Nerve compression

Thoracic Outlet Syndrome

Neurovascular compression at the thoracic outlet. Neurogenic (95%), venous (3-5%), arterial (1-2%). Often poorly diagnosed.

Thoracic outlet syndrome (TOS) is a compression of the neurovascular bundle (brachial plexus, subclavian artery and vein) at three critical anatomical levels: the interscalene triangle (anterior and middle scalene muscles), the costoclavicular space (clavicle and first rib), and the subcoracoid tunnel (pectoralis minor). There are three forms: neurogenic (95% of cases — compression of the inferior trunk C8-T1), venous (3-5% — Paget-Schroetter syndrome, effort thrombosis), and arterial (1-2% — subclavian artery compression, distal ischemia). TOS can mimic shoulder pathology and must be considered in cases of atypical shoulder pain with distal symptoms.

Characteristics

  • Neurogenic form: pain and paresthesias of the upper limb (ulnar territory C8-T1), worsened by overhead positions. Intrinsic hand muscle weakness. Night symptoms.
  • Provocative tests: Roos test (90° abduction + external rotation, fist opening and closing for 3 min), Adson test (scalene compression), Wright test (hyperabduction).
  • Venous form (Paget-Schroetter): sudden onset upper limb swelling, cyanosis, venous distension. Typically after intense muscular effort. Doppler and venographic diagnosis.
  • EMG can be normal in the early stages. Dynamic Doppler ultrasound during provocative maneuvers. Cervical spine MRI to rule out disc pathology.

Medical and surgical management

  • Conservative treatment first line for the neurogenic form: physiotherapy 3-6 months (70-80% improvement). Activity modification, weight loss if applicable.
  • Neurogenic form resistant to conservative treatment: first rib resection (transaxillary or supraclavicular approach) ± anterior scalenectomy. Results variable (60-80%).
  • Venous form: urgent anticoagulation + thrombolysis. First rib resection considered to prevent recurrence. Arterial form: vascular surgical emergency.

Physiotherapy rehabilitation

  • Postural rehabilitation: correction of forward head posture and shoulder protraction. Strengthening of lower trapezius and serratus anterior.
  • Scalene stretching: stretching and relaxation of anterior and middle scalene muscles. Soft tissue mobilization of the cervicothoracic region.
  • Thoracic opening exercises: first rib mobilization, costoclavicular space opening. Diaphragmatic breathing to reduce scalene overuse.

Average duration

8 to 24 weeks

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Scientific sources

General information only: this content cannot provide a diagnosis or prescription. A healthcare professional must assess your situation.