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Thoracic Outlet Syndrome Causes & Treatments For Hand Tingling or Numb At Night

Hand pain, tingling, and numbness can be attributed to Thoracic Outlet Syndrome, a group of disorders that cause shoulder pain, neck pain, or numbness in your arm, hands, and fingers. The most common causes of this syndrome include poor posture, repetitive activity, and pressure on the joints. Your physician may suggest treatment options like physical therapy, Graston technique, and cold laser therapy to minimize and improve symptoms experienced by Thoracic Outlet Syndrome.

What is Thoracic Outlet Syndrome?

Thoracic Outlet Syndrome (TOS) is a group of disorders that occur when blood vessels or nerves in the thoracic outlet – the narrow space between your collarbone and first rib – compress.

Blood vessels, nerves, and muscles that extend from your back to your arms pass through this area. If the space in the thoracic outlet is too narrow, these structures can become compressed and cause pain in your shoulders, neck, or numbness in your fingers. Some people have structural abnormalities which narrow the passageway for the nerves and blood vessels.

latelet rich plasma prolotherapy for neck pain

While the cause of Thoracic Outlet Syndrome isn't always known, it is often diagnosed after a triggering event such as lifting injury or physical trauma from a car accident.

The most common cause of thoracic outlet syndrome is chronic repetitive overuse combined with poor posture. Slouching rounded forward shoulders combined with repetitive hand movements in front of the the body, such as typing, overuse and shorten the scalenes, pectoralis minor, and trapezius muscles. The loss of muscle flexibility combined with elevated and forward rounded shoulders decreases the space for nerve and artery bundles and increases the chance of compression. People with poor posture usually have a history of headaches and neck pain from slouching.

What Are The Symptoms of Thoracic Outlet Syndrome?

There are several types of Thoracic Outlet Syndrome. Three of the most common include:

  • Neurogenic (neurological) thoracic outlet syndrome. This form is characterized by compression of the brachial plexus, a network of nerves that come from your spinal cord. These nerves control muscle movements and sensations in your shoulder, arm, and hand.
  • Vascular thoracic outlet syndrome. This type occurs when one or more of the veins or arteries under the collarbone are compressed.
  • Nonspecific-type (disputed) thoracic outlet syndrome. Individuals with this type have chronic pain in the thoracic outlet that worsens with activity. Some physicians don't believe it exists while others think it's a common disorder.

Symptoms of Thoracic Outlet Syndrome vary depending on which areas are compressed and location of entrapment.

Symptoms of neurological thoracic outlet syndrome include:

  • Numbness or tingling in the arms or fingers
  • Pain or aches in the neck, shoulder, or hand
  • Weakening grip
  • Often most pronounced in the ring and little finger
  • Can occur in both hands, especially at night

Symptoms of vascular thoracic outlet syndrome include:

  • A bluish discoloration of your hand
  • Arm pain and swelling
  • Blood clot in veins or arteries
  • Lack of color in your fingers or hand
  • Weak or no pulse in the affected arm
  • Cold fingers, hands, or arms
  • Arm fatigue
  • Numbness or tingling in your fingers
  • Weakness of arm or neck
  • Throbbing lump near your collarbone

Thoracic Outlet Syndrome from Scalene Muscle Entrapment

Anterior scalene syndrome is a subcategory of thoracic outlet syndrome which is often misdiagnosed by patients who research their condition. Most Internet searches reveal common compression syndromes like carpal tunnel. The location and symptoms of hand pain are different in thoracic outlet syndrome and carpal tunnel because different tissues and nerves are compressed.

The scalene muscles are neck flexors that help stabilize the spine during normal movement, and they lift the rib cage while taking a breath. These muscles travel from the neck down towards the rib cage.

Scalene syndrome is common in people who display a head forward and shoulder-rounded posture and perform activities like working on a computer for long periods of time. Symptoms change depending on the amount and forcefulness of the activities performed. Pain and tingling with prolonged postures and positions may also fluctuate when trying to reproduce the condition in the office.

Causes of Thoracic Outlet Syndrome

The cause of Thoracic Outlet Syndrome is the compression of nerves or blood vessels in the thoracic outlet, which is just under an individual's collarbone (clavicle). The cause of this compression varies and includes:

  • Anatomical defects. Inherited defects such as an extra rib located above the cervical rib (first rib) or an abnormally tight fibrous band connecting your spine to your rib.
  • Poor posture. Things like drooping your shoulders or holding your head in a forward position can compress the thoracic outlet.
  • Trauma. Traumatic events can cause internal changes can compress the nerves. The onset of symptoms is often delayed.
  • Repetitive activity. Doing the same thing over and over can wear your body's tissue.
  • Pressure on your joints. Extra weight can put stress on your joints, as can carrying an oversized bag.
  • Pregnancy. Since joints loosen during pregnancy, signs of thoracic outlet syndrome may first appear when you are pregnant.

Women make up the majority of Thoracic Outlet Syndrome diagnoses, and the syndrome is more common in young adults, between 20 and 40 years old.

How is Thoracic Outlet Syndrome Diagnosed?

The first thing your physician will do is perform a physical exam where they will review your symptoms and medical history. Your physician will also perform provocation tests that are meant to reproduce your symptoms in order to make an easier diagnosis.

A series of orthopedic tests that involve stretching the scalenes and pectoralis minor muscles to try and reproduce symptoms down the arm and shoulder. If the tests can reproduce the pain and likewise relieve the symptoms, that we can be fairly certain of the diagnosis. We always feel more comfortable when we can reproduce symptoms in the hands and then relieve symptoms with specific movements. Especially since the diagnostic imaging tests cannot always confirm or rule out T.O.S.

Diagnostic & Advanced Imaging for Thoracic Outlet Syndrome:

  • An X-ray of the thoracic outlet to determine whether you have an extra rib. It may also rule out other conditions that might be causing your symptoms.
  • An MRI to determine the cause and location of the compression. It may also show structural abnormalities that may be causing your symptoms.
  • During an electromyography test, an electrode is inserted through your skin into various muscles. This evaluates the electrical activity of your muscles at rest and when they are contracted.
  • A nerve conduction study measures how quickly your nerves send impulse to various muscles throughout the body. It can determine if you have nerve damage.

hand median ulnar nerve distribution

Image shows how median nerve compression causes sensation in the thumb, index, and middle fingers while ulnar nerve entrapments effect little and ring fingers. A single nerve does not control feeling in the entire hand, which indicates compression of the artery somewhere between the neck and elbow.

Why Is Thoracic Outlet Often Misdiagnosed?

The location, timing, and onset of pain should help with the diagnosis; however, it is often misdiagnosed as carpal tunnel, disc herniation, or "pinched nerve" coming out of the spine. Carpal tunnel only causes symptoms of the thumb, index, and middle finger. It does not causes numbness, tingling, or weakness in the entire hand. Both conditions can be worse at night, with repetitive activity in front of the body, and can affect both hands. Specific orthopedic tests will also increase carpal tunnel symptoms but do not cause a difference with T.O.S. We have had way too many people come into the office looking for help with their "chronic carpal tunnel" that really had T.O.S.; unfortunately, they went through a lot of unnecessary treatment with little relief.

Video: Thoracic Syndrome (TOS) mistaken for Carpal Tunnel Syndrome

Spinal disc bulges and herniations will cause symptoms in a single nerve root distribution or dermatome. When people feel worse in their two little fingers it is often misdiagnosed as a lower cervical disc injury or cubital tunnel injury. In this case, the orthopedic tests for disc injuries such as maximal cervical compression should increase symptoms and cervical distraction should relieve sensation. In TOS the symptoms are not worse with the compression forces but might be aggravated by the positioning only. Cervical distraction usually does not make a difference. Cubital tunnel tests will not reproduce symptoms in the little figers.

Palpation of the scalene muscle insertion or pectoralis minor insertion will often increase symptoms down the arm. Likewise relieving pressure on the muscles reduces symptoms. Specific tests that stretch the scalene muscles and pectoralis minor will increases sensation down the hand and slightly reducing the stretch will eliminate the tingling.

Many people often start the wrong treatment plans because of the wrong diagnoses and end up not improving for months. A correct diagnoses should involve tests that reproduce the pain, and the opposite tests that relieve the hand and arm sensations.

Pectoralis Minor Trigger Point Referral Pattern

pectoralis minimus trigger point

Scalene Trigger Point Referral Pattern

scalene trigger point

Home Treatments for Thoracic Outlet Syndrome

The first treat is always conservative physical therapy, massage, and chiropractic treatments to increase muscle flexibility and strengthen lower scapula stabilizer muscles. Strengthening the mid back and lower scapula muscles help improve posture and pull the shoulders backward, opening up space for the brachial plexus. People with poor slouching postures often have neck or upper back joint problems that increase slouching behaviors.

home treatments for thoracic outlet syndrome

Over-the-counter medications, such as ibuprofen, may be used to reduce inflammation and pain. Ice is always your friend, and especially in patients with neck and shoulder pain. 15 minutes on and 15 minutes off, rotating several times a day.

Sometimes, your physician may prescribe thrombolytic drugs that are administered through your veins or arteries to dissolve blood clots in the thoracic outlet. They might also prescribe anticoagulants to prevent blood clots from forming.

If an individual is overweight, their physician may recommend a weight loss program or a specific diet to help relieve the symptoms of thoracic outlet syndrome. Maintaining a healthy weight is important for reducing pressure on the joints.

Work setup changes include stand up desks and ergonomic keyboards. Often people need to change their work chair and raise their monitor height. Most people focus on not slouching during the day and taking a few breaks to stretch and move around the office. For people who have a tendency to work on their laptop while sitting on the couch, stop now. This positions only increases strain on your weak muscles and increases slouching postures.

Subtle changes to your driving position or setup can be helpful to reduce strain on the neck and shoulders. Changes to recreational postures and habits will help reduce strain on the scalene muscles and strengthen the mid back muscles.

Over time people will notice their little fingers going to sleep less often or less intense when they wake up. Their entire hand stops tingling and needing to be shaken out during the work day.

Medical Treatments for Thoracic Outlet Syndrome

In severe cases with symptoms that don't improve with medication and physical therapy, your physician may suggest surgery.

Surgery for thoracic outlet syndrome might involve:

  • Removing an extra rib
  • Removing a section of the first rib
  • Rerouting blood vessels around the thoracic outlet.

If the blood vessels in the thoracic outlet are narrowed, an angioplasty may be used to open them up.

Thankfully surgery is seldom required, most cases respond to a combination of conservative therapy, physical therapy, chiropractic, and massage therapy.

Conservative & Non-Surgical Treatments for Thoracic Outlet Syndrome

Your primary care will instruct you to do exercises at home to strengthen and support the muscles surrounding the scapula, upper back, and shoulders. Stretching the upper trapezius, scalenes, and pectoralis major are necessary for healing.

In general, it's ideal to avoid unnecessary stress on your shoulders and thoracic outlet by:

  • Maintaining good posture
  • Taking frequent breaks to move and stretch
  • Maintaining a healthy weight
  • Avoid carrying heavy bags over your shoulder

Physical Therapy can help individuals with TOS by developing a treatment plan to help ease discomfort and improve the ability to perform daily activities. Manual (hands-on) therapy may be used to manipulate or mobilize the nerves of the arm to help reduce numbness and tingling. A physical therapist will also provide patients with muscle-strengthen exercise to improve movement and strength in the affected area.

Graston Technique and Active Release Technique (ART) are also used for treatment as they increase blood flow and decrease inflammation to the tendons, muscles, and soft tissue of the neck.

Class IV cold lasers are an excellent treatment modality for decreasing muscle spasms and inflammation as it relates to anterior scalene syndrome. Cold laser therapy decreases inflammation in the deep muscles and tendons, as well as increases blood flow to the affected area and speeds up recovery. Low level laser therapy enhances nerve repair and regeneration from nerve damage caused by thoracic outlet syndrome. With cold lasers, patient's overall recovery time will decrease along with their duration, intensity, and frequency of symptoms in their hand and arm.

Chiropractic adjustments to enhance spinal joint motions and reduce pain. This is especially important in people with chronic slouching postures, that find it uncomfortable to sit with "good posture."


Diagnosing Thoracic Outlet Syndrome can be difficult as the symptoms and severity vary among individuals with the disorder. There are a number of causes for the disease which can be diagnosed through a physical examination. While the first line of defense is conservative treatments, most cases can be improved with surgery or years of chronic pain.

Alpha Chiropractic and Physical Therapy provides treatment for many patients in Chandler, Gilbert, Mesa, Tempe, Phoenix, and Maricopa. Therapy and treatments for many types of conditions can be improved with our unique combination of treatments and modalities. Learn more about our unique Chiropractic Clinic.