The Thoracic Outlet Syndrome

Most of my time I am either at school learning, or at the gym and on the mats, training and teaching. I watch people training hard, some of them thinking about what they are doing, some of them fooling around making more damage to their bodies than actually doing some good. Lucky me, I always found myself in good hands when it came to training. Everything I did was thoroughly screened and individualized. I trained focused and was able to stay mostly injury and pain free during my time of intensive training. Some previous problems even got much better. Being focused on many different things, I forgot to take proper care of my shoulders. There were no severe problems in movement, but I was always in a lot of pain after hard training sessions, especially in boxing. In addition, I felt my arms getting numb and cold at night, but I didn't know where all of this was coming from. I treated my hurting shoulder with some mobility work, which eventually made things better, but it was no solution in the long hall.

During my studies in Krems I stumbled upon the „Thoracic Outlet Syndrome“. It described symptoms as numb arms, cold hands and hurting shoulders. I got myself tested and without a lot of surprise, the result was positive. Lucky me, everyone was eager to try out the test and the treatment on me, so after intensive treatment I got okay on the same day. I had the best night’s sleep, without waking up to numb arms.

During the next few weeks, I realized that I was able to do more work having less pain. I started testing people myself, realizing that there were many people with a positive result. That got me thinking and that’s why today I want to dig deep into the topic of the “Thoracic Outlet Syndrome”. For me as a physiotherapist-to-be and a trainer of Martial Arts this is a pathology I have to think about, need to take care of and try to avoid.

First, let's clarify which structures we are talking about: if you take a look at the picture of the skeleton to your right, you will find the clavicle painted green. The clavicle is part of the shoulder joint and is responsible for mobility while raising the arms. In addition, it gives muscles the chance to attach. I won't go into much more detail here, I could go on and talk hours about the shoulder joint, but let's focus on our original topic.

Directly under the clavicle, without leaving much space in between, the first rib attaches to the sternum. There are muscles called „scalene muscles“, which you can see on the picture at the left. They function as accessory respiratory muscles and they bend your neck sideward. The important thing for us is, that these muscles originate at the cervical vertebrae, and attach at the first rib. Therefore, they proceed through the space between the clavicle and the first rib forming two holes, the “Thoracic Outlet”.  

Through those holes, one specific nerve and vessels are breaking through: the nerve is called Brachial plexus, and is important for us, because it innervates all the way down into our arms and hands. The subclavian artery supplies our upper extremities and leads all the way down to our arms and hands too. 

To sum it up, the thoracic outlet is made out of the clavicle, the first rib, the anterior and medial scalene muscle, forming two little holes where the brachial plexus und the subclavian artery and vein break through.

Our lifestyle, injuries, or sports can influence these structures and eventually cause problems. For example, a lot of sitting puts the shoulders into a position where they point forward continuously, also called protraction. Because of permanent protraction, the first rib elevates and stays stuck there. It presses the nerve and vessels against the clavicle. This causes problems with blood circulation, numb arms and cold hands are the consequence.

Permanent shoulder protraction is also found in Martial Arts. The guard position in boxing forces the shoulder to point forward all the time. Without proper conditioning and training for shoulder health one of the breast muscles, the pectoralis minor (you can find the muscle at the picture to your right) will get tight and pressure the brachial plexus and the subclavian vessels. Again, numb arms, cold hands and other tense muscles can be the consequence.

I find myself in a field of sports, where we need to do many things encouraging exactly these mentioned positions. We have to stress body parts in a way they are not made for. What we are doing to stop making things worse, is compensating with conditioning and mobility. Still, there are many people with a positive test result. To be more specific: a positive test result for having a tight pec minor. Fixing this problem is very easy, so I thought about how to include a proper stretch into classes. I realized that it is pretty easy: what the pec minor does is to put the shoulder into depression and protraction, so to stretch it you need to retract your shoulder and elevate your arm above 90°. Either on the wall, or on the floor, it is easy to integrate the stretch into class, so I will start doing this on a regular basis.

Having realized all that I hope, that it will be possible to prevent the “Thoracic Oultet Syndrome” and maybe help some people who already have it. Since it is very easy to deal with the second type of the syndrome, it should be easy to accomplish this goal. I will keep you updated on this topic. When it comes to the first type (having an elevated first rib) unfortunately the only possibility to fix it I know, is to go to a therapist who mobilizes your first rib back into order. However, you can prevent both types by being aware of the fact that you need to compensate for burdens you put your body through. Speaking about shoulder health this should be a lot of mobility work and paying extra attention to the movement pattern “pull”, when it comes to your workout.