthcare provider.
Testing for Vascular TOS: The EAST Test
The Elevated Arm Stress Test (EAST)
The Elevated Arm Stress Test (EAST), also known as the Roos test, is particularly useful for identifying vascular compression:
- Raise both arms up into a "stick-up" position, with elbows bent at 90 degrees
- Slowly open and close your fists for 3 minutes
- Watch for these signs of vascular TOS:
- Significant fatigue or heaviness in your arms
- Color changes in your hands (becoming pale or bluish)
- Having to lower your arms before the 3 minutes are up
- Numbness or tingling that develops during the test
Testing for Pec Minor Involvement: The Doorway Check
The pectoralis minor muscle can often be a key player in TOS. Here's how to check:
- Stand in a doorway with your arm positioned at shoulder height, elbow bent to 90 degrees
- Place your forearm against the doorframe
- Step forward through the doorway while keeping your arm in position
- If you experience:
- Tingling down your arm into your fingers
- Heaviness or fatigue in the arm
- Reproduction of your typical symptoms
This suggests pec minor involvement in your TOS symptoms.
Testing for Scalene Involvement: The Neck Rotation Check
The scalene muscles in your neck can compress the thoracic outlet. Here's how to assess them:
- Sitting comfortably, put your hand on the shoulde by the collarbone you are testing, gently tilt your head away from the symptomatic side
- Add a small amount of rotation toward the same side as the tilt
- Hold this position for 10-15 seconds
- You might have scalene involvement if you experience:
- Tingling or numbness that travels down your arm
- A feeling of heaviness or fatigue in the arm
- Recreation of your usual symptoms
- Slight dizziness or visual changes (rare, but possible due to arterial compression)
Important Notes About Self-Testing
Remember that these tests are not definitive diagnoses - they're tools to help you better understand your symptoms. Multiple positive tests often provide more reliable information than a single test alone. Additionally:
- Never force any position that causes pain
- Stop immediately if you experience severe symptoms
- Use these tests as a guide for discussion with healthcare providers
- Keep track of which tests reproduce your symptoms and how quickly they develop
If you experience positive findings with any of these tests, it's worth consulting with a healthcare professional for a proper evaluation.
Taking Action: Your Recovery Toolkit
There are 3 main stratgies for addressing thoracic outlet syndrome
Thoraic outlet at it’s core is an endurance problem with tight muscle patterns forming as compensation for low endurance. Endurance training for the fatigued out postural support muscles, stretching for the tight overworked movement muscles cosplaying as postural support muscles, and nerve gliding to free up the entrapped nerves.
1. Endurance Training
If the compression site is at the scalenes these exercises are great for building the postural endurance of the deep neck flexors which will offload the scalene muscles.
Isometric chin tucks are a great place to start and can be done at your desk if you have a high backed chair with a pillow.
If you're looking for a more tryhard neck progression check out our video on the iron neck here.
For compression at the pec minor (the costoclavicular or subcorocoid space) building the endurance of the muscles of the upper back is critical
For shoulder blade strength Face pulls are a great exercise to start with
2. Strategic Stretching
Stretching the tight muscles entrapping the neurovascular structures is the second strategy for treating TOS effectively. Remember a stretch should never be painful but it’s pretty normal to feel some of your symptoms when doing this because you are stretching the muscles compressing those structures. The symptoms should not linger for more than a couple minutes after finishing the stretch though. If you’re uncertain about this it’s important to consult with a physical therapist to get a good gauge on how much is too much or you can flare the condition up.
If the scalenes are tight you can start with gently stretching them the same way we tested earlier.
If the pec minor is tight the same doorway test we discussed earlier can also be done to stretch them out.
3. Nerve Gliding Exercises
Nerve glides can be done for any of the 3 major nerves that branch off from the brachial plexus and run down the arm (including the ulnar, median, and radial nerve), which glides you will want to do will generally vary based on where you are feeling the symptoms.
These exercises should be approached gently and like the stretches it’s normal to feel some symptoms but they can also flare up your symptoms if done too aggressively.
We typically recommend no more than 10 reps a day.
An example of a level 1 nerve glide for all the relevant nerves can be found here.
When Medical Attention is Necessary
- Persistent numbness or tingling sensations that don't resolve with rest should prompt immediate medical attention. This constant neural irritation can indicate progressive nerve compression that may lead to permanent damage if left untreated.
- Significant weakness in your arm or hand, particularly if it affects your ability to perform precise mouse movements or keyboard actions, warrants professional evaluation. This weakness could indicate severe nerve compression or vascular compromise.
- Changes in your hand's color or temperature that persist even after position changes are concerning signs that require medical assessment. These symptoms suggest significant vascular compromise that could lead to more serious complications if not addressed.
- Pain that consistently disrupts your sleep should never be ignored. Nighttime symptoms often indicate progression of the condition and may suggest the need for more aggressive intervention.
- Symptoms that don't improve with basic ergonomic changes and rest require professional evaluation to prevent potential chronic issues. Early intervention often leads to better outcomes and faster return to normal activities.
Setting Up for Success: Ergonomics 101
Your gaming or work setup isn't just about performance; it's your first line of defense against thoracic outlet syndrome (TOS). Proper ergonomics can significantly reduce the risk of TOS by promoting optimal posture and reducing strain on muscles and nerves. Position your monitor so your eyes align with the top third of the screen, keeping your neck in a neutral position to prevent forward head posture. Ensure your keyboard allows for a relaxed elbow angle and a neutral wrist position, while your chair should be adjusted so your feet rest flat on the floor, with your thighs parallel to the ground. Place your mouse in front of your shoulder at the same height as your elbow, to minimize shoulder strain. When using a gaming controller, crafting on the couch, support your elbows and keep your wrists straight to avoid unnecessary tension using a pillow for support.
Custom-made gaming pillows like the Valari can be incredibly helpful. By focusing on these ergonomic principles of neutral, you create a space that supports your body and reduces the likelihood of developing TOS.
The 45-Minute Rule - Your next posture is your best posture
Think of your body like a race car - even Formula 1 cars need pit stops! Set a timer for every 45 minutes and take a 5-minute "pit stop" to:
- Stand up and walk around
- Do some shoulder rolls
- Gentle neck stretches
- Quick scalene stretches
- Doorway pec stretches
Pro Tip: Use these breaks between matches or loading screens.
Is it Really TOS? Understanding Different Wrist Pain Patterns
When you're experiencing wrist pain or tingling, it's crucial to understand that not all hand symptoms are created equal. TOS can often be confused with other common conditions, but there are some key differences that can help you identify what's really going on.
When dealing with neurovascular compression syndromes it’s really important to understand how these issues present, typically impingement syndromes present downstream from an entrapment site. This will help to differentiate between symptoms of these common issues.
TOS vs. Carpal Tunnel Syndrome
While both conditions can cause tingling and numbness, the pattern is distinctly different. Carpal tunnel syndrome typically affects your thumb, index, and middle fingers, like wearing half a glove. All symptoms are below the wrist. Any symptoms above the wrist could indicate TOS or another nerve entrapment higher up the arm. Additionally, carpal tunnel symptoms often worsen with wrist flexion or extension, while TOS symptoms typically worsen with arm elevation, looking up at your monitor or sitting in a slouched posture for prolonged periods.
TOS vs. Cubital Tunnel Syndrome
Cubital tunnel syndrome (compression of the ulnar nerve at the elbow) can mimic TOS because it can also affects the pinky and ring fingers. However, cubital tunnel symptoms are typically only seen in the hand where thoracic outlet is more likely to be seen above the wrist. Cubital tunnel symptoms typically worsen when you bend your elbow for long periods, like when sleeping or talking on the phone, or apply compression to the inside elbow like on a hard surface like your desk. TOS symptoms, meanwhile, are more positional and often worsen with shoulder and neck movements.
TOS vs. Tendinopathy
When you're having arm or hand pain, it's important to understand that tendon problems feel very different from TOS. Tendinopathy (irritation or breakdown of tendons) can occur in any of the muscle groups you use frequently while gaming or working - like the fingers, forearms, wrists, or shoulders. However, the way these problems develop and feel is quite distinct from TOS.
Understanding Tendinopathy Patterns:
Tendon problems typically start gradually and are directly related to how much you use the affected muscles. The pain tends to be localized to specific spots where you can point with one finger, and these spots are usually tender when you press on them. You'll notice the pain most when you're actively using those muscles - like clicking a mouse, typing, or lifting your arms.
Understanding TOS Patterns:
TOS, in contrast, often causes symptoms that spread across a broader area and follow nerve pathways down your arm. Rather than being worse with specific movements, TOS tends to flare up when you hold certain positions - like having your arms forward at your keyboard or looking up at your monitor. You might also experience numbness, tingling, or temperature changes that you won't necessarily get with tendon problems. (note it is possible for tight irritated tendons to compress nerves which will cause the same kinds of symptoms but usually the problem will be downstream from the irritated muscle / tendons)
The Hidden Connection:
Here's something crucial to understand: TOS can actually make tendon problems worse or harder to heal. When nerves and blood vessels are compressed in TOS, it can:
- Reduce blood flow to tendons, making them more susceptible to injury and slower to heal
- Affect nerve signaling to muscles, leading to poor movement patterns that put more stress on tendons
- Create a "double-whammy" effect where treating just the tendon problem might not give complete relief if TOS is also present
How They Develop Differently:
- Tendinopathy builds up over time from repetitive strain on specific muscles and usually improves with endurance exercise
- TOS develops from compressed nerves and blood vessels due to posture and positioning, and can sometimes worsen even with rest if you're in certain positions
- Often, addressing TOS can help resolve stubborn tendon problems that haven't responded to standard treatment
Key Ways to Tell the Difference:
- Press on the painful area - if you can find a specific spot that reproduces all your symptoms, it's more likely to be a tendon issue
- Notice when it hurts - tendon pain is worst during or right after activity, while TOS can persist regardless of activity level
- Look for numbness - if you're experiencing numbness or tingling, especially higher in the arm than RSI pain, that's more likely to be TOS
- Check positions - if changing your arm position (like raising it overhead or slumping your shoulders) dramatically changes your symptoms, that suggests TOS
- Consider healing time - if your tendon problems aren't improving with standard care, you might need to check for underlying TOS
When You're Not Sure
If you're experiencing any of these symptoms and can't quite pin down the cause, it's best to seek professional evaluation. As physical therapists, we specialize in distinguishing between these conditions and can perform specific tests to determine exactly what's causing your symptoms. This is crucial because the treatment approach differs significantly depending on the underlying cause.
If you guys have any questions feel free to leave them in the comments below or reach out to us!
References
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