An overview and guide to instructing clients with Thoracic Outlet Syndrome
Anatomy of the Thoracic Outlet:
Before jumping into a discussion of TOS, it's important to understand the anatomy of the thoracic outlet. In particular, there are 3 main areas we need to focus on:
Brachial plexus: a network of nerves that connects to the spinal cord in the neck and upper back and controls movement and sensation in the shoulder, arms, forearms, and hands.
Subclavian artery: a large artery that delivers oxygen-rich blood to the arm. It is located below the collarbone (“subclavian” means below the clavicle, also known as the collarbone).
Subclavian vein: a deep vein that passes below the clavicle and drains blood from the arm. [1]
[2]
What is Thoracic Outlet Syndrome?
Thoracic Outlet Syndrome (TOS) is a series of disorders in which nerves, arteries, and veins in the thoracic outlet (space between the collarbone and first rib) are compressed. There are 3 types of TOS: Neurogenic, Venous, and Arterial
Neurogenic TOS: This is the most common form of TOS and accounts for nearly 90% of TOS diagnosis. In neurogenic TOS the Brachial Plexus nerve is compressed between the first rib, clavicle and the scalene muscles.
Venous TOS: The second most common form of TOS. Caused by the compression of the subclavian vein between the collarbone (clavicle), first rib, subclavius muscle and the costoclavicular ligament (a ligament located in the upper chest in the area of the first rib and the collarbone)
Arterial TOS: The least common form of TOS, impacting only 2-5% of TOS patients. Caused by the compression of the subclavian artery between the first rib, clavicle, and scalene muscles.[3][4]
How is Thoracic Outlet Syndrome diagnosed?
TOS is typically diagnosed through a series of tests including physical examinations, imaging, electromyography (EMG) testing, nerve conduction studies, and local anesthetic injections.
While a medical examination is highly suggested, there are some physical tests we can perform on clients we suspect of having TOS:
Elevated Arm Stress Test
Arms placed with shoulders at a 90* abduction-external rotation and elbows flexed to 90*. Client would slowly open and close the hands for 3 minutes.
Watch for: Pain, paresthesia (tingling/prickling sensation), and diminished radial pulse
Video Example: Click Here
Upper Limb Tension Test
The client will extend one arm out straight in front of them with the palm facing forward and the elbow fully extended. Keeping this position, they will bend their head to meet their ear with the shoulder of the extended arm. Maintaining the straight arm and the head tilt they will then extend the other arm out to the side with the palm facing upward.
Watch for: pain, paresthesia, or diminished radial pulse and which sides are experiencing symptoms [9]
Adson Test
Abduct the arm 30* to the side (a dodgeball size space between the wrist and hip) with full extension of the elbow and palm facing forward. Extend the head and rotate it toward the opposite side from the abducted arm
Watch for: Diminished or absent radial pulse [5]
Video Example: Click Here
It is important to note that Venous and Arterial TOS can have serious health implications. Should you suspect a client of having TOS, refer them to seek out medical expertise prior to continuing training sessions.
Who is impacted by Thoracic Outlet Syndrome?
While TOS can be diagnosed in anyone, it is most commonly diagnosed in women and in the 20-50 age range [1]. Those who participate in overhead or repetitive shoulder activities such as swimming, rowing, volleyball, and baseball have a heightened risk for TOS. [6]
TOS may also be caused by anatomical variations such as a cervical rib (extra top rib) or a traumatic injury to the thoracic outlet (such as an improperly healed collarbone).
Other possible causes are tumors, muscle imbalances (such as in weight lifters)[2].
How do you 'fix' Thoracic Outlet Syndrome?
Treatment for thoracic outlet syndrome varies between the its different types due to the differences in severity and what component of the thoracic outlet is being compressed.
Treatment for Neurogenic:
Physical Therapy is usually the first treatment.
Should physical therapy not alleviate all symptoms, medical professionals may decide to try Botulinum Toxin injections to relieve symptoms further.
If PT and injections are not effective surgery may be recommended. This surgery would typically involve cutting small muscles of the neck (anterior and middle scalene) and removing the cervical or first rib
Treatment for Venous:
Surgery is typically recommended straight away due to the compression of the vein. Surgery may involve removal of both the scalene and subclavius muscles and first rib.
The vein must also be treated as blood clots may develop where compression was causing damage. This would typically involve blood thinning medication or a thrombolysis procedure to retrieve the clot.
Treatment for Arterial:
Surgery is typically recommended straight away due to the compression of the artery. This may involve removing both the scalene muscles in the neck, the cervical rib if present and the first rib.
Similarly to venous, blood thinning medications may be necessary to treat clots
If there is a clot or aneurysm within the artery, reconstruction or replacement of the artery may be necessary. [2]
Where does Pilates comes into play?
Similar to numerous subjects within the realm of Pilates, thoracic outlet syndrome and our role in addressing it are shrouded in controversy and conflicting viewpoints.
There is limited evidence to indicate that Thoracic Outlet Syndrome can be prevented. Nonetheless, it could be argued that engaging in exercises commonly prescribed for TOS patients on a regular basis may serve as a preventive strategy.
When it comes to working with clients who have been diagnosed or we suspect have TOS. We can play a vital role as pilates instructors. TOS is not free from re-lapsing, and thus it is important to maintain proper care and exercise following the physical therapy period.
To effectively assist clients with TOS its important that we know some of the basic exercises prescribed by physical therapist. University of Michigans Frankel Cardiovascular Center prescribes post-operative TOS patients a program consisting of:
Shoulder Flexion:
Shoulder Rotation:
Chin Tuck:
Neck Rotation with Chin Tuck:
Lateral Neck Flexion with Chin Tuck
Scapula Retraction
[7]
A physical therapy program from The Ohio State University Medical Center adds swan, prone thoracic extension (chest stretch), and a standing lunge utilizing a wall to expand the chest.
Swan
Prone Thoracic Extension (chest stretch)
[8]
What you will find common amongst most TOS Physical Therapy programs is the need to expand the thoracic outlet and strengthen the muscles in the afflicted shoulder and thoracic area.
To create a valuable pilates program, you will want to include: Scapular Retraction and Depression, Chest Opener, Thoracic Extension, Neck Flexion/Extension, Shoulder Blade Squeezes [7][8]
Contraindicatons and Modifications:
When instructing clients with thoracic outlet syndrome, it is important to know what exercises and movements to avoid as well as how to modify movements to allow for proper rehabilitation.
When it comes to contraindications, or what specifically to avoid we have a few items. For example, heavy resistance can place excessive strain on the neck and shoulders. Similarly, static postures and repetitive overhead movements can exacerbate pressure on the neck. Lifting of the head and chest in supine can cause increased compression.
Over stretching may also exacerbate TOS symptoms as it may worsen compression of the nerves and blood vessels.
When modifying in a class format you should focus on:
Posture and alignment:
Maintaining proper spinal alignment and posture is key to improving thoracic outlet syndrome. You will want to ensure that their shoulders are kept down and back. Adding core exercises will help to suppprt the spine and reduce strain on the upper body
it is worth noting that nearly every institution marks posture as the first phase of physical therapy
Keep the head down in supine exercises:
While curling the head and neck is a common practice within pilates, with TOS patients it is adding further compression of the spine. During the rehab stage, keeping the head down will allow for your client to focus on expanding the thoracic outlet and improving posture/spinal alignment.
Per the discussed University of Michigan PT program, post-operative clients should not round or bend the head or neck forward [7]
Increased focus on breathing:
Focusing on the breath allows for relaxation of the thoracic muscles and when used in combination with supine exercises may act to expand the chest
Modifying for a group class setting:
I wanted to provide a list of modifications pilates instructors may find helpful in a class setting. All of the below modifications come from researching clinical studies, personal experience, and discussions with trained PT and pilates professionals.
Footwork:
Have the person keep their feet parallel or hip width on the bar. Do not have them participate in wide or external rotation.
The idea with this is allowing the client to participate in external rotation may cause them to pop out of, or lose the neutral spine we are trying to maintain. By keeping their feet parallel they will able to focus on strengthening their core muscles to effectively support the upper body and improving posture.
Bridging:
No external rotation, see same reasoning for footwork
Arms on mat and reaching towards the feet. No arms overhead
By keeping the arms resting by the sides, participants can focus on pelvic stabilization and controlled movement of the spine, minimizing strain on the thoracic outlet.
Work towards single-leg as client performance improves
Abs/core:
Keep the arms and head down
The intention behind this mod is the alleviate neck strain, reduce further compression of the thoracic outlet, and prevent improper alignment of the spine. TOS clients may round through. the thoracic outlet if asked to lift the head or chest which may lead to further compression.
Arms:
Lighter weights/springs:
consider dropping springs or weight dependent on client strength level and progress
Keep arms and head downn- see abs/core
Maintain neutral spine and shoulders down and back
Leg work:
Proper alignment (particularly in single leg)
Not much modification is needed for leg work. The most important thing is to ensure the client maintains proper alignment through the spine. This may come into particular play when doing single leg footwork laying on the side. Ensure that their hips and shoulders are stacked and inline, keep a small ball or their arm under the head to prevent kinks in the neck as this may exacerbate TOS.
Planks:
Perform on forearms
The intention behind this modification is to strengthen the core and upper body while minimizing strain on the shoulders and neck. By performing plank exercises on the forearms, participants can reduce the load on the shoulders and wrists, focusing on proper alignment and engagement of the core muscles to support the spine and reduce strain on the thoracic outlet.
Balance Challenges:
There are not many 'balance challenge' modifications to give, but here are a few things. to keep in mind:
Overhead repetitive movements:
TOS can be exacerbated by overhead repetitive movements. This may eliminate or require a smaller amount of reps for challenges such as Bird Dog
Unsupported Arm Weight Bearing
Some variations of exercises such as plank may exacerbate symptoms, particularly those that have one arm extended or moving.
Citations:
[1] Yale Medicine. (2023, May 16). Thoracic outlet syndrome. Yale Medicine. https://www.yalemedicine.org/conditions/thoracic-outlet-syndrome
[2] Thoracic outlet syndrome. Johns Hopkins Medicine. (2024, May 24). https://www.hopkinsmedicine.org/health/conditions-and-diseases/thoracic-outlet-syndrome
[3] Types of thoracic outlet syndrome (TOS). Center for Thoracic Outlet Syndrome. (n.d.). https://tos.wustl.edu/what-is-tos/types-of-tos/
[4] Pennmedicine.org. (n.d.). https://www.pennmedicine.org/for-patients-and-visitors/patient-information/conditions-treated-a-to-z/thoracic-outlet-syndrome
[5] Li N, Dierks G, Vervaeke HE, Jumonville A, Kaye AD, Myrcik D, Paladini A, Varrassi G, Viswanath O, Urits I. Thoracic Outlet Syndrome: A Narrative Review. J Clin Med. 2021 Mar 1;10(5):962. doi: 10.3390/jcm10050962. PMID: 33804565; PMCID: PMC7957681.
[6] Thoracic Outlet Syndrome (TOS). Thoracic Outlet Syndrome (TOS) | Boston Children’s Hospital. (n.d.). https://www.childrenshospital.org/conditions/tos#:~:text=Thoracic%20outlet%20syndrome%20affects%20people,baseball%20players%2C%20and%20volleyball%20players.
[7] Frankel Cardiavascular Center. (2021, November). Thoracic Outlet Syndrome Physical Therapy. Frankel Cardiovascular Center - Michigan Medicine.
[8] Thoracic Outlet Syndrome exercises II. (n.d.). https://www.saintjohnscancer.org/thoracic/wp-content/uploads/sites/5/2018/09/TOS-exercises-1.pdf
[9] Diagnosis of neurogenic thoracic outlet syndrome is critical. Thoracic Outlet Syndrome Testing, Specialists, Symptoms, Exercises, -NeoVista® MRI for TOS. (2024, April 18). https://www.tosmri.com/diagnosis-of-neurogenic-thoracic-outlet-syndrome/
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