This blog post will cover the best Thoracic Outlet Syndrome exercises that will help fix your pain.

What is Thoracic Outlet Syndrome?

Thoracic Outlet Syndrome (TOS) is the compression of the group of nerves that are located between the neck and shoulder.

Collectively – the nerves in this area are known as the Brachial Plexus.

(Note: This blog post will specifically cover Neurogenic Thoracic Outlet Syndrome. The other types of Thoracic Outlet Syndrome: Arterial and Venous.)

In This Blog Post

• Location Of Nerve Compression
• Causes
• Tests To Determine If You Have It
• Thoracic Outlet Syndrome Exercises
• Common Questions

Location Of Nerve Compression

There are 3 main areas where the Brachial Plexus nerves can become compromised.

1. Inter-Scalene Triangle

This area is between the Anterior and Middle Scalene muscles in the side of the neck.

2. Costoclavicular Space

This area is between the Clavicle (Collar bone) and the 1st Rib.

3. Sub-Coracoid Space

This area is underneath Pectoralis Minor muscle and Coracoid Process (a bony part of the shoulder blade).

What are the Causes?

Compression of the nerves in the Brachial Plexus may be involved with:

• Structural Abnormalities (Eg. Cervical Rib, Irregularities of the 1st rib, Enlarged Transverse Process of C7, Muscular insertions)
• Tight Scalene muscles
• Tilted head
• Weak scapula elevators
• Tight Pectoralis Minor
• Poor clavicular mobility
• Inefficient Breathing Pattern
• Drooping shoulders: This posture causes depression of the shoulder blades which can decrease the amount of space between the clavicle and 1st rib. (Can be related to carrying heavy bags.)
• Repetitive over head movements

Thoracic Outlet Syndrome Test

There is no ONE definitive test that can determine if you have Thoracic Outlet Syndrome.

Note: Thoracic Outlet Syndrome is difficult to diagnose as it shares similar symptoms with conditions such as:

For best results – Use the collective findings from the following tests:

Pain Pattern

Pain that refers down the arm suggests that there may be an issue with the nerves from the neck and/or shoulder region.

With Thoracic Outlet Syndrome – the pain pattern is usually non-dermatomal and may extend into the fingers.

Neurological Symptoms

Upper Limb Tension Test

This can test for irritability of the nerves that are located between the neck and fingers.

Instructions:

• Have your arm straight by your side with the palms facing forwards.
• Pull your shoulder downwards.
• Lift your arm up to shoulder height.
• Keep your arm in a straightened position.
• Bend your wrist backwards.
• Twist your forearm in a backwards direction so that your fingers are facing towards the floor.
• Tilt your head towards the opposite side.
• Take note of any stretch and/or symptoms experienced in the arm.
• Compare with the unaffected side.

Nerve Studies

A Nerve Conduction and/or Electromyography test can test the conductivity of the nerves.

Scans

X-rays and MRI scans can be used to determine if there are any structures (eg. Cervical Rib) compressing the nerves.

Special Tests for Thoracic Outlet Syndrome

To get the most out of these tests – I suggest that you get a health professional to conduct them on you.

Supraclavicular Pressure

Instructions:

• Locate the Anterior Scalene in the region of the 1st rib. (See image)
• Apply a firm pressure to the Anterior Scalene.
• Hold for 30 seconds.

Costoclavicular Maneuver

Instructions:

• Pull your shoulders back and down as much as possible.
• Hold this position for 30 seconds.

Hyperabduction Test

Instructions:

• Place your arms over head.
• Pull your shoulders back and down firmly.
• Hold this position for 30 seconds.

Exercises for Thoracic Outlet Syndrome

STEP 1: Symptom Management
STEP 2: Gentle Movements
STEP 3: Releases
STEP 4: Stretches
STEP 5: Mobilizations
STEP 6: Nerve Stretches
STEP 7: Strengthening Exercises
STEP 8: Breathing Exercise
STEP 9: Shoulder Blade Position
STEP 10: Address Posture
STEP 11: Surgery

Step 1: Manage the symptoms

It is important to get the symptoms under control before starting the Thoracic Outlet Syndrome exercises.

Minimize Exposure To Aggravating Activities

Reduce exposure to the activities, positions and/or movements which aggravate the symptoms associated with Thoracic Outlet Syndrome.

Reduce Inflammation

This may involve using:

Pain/Nerve Medication

If there is a significant amount of pain preventing you from performing exercises, consider seeing your doctor to determine if pain killers and/or nerve medication is appropriate in your situation.

(Note: Seek medical guidance before taking any medication.)

Step 2: Gentle movements

It is important to maintain and preserve the normal movement of the neck and shoulders.

Neck Circles

Instructions:

• Perform slow and gentle circles with your head.
• Gradually increase the amount of movement as comfortably tolerated.
• Repeat 20 repetitions in each direction.

Shoulder Blade Rolls

Instructions:

• Roll your shoulders in a backwards direction.
• Gradually increase the amount of movement.
• Make sure that there is no pain associated with this exercise.
• Perform 20 repetitions in each direction.

(Note: Avoid excessively pulling your shoulders downwards as this may aggravate your symptoms.)

Arm Raises On Wall

Instructions:

• Place your hands on a wall.
• Slowly slide your hands up the wall.
• Gradually reach higher as tolerated.
• Perform 20 repetitions.

Step 3: Releases

Releases can help to reduce the over-activity of the muscles that may be associated with the Thoracic Outlet Syndrome.

Scalene

Tightness in these neck muscles can potentially compress the nerves that exit the neck region.

Instructions:

• Make a gentle fist with the hand.
• Apply the back portion of the fingers against the side of the neck.
• Starting at the collar bone, perform slow upwards strokes towards behind the ear.
• Perform 10 upward strokes.
• Repeat on the other side if required.

Chest

The chest muscles (along side the Latissimus Dorsi, Serratus Anterior and Lower Trapezius) can drag/pull the shoulder girdle downwards.

This causes a narrowing in the space between then collar bone and 1st rib.

As the nerves pass through this region, this can subject them to being squashed.

(Target Muscles: Pectoralis Major/Minor, Subclavius)

Instructions:

• Face a wall.
• Position a massage ball between the chest and the wall.
• Keep your shoulder relaxed.
• Place as much as your body weight on top of the ball as tolerated.
• Make sure to cover the entire chest region.
• Continue for 1-2 minutes.

Latissimus Dorsi and Serratus Anterior

Instructions:

• Lie down on the side.
• Place a foam roller directly under the side and side/back of the rib cage.
  • This is where the Latissimus Dorsi and Serratus Anterior muscle are located.
• Apply an appropriate amount of body weight on top of the foam roller.
• Roll your body up/down on the foam roller.
• Make sure to cover the entire region of the muscle.
• Continue for 1-2 minutes.

Lower Trapezius

Instructions:

• Lie down on your back.
• Place a massage ball in the area between the lower part of the shoulder blade and spine.
• Apply as much of your body weight on top of the massage ball.
• Do not hold your breath.
• Continue for 1-2 minutes.

Step 4: Stretches

Stretches will reduce the tightness in the muscles which are associated with Thoracic Outlet Syndrome.

Anterior/Middle Scalene

Instructions:

• Look slightly upwards.
• Turn your head towards the side of the neck that you would like to stretch.
• Tilt your head towards the opposite side.
  • (“Ear to the shoulder.”)
• Gently pull your head down towards the side.
• Aim to feel a stretch on the side of the neck.
• Hold for 30 seconds.

Chest

(Target muscles: Pectoralis Major/Pectoralis Minor)

Instructions:

• Place your forearm onto a door frame. (see above)
• Have your shoulder in a slight shrugged position.
• Keep your shoulders pulled back throughout this stretch.
• Lunge forward.
• Do not arch your lower back.
• Aim to feel a stretch in the chest region.
• Hold for 30 seconds.

Note: Please be careful with this stretch if your symptoms are aggravated in the arms over head position.

Latissimus Dorsi

Instructions:

• Assume the position as seen above.
• Whilst holding onto the door frame, let your upper arm take the weight of your body.
  • “Let your body hang.”
• Whilst anchoring your legs as shown, aim to bend your mid section as much as possible.
  • Use your body weight to sink into the stretch
• Aim to feel a stretch on the side of your torso.
• Hold for 30 seconds.

Want more stretches like this?

See Post: Lat Stretches

Lower Trapezius

Instructions:

• Sit down on a chair.
• Slouch your upper back as much as you can.
  • Focus at bending your spine at the level of the lower shoulder blade.
• Shrug the shoulders upwards
• Try to take a deep breath into the middle of your back.
• Aim to feel a stretch in the region around the lower shoulder blade.
• Hold for 30 seconds.

Serratus Anterior

Instructions:

• Lie down on your side.
  • The side that you will be stretching will be closer to the floor.
• Prop your torso up whilst having your forearm on the ground.
• Lean your upper body weight onto your forearm.
  • Your shoulder should naturally hitch upwards.
• Whilst keeping your waist pinned down to the ground, push your torso up right.
• Aim to feel a stretch on the side of your rib cage.
• Take a deep breath into the area where you feel the stretch.
• Hold for 30 seconds.

For more stretches: Serratus Anterior Stretch

Step 5: Joint Mobilizations

Stiffness in certain joints may predispose you to developing Thoracic Outlet Syndrome.

1st Rib

Instructions:

• Place a strap over the junction between the neck and shoulder. (see above)
• Pull the strap firmly in a downwards direction.
• Tilt your head to the opposite side.
• Repeat 30 times.

Sternoclavicular Joint

Instructions:

• Sit down on a chair.
• Place the weight of your arm onto a pillow.
• Keep your shoulder completely relaxed.
• Using a pinch grip, hold onto the proximal end of the collar bone. (see above)
• Firmly wiggle the collar bone in an upwards and downwards motion.
• Repeat 30 times.

Scapula

(You will need someone to help you with this exercise.)

Instructions:

• Lie down on your side.
  • The shoulder on the upper side will be targeted.
• Instruct your helper hold your shoulder blade and glide it towards the head.
• Repeat 30 times.

Step 6: Nerve stretches

The following exercises are designed to gently stretch the nerve.

Aim to feel a light/faint stretch.

Median Nerve

Instructions:

• Pull your shoulder downwards.
• Keep your arm straight by the side of your body.
• Twist your arm outwards so that your palms are facing outwards.
• Bend your wrist backwards towards the side of your body.
• Start to slowly raise your arm out to the side and stop when you first start to feel a gentle stretch in the arm.
• Tilt your head to the opposite side.
• Aim to feel a gentle stretch in the thumb/pointer/index finger, front of arm and/or side of neck.
  • Do not over stretch!
• Hold for 1-3 seconds.
• Repeat 5-10 times.

Radial Nerve

Instructions:

• Pull your shoulder downwards.
• Straighten your arm by your side.
• Twist your arm inwards so that your palm is facing outwards.
• Make a fist with your hand.
• Bend your wrist towards the side.
• Raise your arm out to the side.
• Tilt your head to the opposite side.
• Aim to feel a gentle stretch in the top of your forearm and/or side of neck.
  • Do not over stretch!
• Hold for 1-3 seconds.
• Repeat 5-10 times.

Ulnar Nerve

Instructions:

• Pull your shoulder downwards.
• Completely bend your elbow.
• Bend your wrist backwards.
• Lift your elbow up towards the side.
• Tilt your head to the opposite side.
• Aim to feel a gentle stretch in the pinky/ring finger, inside of the elbow/arm and/or side of neck.
  • Do not over stretch!
• Hold for 1-3 seconds.
• Repeat 5-10 times.

Step 7: Strengthening Exercises

Focus on strengthening the following muscles:

Deep Neck Flexors

The Deep Neck Flexors are a group of muscles that are involved with achieving and maintaining the ideal position of your head and neck.

The Scalene are a group of neck muscles which tend to compensate for weakness in the Deep Neck Flexors.

This can lead to increased muscle bulk and compression of the nerves in the neck.

Strengthening the Deep Neck Flexors can help reduce the over-activity of the Scalene muscles.

For a full guide on this group of muscles:

See Post: Deep Neck Flexor Exercises

To get you started – it is important to learn the following exercise:

Chin Nods (Head Supported)

Instructions:

• Lie down with your knees bent and feet on the floor.
• Support your head with a pillow.
• Keep the weight of your head on top of the pillow throughout the exercise.
• Relax your superficial neck muscles as much as possible.
  • You can try flattening your tongue to the roof your your mouth to help reduce the tension in the neck.
• Gently nod your chin towards your upper chest.
• Aim to feel a gentle contraction in the muscles at the back of your throat.
• Hold for 5 seconds.
• Repeat 30 times.

Note: If you are having difficulty keeping your neck muscles relaxed, support your head with a thicker pillow to begin with. Over time – progress to a thinner pillow to challenge your neck muscles.

Scalene Muscles

If you have weak Scalene muscles, it is possible that this may lead to increased tension in the neck.

Here is how to strengthen these muscles:

Scalene Strengthening

Instructions:

• Lie down on your side with your head supported on a pillow.
• Activate the Deep Neck Flexors. (See previous point)
• Gently lift your head off the pillow.
• Aim to feel a muscular contraction in the side of your neck.
• Repeat 5-20 times. (Depending on you ability)

Note: Please be careful with this exercise as overdoing it can lead to increased symptoms in your arm! Start with 1-2 times per week and see how your body responds.

Scapula Stabilizers

Strengthening the muscles that attach to the scapula will help place the scapula in a more optimal position.

Scapula Shrugs

Instructions:

• Stand in front of a wall.
• Place your hand high up onto the wall.
• Lean your torso slightly forwards.
• Pull your shoulders back.
• Shrug your shoulders upwards.
• Feel the contraction of the Upper Trapezius.
• Hold for 30 seconds.

Serratus Anterior

This muscle will help with upward rotation of the scapula.

This movement can help reduce compression of the nerves underneath the Coracoid process as the arm is raised.

Instructions:

• Stand in front of a wall.
• Place your forearms on the wall.
• Activate the Serratus Anterior:
  • Tilt the shoulder blades BACKWARDS.
  • Pull your shoulder blades AROUND the ribs.
  • Keep your shoulders long and wide.
• Keep your neck completely relaxed.
• The shoulder blades should be “floating” on the rib cage. Do not excessively pull them downwards.
• Push your forearms into the wall.
• Aim to feel the contraction in the lower and side region of the scapula.
• Whilst maintaining the activation of the Serratus Anterior, slide your forearms up/down the wall.
• Repeat 10-20 times.

For more exercises for the Serratus Anterior

See Post: Serratus Anterior Exercises

Step 8: Diaphragmatic Breathing

Ineffective breathing patterns can lead to over-activity of the Scalene muscles.

The following exercise will help engage the Diaphragm (the main breathing muscle) and encourage the expansion of the rib cage.

Instructions:

• Lie down on your back with your knees bent and feet supported on the floor.
• Take a deep breath in through your nose.
• As you breathe out through your mouth, slowly push out ALL of the air out of your lungs:
  • Engage your core muscles (“draw belly button in AND gently tense your abdominal muscles”)
  • Lower the front portion of the lower rib cage
  • Flatten your lower back completely
• Whilst maintaining this position, take a slow deep breath in through the nose:
  • Imagine the whole circumference of your torso/abdominal region is inflating like a balloon.
• Keep your neck and chest completely relaxed.
• Repeat 5 times.
• Perform 3 sets.

Step 9: Shoulder blade Position

Poor positioning of the shoulder blade can contribute to the symptoms associated with Thoracic Outlet Syndrome.

Below is a quick and easy way to reset your shoulders into a more neutral position.

Shoulder Reset Exercise

Instructions:

• Reach and stretch out your hands as far to opposite sides as possible. (see above)
  • Think: “Wide and Long shoulders.”
• Retraction: Slightly bring your arms backwards.
  • Aim to feel a gentle contraction between your shoulder blades.
  • Do NOT over squeeze your shoulders back together.
• Posterior Tilt: Twist your arms in a backwards direction.
  • Your palms should start to face towards the sky with the thumbs angled down towards the floor.
• Whilst maintaining the position of the shoulder blade, gently lower your arms by your side.

Congratulations! Your shoulders are now in a more neutral position!

I encourage you to perform this simple exercise throughout the day as it can potentially help with Thoracic Outlet Syndrome.

Step 10: Address Posture

In my opinion – Certain postures can potentially predispose you to developing Thoracic Outlet Syndrome.

Here are links to comprehensive guides to help you address your posture:

Forward Head Posture

This involves the head being pushed forwards so that it is in front of the midline of the torso.

This position can be associated with over-activity of the Scalene muscles.

For more information:

See Post: Exercises for Forward Head Posture

Hunchback Posture

This involves the upper back slouching forwards.

The position of the upper back has a strong influence on the position of the head and shoulders.

For more information:

See Post: Exercises for Hunchback Posture

Rounded Shoulders

This involves the shoulder position being in front of the midline of the torso.

This may lead to the depression of the shoulder girdle which can compress the nerves underneath the collar bone.

For more information:

See Post: Exercises for Rounded Shoulders

Winged Scapula

This is when the medial (inner) border of the shoulder blade protrudes off the rib cage.

Poor positioning of the scapula may predispose one to Thoracic Outlet Syndrome.

For more information:

See Post: Exercises for Winged Scapula

Step 11: Surgery

If you have persisted with the recommended exercises for at least 4-12 weeks and still present with significant symptoms, the next step would be to seek a review from a specialist to see if surgical intervention is necessary.

Possible Surgeries

In my opinion: Surgery for Thoracic Outlet Syndrome should rarely be considered as the initial intervention. Please give the exercises a chance!

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Common questions

Have more questions? Feel free to ask me in the comment section and I will get back to you.

How long will it take for these Thoracic Outlet Syndrome exercises to work?

If you are lucky – You may actually experience an immediate reduction in your symptoms after performing the Thoracic Outlet Syndrome exercises.

If there has been no improvement after 6-12 weeks, I would suggest to get a review from a Specialist.

Do I need to avoid anything?

You don’t need to avoid anything unless it is definitely making your symptoms worse.

That being said, you may need to minimize your exposure to the following:

• Carrying heavy bags
• Repetitive over head movements
• Pulling your shoulders “back and down” excessively
• Allowing your arms to “hang” whilst holding onto heavy weights
• Sleeping on an outstretched arm (see below)

How to sleep with Thoracic Outlet Syndrome?

Do not sleep with your arm in a hyper-abducted position (see above).

This may increase the likelihood of the nerves getting compressed.

Instead – I recommend sleeping on the back.

This will encourage a more neutral position of the neck and shoulder.

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Conclusion

• Thoracic Outlet Syndrome is the compression of the nerves that are part of the Brachial Plexus.
• Symptoms usually involves pain that refers down the arm, tingling, numbness and weakness.
• It is difficult to accurately diagnose as it shares multiple symptoms with several other conditions.
• Persist with the suggested Thoracic Outlet Syndrome exercises for at least 4-12 weeks.
• Get a review with your doctor/neurologist if you have any doubts.

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Disclaimer: The content presented on this blog post is not medical advice and should not be treated as such. It is not intended to be used as a substitute for professional advice, diagnosis or treatment. Use of the content provided on this blog post is at your sole risk. Seek guidance from a healthcare professional before starting any exercise and/or implementing any recommendation. For more information: Medical Disclaimer.