Thoracic Outlet Syndrome Exercises

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 – these nerves are known as the Brachial Plexus.

(Note: This blog post will specifically cover Neurogenic Thoracic Outlet Syndrome.)

The nerves can be compressed at the:

a) Inter-Scalene Triangle: Between Anterior and Middle Scalene.

b) Costoclavicular Space: Between Clavicle and 1st Rib.

c) Sub-Coracoid Space: Underneath Pec Minor and Coracoid Process.

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)
• Hypertrophied 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 blade which can increase the likelihood of the nerves being compressed between the Clavicle and 1st Rib. (Can be related to having large breasts and 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. For best results – Use the collective findings from the following tests.

(Please note: Thoracic Outlet Syndrome is difficult to diagnose as it shares similar symptoms with conditions such as Cervical Radiculopathy, Carpal Tunnel Syndrome, Complex Regional Pain Syndrome, Peripheral Neuropathies and Brachial Neuritis.)

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a) 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.

b) Neurological symptoms

• Neck pain
• Tingling
• Numbness
• Shooting/Burning pain
• Altered reflexes
• Pain between the Shoulder Blades
• Weakness
• Muscle wasting

c) Upper limb tension test

Instructions:

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

Results:  If this test reproduces the neurological symptoms down the arm, this indicates that the nerves may be irritated.

d) Nerve studies

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

e) Scans

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

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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.

f) 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.

Results: The reproduction of any symptoms in your arm suggests compression of the nerves in between the Scalene muscles.

g) Costoclavicular Maneuver

Instructions:

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

Results: The reproduction of any symptoms in the arm suggests compression of the nerves between the Clavicle and 1st rib.

h) Hyperabduction test

Instructions:

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

Results: The reproduction of any symptoms in the arm suggests compression of the nerve underneath the Coracoid Process and/or Pectoralis Minor.

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Exercises for Thoracic Outlet Syndrome

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. For more information: Medical disclaimer.

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Step 1: Manage the symptoms

It is important to get the symptoms under control before starting the Thoracic Outlet Syndrome exercises. (… Some exercises can make your symptoms worse!)

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a) Minimize exposure to aggravating activities

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

b) Reduce Inflammation

This may involve using:

• Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)
• Anti-Inflammatory Gel
• Ice therapy
• Natural remedies such as Turmeric and Fish oil

c) Pain Killers/Nerve Medication

If there is a significant amount of pain, 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

The following exercises are designed to be completely pain-free. The aim is to encourage as much movement as possible without causing any symptoms.

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a) 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.

b) Shoulder blade rolls

Instructions:

• Roll your shoulders in a backwards direction.
• Gradually increase the amount of movement.
• Perform 20 repetitions in each direction.
• (Note: Avoid excessively pulling your shoulders downwards as this may aggravate symptoms.)

c) 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 will reduce the over-activity of the muscles that are contributing to the Thoracic Outlet Syndrome.

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a) Scalene

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.
• Continue for 30 seconds.

b) Chest

(Target muscles: Pectoralis Major/Minor, Subclavius)

Instructions:

• Face a wall.
• Position the ball between the chest and the wall.
• Place your chest on top of a massage ball.
• 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.

c) Latissimus Dorsi and Serratus Anterior

Instructions:

• Lie down on the side.
• Place a foam roller directly under the Latissimus Dorsi and Serratus Anterior muscle.
  • (Use Google if you are not sure where this muscle is.)
• Apply an appropriate amount of body weight on top of the foam roller.
• Roll your body up/down on the foam roller.
• Do NOT hold your breath.
• Make sure to cover the entire muscle.
• Continue for 1-2 minutes.

d) Lower Trapezius/Rhomboids

Instructions:

• Place a massage ball between your shoulder blades and spine.
• Apply as much of your body weight on top of the massage ball.
• Target those painful areas!
  • The more tight and/or overactive the muscle is, the more pain there will be. Don’t stop!
• Do not hold your breath. Relax.
• Continue for 1-2 minutes.

Step 4: Stretches for Thoracic Outlet Syndrome

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

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a) 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 other 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.

b) Chest

(Target muscles: Pectoralis Major/Pectoralis Minor)

Instructions:

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

c) 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.

Note: For more stretches for the Latissimus Dorsi, check out this post.

d) 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.

e) 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.

Step 5: Joint Mobilizations

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

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a) 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.

b) Clavicle

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 end of the collar bone.
• Firmly wiggle the collar bone forwards and backwards.
• Repeat 30 times.

c) Scapula

Instructions:

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

• 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. Do not over-stretch the nerve as this may lead to an increase in your symptoms.

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a) 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 3-5 seconds.
• Repeat 5-10 times.

b) 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 3-5 seconds.
• Repeat 5-10 times.

c) 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 3-5 seconds.
• Repeat 5-10 times.

Step 7: Thoracic Outlet Syndrome Strengthening Exercises

Deep Neck Flexors

Strengthening the Deep Neck Flexor muscles can help reduce the over-activity of the scalene muscles.

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a) 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.
• Gently nod your chin towards your upper chest.
• Aim to feel a gentle contraction in the muscles at the back of your throat.
• Relax your 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.
• Hold for 5 seconds.
• Repeat 30 times.
• Note: If this exercise is too difficult, use a thicker pillow.

b) Chin nod with head lift

Instructions:

• Lie down on your back with your knees bent.
  • (Support your head on a pillow if required.)
• Gently flatten your tongue to the roof of your mouth throughout the exercise.
  • This will help engage the right muscles in the neck.
• Tuck your chin in.
• Nod your chin downwards.
• Whilst keeping your chin in the nodded position, lift your head off the ground.
  • Imagine you are gently squashing an apple between your lower jaw and throat throughout movement.
• DO NOT let your chin jut forward as you lift your head.
• Aim to feel the contraction of the muscles at the front of your neck.
• Hold for 5-10 seconds.
• Repeat 10 times.
• Note: If you find this exercise difficult, support the weight of your head with your finger tips.

Scapula Stabilizers

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

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c) Shrugs with retractions

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.

d) Serratus Anterior

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 DOWN and AROUND the ribs.
  • Keep your shoulders long and wide.
• Keep your neck completely relaxed. (Don’t shrug!)
• 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, check out this post.

Step 8: Diaphragmatic Breathing

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

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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 your rib cage
  • Flatten your lower back completely
• Whilst maintaining this position, breathe in towards the lower torso and abdominal region.
  • 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.

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Instructions:

• Reach and stretch out your hands as far to opposite sides as possible. (see above)
  • Think: “Wide and Long shoulders.”
  • The shoulder blades should “float” on top of your rib cage.
• 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

Certain postures can potentially predispose you to developing Thoracic Outlet Syndrome.

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

a) Forward Head Posture

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

For more information: Exercises for Forward Head Posture.

b) Hunchback Posture

This involves the upper torso slouching forwards.

For more information: Exercises for Hunchback Posture.

c) Rounded Shoulders

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

For more information: Exercises for Rounded Shoulders.

e) Winged Scapula

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

For more information: Exercises for Winged Scapula.

Step 11: Surgery for Thoracic Outlet Syndrome

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.

(Note: If you have prominent neurological symptoms (Loss of muscle, obvious weakness, high level of pain etc.), I would strongly recommend that you see the specialist as soon as possible.)

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Common surgeries:

• Pectoralis Minor release
• Rib Resection
• Scalenectomy
• Shaving of bony irregularities

Common questions:

a) 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 12 weeks, I would suggest to get a review from a Specialist.

b) Is there anything to avoid?

• Carrying heavy bags
• Repetitive over head movements
• Pulling your shoulders “back and down” excessively
• Sleeping on an outstretched arm (see below)

c) How to sleep with Thoracic Outlet Syndrome?

Do not sleep with your arm in a hyper-abducted position.

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.

Conclusion

• Thoracic Outlet Syndrome is the compression of the nerve(s) 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 and 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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