What to Expect in Thoracic Outlet Syndrome Physical Therapy

Thoracic outlet syndrome (TOS) is a cluster of disorders that occur when the nerves, arteries, or veins that run between your clavicle (collarbone), highest rib, and two of the scalene muscles are pinched or compressed. It is named for the pathway (the thoracic outlet) through which these blood vessels and nerves travel en route to your arms and hands. 

While anyone can get TOS, individuals participating in repetitive overhead activities or sports, those with poor posture or weak shoulder muscles, people in their middle ages, and females are the most likely to experience it.

Fortunately, in many cases, the symptoms of thoracic outlet syndrome can be addressed with physical therapy. This article will discuss physical therapy assessment, goals, exercises, and outcomes for thoracic outlet syndrome.

Assessing Thoracic Outlet Syndrome

One of the first steps a doctor or physical therapist takes when assessing TOS is to figure out which version of the condition you have. There are three unique varieties, each with its own specific presentation.

• Venous thoracic outlet: More acute in onset, this variety typically occurs when new or tiring arm movements cause damage to the veins in the lower neck or upper chest. The venous version can lead to swelling in the arms or hands, chest wall vein dilation, and a heavy sensation in the arm or hand muscles.
• Arterial thoracic outlet: This occurs when a boney abnormality in the thoracic outlet area compresses the arteries that travel through it and limits their blood flow. It is the least frequently seen form, but also the most serious. It can cause numbness, coldness, pain, or sores in the hands or fingers. It can impair the circulation in your arm and hand.
• Neurogenic thoracic outlet: The most common and treatable form, this occurs when weak or tight muscles cause the brachial plexus (a nerve bundle that controls arm muscles and sensation) to become pinched or inflamed. It can cause achiness in the neck, arm, or hand. Depending on the nerve branch that is compressed, it can also lead to tingling in the fourth or fifth fingers and clumsiness with hand movements.

To properly differentiate between these forms of TOS, a comprehensive evaluation of your strength and sensation is typically performed by your physical therapist.

A cluster of tests (including the Roos test, Adson test, or Wright test) that assesses changes in your radial (wrist) pulse while turning your neck or elevating your arm over your head can also be used to diagnose the cause of your TOS.

Finally, in some cases imaging may be necessary to figure out the cause of your symptoms. This often includes an electromyogram (EMG), magnetic resonance imaging (MRI), or an X-ray. In other cases, vascular studies, arteriograms, venograms, or blood tests may also be ordered by your physician to properly identify the problem.

Physical Therapy for Thoracic Outlet Syndrome

In the case of neurogenic thoracic outlet syndrome, conservative management with physical therapy (PT) is usually the first treatment strategy. Following your assessment, your therapy typically has several distinct goals.

Goal One: Nerve Compression Reduction

The first step in controlling your TOS symptoms (such as pain and numbness) is to reduce the amount of compression on the nerves of the brachial plexus. PT can help you accomplish this goal in a number of different ways.

First, soft tissue massage can be performed on several neck and chest muscles to relax these structures. Specifically, the pectoral, trapezius, scalene, levator scapulae, sternocleidomastoid, and suboccipital muscles are usually targeted.

In addition, stretching and mobilization techniques are also generally utilized by your physical therapist. By improving the range of motion and flexibility in these muscles, the pressure is reduced on the nerves in the region and your thoracic outlet symptoms should begin to subside.  

Goal Two: Strengthening

While the pressure reduction techniques described above are important for symptom reduction, strengthening activities also play a crucial role in preventing your symptoms from reoccurring. Generally, your physical therapist will have you perform exercises that target the muscles in the shoulder and shoulder blade (scapular) regions.

Building strength in these areas can help improve your sitting and standing posture and reduce the likelihood that the nerves that travel through the thoracic outlet become re-pinched.

At a bare minimum, four to six weeks of PT are usually attempted before your physician would consider a more invasive injection or surgical intervention. That said, it may take up to four to six months of physical therapy to fully relieve the arm, hand, or finger symptoms you are experiencing.

Post-Surgery Physical Therapy

In certain situations, physical therapy and other conservative measures fail to improve the symptoms of TOS and surgery is needed.

In the case of neurogenic or venous thoracic outlet syndrome, this involves decompressing the affected structures by removing your first rib and creating more room in the thoracic outlet. For the arterial form of the condition, the affected blood vessel may need to be repaired by the surgeon.

Following these surgical procedures, PT is generally necessary to help you recover and regain your function. Early on after surgery, rehab typically consists of light range of motion exercises for the shoulder and neck.

During this time, it is important to protect the structures in the thoracic outlet area. Your physical therapist may also teach you different ways to sit or sleep that help reduce the chances that your pain levels increase. After about a month, gentle stretching and nerve gliding exercises may be initiated and massage may be performed near the site of the surgery.

Strengthening exercises for the shoulder and postural muscles are generally not initiated until the three- to four-month mark, though the rehab protocol will vary from surgeon to surgeon. Some begin postural muscle strengthening after a month, but weight lifting is restricted for three months.

During this phase, light sport-specific movements (like throwing) may also be initiated if you are trying to return to a more demanding athletic activity. If this is the case, a regimented throwing program will be issued to you by your physical therapist to ensure that you take a graded approach when reintroducing these potentially stressful arm movements.

Ultimately, it can take up to six to nine months for a full return to higher-level exercise and sporting activities.

Thoracic Outlet Syndrome Exercises

During the course of physical therapy for thoracic outlet syndrome, several specific exercises are used to manage your symptoms. Some of the hallmark techniques traditionally utilized are listed below.

Postural Stretching

Falling into a rounded shoulder and forward head posture can cause your neck and chest muscles to become tight. Maintaining this posture for a long period of time can also compress the structures that travel through the thoracic outlet.

Because of this, your therapist will typically teach you stretches for the chest (pectoral), neck (scalene, sternocleidomastoid, suboccipital), and scapular (levator scapulae, trapezius) muscles. Gaining flexibility in these structures can help you stay in a better sitting or standing posture and is one of the keys to improving your TOS symptoms.

Scapular Strengthening Exercises

In addition to stretching, strengthening the scapular muscles in your upper and mid-back can help you maintain a more erect posture while you are sitting and standing. This, in turn, can help prevent symptom reoccurrence.

Machines or other types of gym equipment may be utilized by your physical therapist to strengthen these areas, though in most cases a simple resistance band or dumbbell is all that is necessary. While there are many different strengthening exercises that target these regions, several common techniques are often utilized in rehab.

Lying on your stomach and performing a prone shoulder row or prone shoulder extension exercise can target the muscles that bring your shoulder blades into a down (depressed) and back (retracted) position.

Similarly, doing a reverse fly or rested external rotation movement with an elastic band can also activate these important structures.

Finally, the push-up plus exercise, which encourages you to bring your shoulder blades into a forward or protracted position at the end of the movement, is another effective technique.

During your time in therapy, your physical therapist will walk you through a wide variety of exercises that can address any weakness that may be contributing to your thoracic outlet syndrome symptoms.

Nerve Gliding Techniques

Another common addition to your TOS rehab is nerve gliding. These movements attempt to free a nerve from any restriction or compression by gently flossing or gliding the structure back and forth.

To do this, the therapist will instruct you on gently moving your arm between a position that tenses the nerve and one that relaxes it. Alternating between these two arm movements can help relieve some of your TOS symptoms over time.

Prevention

If you have experienced the symptoms of thoracic outlet syndrome in the past, there are several steps that you can take to prevent the condition from reoccurring.

First, try to avoid carrying heavy backpacks, bags, or purses over the affected shoulder. Doing so can push down on your collarbone (clavicle) and cause the structures in this area to become compressed.

In addition, continue to perform the stretching and strengthening exercises your physical therapist teaches you, even after your symptoms resolve. While these exercises can provide symptom relief in the moment, they can also help you maintain good posture and reduce the likelihood that your thoracic outlet symptoms reappear.

Outlook

If left untreated, thoracic outlet syndrome can lead to serious consequences like blood clots, permanent loss of nerve function, and chronic pain or swelling of the arm. Fortunately, in most cases, this is a very treatable condition.

Typically, neurogenic TOS is well addressed with a combination of physical therapy, muscle relaxants, pain medication, and (occasionally) injections. Conservative treatment, however, may take up to six months to provide significant relief.

Venous thoracic outlet syndrome typically does not respond well to physical therapy. Instead, it is usually initially treated with a combination of medications that help dissolve any existing blood clots and keep future ones from forming.

Finally, in the case of arterial thoracic outlet syndrome, surgery is usually necessary to provide symptom relief.

Summary

Physical therapy can help with the symptoms of thoracic outlet syndrome. Depending on the type, surgery may be needed, with physical therapy both before and after. Physical therapy begins with range of motion exercises, stretching, and mobilization exercises. It then may progress to strengthening exercises for the shoulder.

A Word From Verywell

Regardless of which type of thoracic outlet syndrome you have, you can take comfort in knowing that the condition is usually treatable. In the case of neurogenic TOS, physical therapy can help resolve your symptoms and return you to the activities you love.

If you suspect you have thoracic outlet syndrome, be sure to have your symptoms evaluated by a physical therapist or a physician. These medical professionals can help determine which form of the diagnosis, if any, you have and whether PT will be of benefit to you. 

Frequently Asked Questions

What physical therapy exercises are recommended to relieve thoracic outlet syndrome?

Physical therapy for thoracic outlet syndrome typically focuses on three types of exercises. First, postural stretches are prescribed to improve the flexibility in the muscles that surround the affected nerves.

Next, nerve flossing or gliding techniques help free your nerves from any restrictions that are keeping them from moving normally. Finally, shoulder and shoulder blade strengthening activities help improve your posture, provide symptom relief, and prevent your TOS from recurring.

How long do you need physical therapy to help with thoracic outlet syndrome?

The amount of time it takes for PT to help the symptoms of TOS varies from person to person. That said, it is not unusual to see progress in as little as four to six weeks. In some cases, however, it can take four to six months to completely resolve your symptoms.

How many sessions of physical therapy do you need after surgery for thoracic outlet syndrome?

Depending on the activities you are looking to return to, rehab after a thoracic outlet syndrome surgery can last for six months or more. Early on, your therapist may want to see you one to two times per week while you are initially recovering from surgery.

As time goes on and you enter the later phases of PT, however, the sessions usually become less frequent. During this time, you may only see your therapist once weekly or even once every few weeks to update your home program.