Thoracic Outlet Syndrome

Thoracic Outlet Syndrome (TOS) is a potentially painful and disabling condition of the upper extremity. It results from the compression of structures in the thoracic outlet, a space just above the first rib, and behind the clavicle (collar bone). Due to the range of signs and symptoms that can lead to a diagnosis of TOS, the incidence rates of the condition currently are unknown. Physical therapists work with individuals who have TOS to ease their symptoms and restore their upper-body function.

How Does it Feel?

Because TOS generally is classified based upon the type of structures compressed, the symptoms experienced may vary. However, more than 90% of TOS cases are thought to be neurogenic (nerve compression) in nature (categories 3 and 4 below).

Arterial TOS

  • Pain in the hand; rarely in shoulder or neck
  • Coldness or cold intolerance
  • Numbness and tingling

Venous TOS

  • Pain in the arm
  • Swelling in the arm
  • Change in arm coloration (appears bluish)
  • Feeling of heaviness in the arm
  • Numbness and tingling in fingers and hands

True Neurogenic TOS

  • Pain, numbness, and tingling in the hand, arm, shoulder, and often the neck
  • Headaches
  • Numbness and tingling of the arm, often waking the individual up at night
  • Hand clumsiness
  • Intolerance to cold
  • Hand coldness and color changes

Disputed Neurogenic TOS

  • Pain, numbness and tingling in the hand, arm, shoulder and often the neck
  • Headaches
  • Numbness and tingling of the arm, often waking the individual up at night
  • Hand clumsiness
  • Intolerance to cold
  • Hand coldness and color changes
  • Symptoms greater at night vs day
  • Tests may come back normal (hence, the term "disputed").

How Is It Diagnosed?

Diagnosis of TOS begins with a thorough health history and clinical examination.

Your physical therapist will likely check for color changes in the affected area, and gently attempt to provoke symptoms by moving the affected limb in different directions.

You also may be referred for diagnostic testing, such as a Doppler ultrasound, which can confirm arterial and venous TOS, or nerve conduction velocity testing to help confirm a true neurogenic TOS.

Your physical therapist may be the first to recognize an onset of TOS, because of its effects on your physical function. Your physical therapist may ask you:

  • When did you begin experiencing these symptoms, and when are they the worst?
  • Have you noticed any change in your symptoms when the temperature changes?
  • Have you noticed any significant changes in your ability to perform physical tasks that require hand movements?
  • Have you noticed any changes in the appearance of your arm or hand?

In addition, your physical therapist will rule out other conditions, which may mimic this disorder. Your therapist may ask you to fill out a questionnaire in order to better understand your physical state, and to screen for the presence of other conditions.

How Can a Physical Therapist Help?

Once you have received a diagnosis of TOS, your physical therapist will work with you to develop a treatment plan to help ease the discomfort, and improve your ability to perform daily activities. Most research on this condition recommends a treatment plan that involves physical therapy to help ease your symptoms and improve function.

Physical therapy treatments may include:

Manual Therapy. Manual (hands-on) therapy may be applied to manipulate or mobilize the nerves of the arm to help reduce symptoms, such as pain and numbness/tingling. Your physical therapist also may attempt to gently mobilize your first rib and/or collar bone.

Movement and Strengthening Exercises. Your physical therapist will teach you muscle-strengthening exercises to improve movement and strength in the affected area.

Education. Your physical therapist will teach you strategies that can help minimize your symptoms while performing your daily functional activities.

Activity modification and postural strategies: Your physical therapist will teach you positions and strategies to place less stress on the structures involved with TOS.

Can this Injury or Condition be Prevented?

While some cases of TOS cannot be prevented, such as those due to anatomical variations, congenital conditions, trauma, or space-occupying lesions, others may be avoidable. Understanding risk factors that could make you more likely to develop this condition is the first step in prevention.

Your physical therapist will work with you to develop strategies to help you better understand and manage your risk factors and symptoms. As with many conditions, education is key. Understanding strategies, such as methods of reducing symptoms while performing activities, can help you live a full and functional life after the onset of TOS.

Real Life Experiences

George is a 45-year-old used-car salesman who takes potential customers on test drives in a crowded city area. Recently on a test drive, his customer ran a red light and the vehicle was struck by another motorist on the passenger side, where George was sitting. George was shaken up, although the police assured him the actual collision was minor.

George was taken to the emergency room following the accident, and received an X-ray, which was negative for a fracture of his clavicle. Fearing that he may be having a heart attack, he also followed up with his primary care physician, who was able to rule that out as well.

Over the next few days, George felt pain on his right side, and numbness and tingling down his right arm. His symptoms seemed to be worse at night. He called in sick to work, fearing he could be injured further on the job. He called his physical therapist.

George's physical therapist conducted a full physical examination. During the exam, George reported that he felt very anxious about the recent event, and wasn’t sure he'd be able to trust taking customers on test drives anymore.    

George's physical therapist noticed the presence of a rounded shoulder and forward-head posture, as she examined him. She was able to provoke George’s symptoms by gently placing his arm in particular positions, and gently pressing in the region of George’s first rib. She carefully checked for any other conditions that could be causing his symptoms. She told George that she suspected neurogenic TOS.

She developed a strategy for physical therapy that was best for him, consisting of activities and exercises to increase his strength, confidence, and function, while also easing his pain. She showed him postural activities to reduce compressive forces on his nerves. She also helped him with "nerve gliding" activities (encouraging his nerves to glide normally as his joints moved) to improve the function of the affected nerves.

Despite the complexity of the condition, George did well with his personalized course of physical therapy. Following several weeks of treatment and exercise, he was able to return to work without symptoms, and with a new-found confidence that he could ride in a car with customers again. With his physical therapist's ongoing help, George has returned to his normal activities of daily living.

This story highlights an individualized experience of TOS. Your case may be different. Your physical therapist will tailor a treatment program to your specific needs.

What Kind of Physical Therapist Do I Need?

All physical therapists are prepared through education and clinical experience to treat a variety of conditions or injuries.  You may want to consider:

  • A physical therapist who is experienced in treating people with TOS.
  • A physical therapist who is a board-certified clinical specialist or who completed a residency or fellowship in physical therapy. This therapist has advanced knowledge, experience, and skills that may apply to your condition.

You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.

General tips when you're looking for a physical therapist (or any other health care provider):

  • Get recommendations from family and friends or from other health care providers.
  • When you contact a physical therapy clinic for an appointment, ask about the physical therapists' experience in helping people with TOS.
  • During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible. Keeping a journal highlighting when you experience pain will help the physical therapist identify the best treatment approach.

Further Reading

The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions, and also prepare them for their visit with their health care provider.

The following articles provide some of the best scientific evidence related to physical therapy treatment of TOS. The articles report recent research and give an overview of the standards of practice both in the United States and internationally. The article titles are linked either to a PubMed* abstract of the article or to free full text, so that you can read it or print out a copy to bring with you to your health care provider.

Hooper TL, Denton J, McGalliard MK, Brismée JM, Sizer PS Jr. Thoracic outlet syndrome: a controversial clinical condition; part 1: anatomy and clinical examination/diagnosis. J Man Manip Ther. 2010:18(2):74–83. Free Article. Article Summary in PubMed.

Hooper TL, Denton J, McGalliard MK, Brismée JM, Sizer PS Jr. Thoracic outlet syndrome: a controversial clinical condition; part 2: non-surgical and surgical management. J Man Manip Ther. 2010;18z(3):132–138. Free Article. Article Summary in PubMed.

Watson LA, Pizzari T, Balster S. Thoracic outlet syndrome part 2: conservative management of thoracic outlet. Man Ther. 2010;15(4):305–314. Article Summary in PubMed.

Vanti C, Natalini L, Romeo A, Tosarelli D, Pillastrini P. Conservative treatment of thoracic outlet syndrome: a review of the literature. Eura Medicophys. 2007;43(1):55–70. Article Summary in PubMed.

*PubMed is a free online resource developed by the National Center for Biotechnology Information (NCBI). PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine's MEDLINE database.

Authored by Joseph Brence, PT, DPT, FAAOMPT, COMT, DACReviewed by the MoveForwardPT.com editorial board.

Guide to Calf Strain

What is a Calf Strain?

The “calf muscle” consists of 9 different muscles. The gastrocnemius, soleus, and plantaris muscles attach onto the heel bone, and work together to produce the downward motion of the foot. The other 6 muscles cause knee, toe, and foot movements in different directions; these muscles are the popliteus, flexor digitorum longus, flexor hallucis longus, tibialis posterior, and the fibularis (or peroneal) longus and brevis. They extend from the lower leg bones around the sides of the ankle and attach to various parts of the foot and toes. Injuries to these 6 muscles are sometimes wrongly attributed to the first 3 muscles mentioned here, as the pain is felt in similar areas of the calf.

A calf strain is caused by overstretching or tearing any of the 9 muscles of the calf. Calf strains can occur suddenly or slowly over time, and activities, such as walking, climbing stairs, or running can be painful, difficult, or impossible.

A muscle strain is graded according to the amount of muscle damage that has occurred:

  • Grade 1. A mild or partial stretch or tearing of a few muscle fibers. The muscle is tender and painful, but maintains its normal strength. Use of the leg is not impaired, and walking is normal.
  • Grade 2. A moderate stretch or tearing of a greater percentage of the muscle fibers. A snapping or pulling sensation may occur at the time of the injury and after the injury. There is more tenderness and pain, noticeable loss of strength, and sometimes bruising. Use of the leg is visibly impaired, and limping when walking is common.
  • Grade 3. A severe tear of the muscle fibers, sometimes a complete muscle tear. A “popping” sound may be heard or felt when the injury occurs. Bruising is apparent, and sometimes a “dent” in the muscle where it is torn is visible beneath the skin. Use of the leg is extremely difficult, and putting weight on the leg is very painful.

When muscles are strained or torn, muscle fibers and other cells are disrupted and bleeding occurs, which causes bruising. Within a few hours of the injury, swelling can occur, causing the injured area to expand and feel tight and stiff.

After a severe calf strain, bruising may also be seen around the ankle or foot, as gravity pulls the escaped blood toward the lower part of the leg.

 

How Does it Feel?

If you strain your calf muscles, you may feel:

  • Sharp pain or weakness in the back of the lower leg. The pain can quickly resolve, or can persist.
  • A throbbing pain at rest with sharp stabs of pain occurring when you try to stand or walk.
  • A feeling of tightness or weakness in the calf area.
  • Spasms (a gripping or severe tightening feeling in the calf muscle).
  • Sharp pain in the back of the lower leg, when trying to stretch or move the ankle or knee.
  • A “pop” or hear a “pop” sound at the time of injury (with a Grade 3 calf strain).

 

Signs and Symptoms

With a calf strain, you may experience:

  • A snap or pull felt or heard at the time of injury (with a Grade 1 and 2 calf strain). A "pop" may be felt or heard at the time of injury of a Grade 3 calf strain.
  • Pain and weakness in the calf area.
  • Swelling in the area.
  • Tightness in the area.
  • Bruising.
  • Weakness in the calf when trying to walk, climb stairs, or stand.
  • Limping when walking.
  • Difficulty performing daily activities that require standing and walking.
  • An inability to run or jump on the affected leg.

 

How Is It Diagnosed?

If you see your physical therapist first, your physical therapist will conduct a thorough evaluation that includes taking your health history. Your physical therapist will ask you:

  • What were you doing when you first felt pain?
  • Where did you feel the pain?
  • Did you hear or feel a "pop" when it occurred?
  • Did you receive a direct hit to your calf area?
  • Did you see severe swelling in the first 2 to 3 hours following the injury? 
  • Do you feel pain when moving your ankle or knee, standing, or walking?

Your physical therapist will perform special tests to help determine whether you have a calf strain, such as:

  • Watch how you walk, and see if you can bear weight on the injured leg.
  • Test the different calf muscles for weakness.
  • Look for swelling or bruising.
  • Gently feel parts of the muscle to determine the specific location of the injury (palpation).

Your physical therapist may use additional tests to assess possible damage to specific muscles of the lower leg.

In certain cases, your physical therapist may collaborate with an orthopedist or other health care provider. The orthopedist may order further tests, such as an x-ray or magnetic resonance imaging (MRI), to confirm the diagnosis and to rule out other potential damage. These tests, however, are not commonly required for a calf strain.

 

How Can a Physical Therapist Help?

Your physical therapist will design a specific treatment program to speed your recovery, including exercises and treatments that you can do at home to help you return to your normal lifestyle and activities.

The First 24 to 48 Hours

Your physical therapist may advise you to:

  • Rest the area by avoiding walking or any activity that causes pain. Crutches or a brace may be recommended to reduce further strain on the muscles when walking.
  • Apply ice packs to the area for 15 to 20 minutes every 2 hours.
  • Compress the area with an elastic bandage wrap.
  • Insert heel lift pads into both of your shoes.
  • Consult with another health care provider for further services, such as medication or diagnostic tests.

Treatment Plan

Your physical therapist will provide treatments to:

Reduce Pain. Your physical therapist can use different types of treatments and technologies to control and reduce your pain, including ice, heat, ultrasound, electricity, taping, exercises, heel lifts, and hands-on therapy, such as massage.

Improve Motion. Your physical therapist will choose specific activities and treatments to help restore normal movement in the knee and ankle. These might begin with "passive" motions that the physical therapist performs for you to gently move your knee and ankle, and progress to active exercises and stretches that you perform yourself to increase muscle flexibility.

Improve Strength. Certain exercises will benefit healing at each stage of recovery; your physical therapist will choose the appropriate exercises, and teach you how to safely and steadily restore your strength and agility. These may include using cuff weights, stretchy bands, weight-lifting equipment, and cardio exercise equipment, such as treadmills or stationary bicycles.

Speed Recovery Time. Your physical therapist is trained and experienced in choosing the right treatments and exercises to help you safely heal, return to your normal lifestyle, and reach your goals faster than you are likely to do on your own.

Return to Activities. Your physical therapist will collaborate with you to decide on your recovery goals, including your return to work or sport, and will design your treatment program to help you reach those goals in the safest, fastest, and most effective way possible. Your physical therapist will apply hands-on therapy, such as massage, and teach you exercises, work retraining activities, and sport-specific techniques and drills to help you achieve your goals.

Prevent Future Reinjury. Your physical therapist can recommend a home-exercise program to strengthen and stretch the muscles around your ankle and knee to help prevent future reinjury of your calf. These may include strength and flexibility exercises for the calf, toe, knee, and ankle muscles.

If Surgery Is Necessary

Surgery is rarely necessary in the case of calf strain, but if a calf muscle fully tears and requires surgical repair, your physical therapist will help you minimize pain, restore motion and strength, and return to normal activities in the safest and speediest manner possible after surgery.

 

Can this Injury or Condition be Prevented?

Calf strains can be prevented by:

  • Increasing the intensity of any activity or sport gradually, not suddenly. Avoid pushing yourself too hard, too fast, too soon.
  • Always warming up before starting a sport or heavy physical activity.
  • Following a consistent strength and flexibility/stretching exercise program to maintain good physical conditioning, even in a sport's off-season.
  • Wearing shoes that are in good condition and fit well.

 

What Kind of Physical Therapist Do I Need?

All physical therapists are prepared through education and experience to treat calf strains. However, you may want to consider:

  • A physical therapist who is experienced in treating people with calf strains.
  • A physical therapist whose practice focus is in orthopedics or sports rehabilitation.
  • A physical therapist who is a board-certified clinical specialist, or who completed a residency or fellowship in sports physical therapy. This therapist has advanced knowledge, experience, and skills that may apply to your condition.

You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.

General tips when you're looking for a physical therapist (or any other health care provider):

  • Get recommendations from family and friends or from other health care providers.
  • When you contact a physical therapy clinic for an appointment, ask about the physical therapists' experience in helping people who have calf strains.
  • During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and describe what makes your symptoms worse.

Authored by Andrea Avruskin, PT, DPT. Reviewed by the MoveForwardPT.com editorial board.