Thoracic Outlet Syndrome: 5 Exercises to Help

Thoracic outlet syndrome (TOS) refers to compression of the major nerves and blood vessels in the area between the neck and shoulder.  More than 90% of cases involve compression and irritation of the nerves as they pass through the thoracic outlet.  It is less common for the blood vessels to be involved.

Common symptoms of thoracic outlet syndrome include pain in the neck, upper back, shoulder, arm, or hand.  It is also common to experience numbness, tingling, and weakness of the arm, hand, and fingers.  Symptoms are aggravated with overhead positions or activities such as throwing a baseball.  Also, repetitive tasks such as prolonged typing exacerbate symptoms of TOS.

Anatomy of the Thoracic Outlet

Thoracic outlet syndrome exercise

There are 3 components to the thoracic outlet extending from the neck to the front of the shoulder.  The 1st component is the interscalene triangle.  Nerves exit the neck and pass between the two scalene muscles.  Abnormalities of these muscles can contribute to compression or irritation of the nerves.  The 2nd component of the thoracic outlet is called the costoclavicular space.  This is the area between the collar bone and first rib.  Abnormalities of the first rib or an extra rib sometimes called a “cervical rib” can lead to irritation of the nerves or blood vessels.  The 3rd component of the thoracic outlet is the area between the pectoralis minor muscle and the rib cage.

Treatment for Thoracic Outlet Syndrome

Treatment for TOS begins with rest from any aggravating activity such as overhead sports (baseball pitching) or repetitive tasks such as keyboarding.  Referral to a physical therapist is the next step.  Physical therapy for thoracic outlet syndrome targets the 3 primary compression sites.  Manual therapy techniques and stretching exercises target the scalene muscles, first rib, and pectoral muscles.   Nerve gliding exercises are prescribed to improve the health of the irritated nerves.  Postural correction exercises are also an important component.  A slouched or flexed posture closes down the space of the thoracic outlet and increases irritation of the nerves and blood vessels.  Finally, pain-free strengthening exercises for the shoulder and upper back muscles are prescribed based on the patient’s individual needs and goals.

Scalene Muscle Stretch

Stretching the scalene muscles alleviates irritation of the nerves and blood vessels within the interscalene triangle.   Begin sitting with a strap or belt draped over the affected shoulder.  Pull down on the strap towards your opposite hip.  Side-bend the neck away from the affected side and slightly turn towards the affected side. Finally, perform a gentle chin tuck to increase the stretch in the side of the neck.  Hold this position for 30 seconds.  If you experience symptoms during the stretch, start with shorter hold times and work up to 30 seconds.

First Rib Self-Mobilization

Improving the mobility and position of the first rib alleviates irritation of the nerves and blood vessels just below it.   Begin sitting with a strap or belt draped over the affected shoulder.  Pull down on the strap towards your opposite hip.  Side-bend the neck toward the affected side.  Look down to the armpit.  This position relaxes the scalene muscles so the forces are directed to the rib.   While holding pressure with the strap, perform 10 slow and deep breaths to mobilize the rib.

Pec Minor Stretch

Improving pectoralis minor length and mobility will alleviate irritation of the nerves under this muscle.  Begin lying over a foam roll under the hips and spine.   With the elbow bent allow the arms to fall down towards the floor.  Fully exhale and relax in this position for 30 seconds.  It is important for your spine to maintain contact with the foam roll.  If you experience symptoms during the stretch, start with shorter hold times and work up to 30 seconds.

Trapezius Muscle Strengthening

To strengthen the lower trapezius muscle lie face down with one arm over the side of the table or bench.  Be sure to keep the neck in a relaxed neutral position resting on your other forearm.  With the thumb up, arm straight, elbow slightly bent, lift toward the ceiling at a 45-degree angle from your head (the 10:00 and 2:00 positions of a clock).  This position is aligned with the muscle fibers of the lower trapezius.  Be careful to avoid shrugging the entire shoulder as you raise the arm.  Instead, think about tilting the shoulder blade backward as you raise the arm.  Pause at the top of the movement before returning to the start position.

The middle trapezius is trained in a similar fashion.  To target the middle trapezius perform the movement with the arm straight out to the side.  This corresponds to the 9:00 and 3:00 positions of a clock.  Strengthening both the middle and lower trapezius will orient the shoulder blade so that irritation of the nerves in the thoracic outlet is diminished.

Closing Thoughts About Thoracic Outlet Syndrome

Thoracic outlet syndrome can be debilitating and negatively impact your quality of life.  Not everyone with TOS has to suffer.  These 5 exercises are only a small sample of the types of exercises that can help.  Meet with your physical therapist and get started on the road to recovery.  Your physical therapist will continually assess your injury and progress your exercise program based on your goals.  The objective is to decrease pain and give you your quality of life back as quickly as possible.  Contact us today if you are experiencing symptoms suggestive of TOS or if you have questions about which treatments are right for you.


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