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Thoracic Outlet Syndrome (TOS) is characterized by upper extremity pain or paresthesia caused by compression, injury, or irritation to the neurovascular structures traversing the thoracic outlet.  To achieve exceptional clinical outcomes, chiropractors must efficiently differentiate this malady from similar cervical radicular presentations.

A new study from the Journal of Sports Rehabilitation (1) outlines the most appropriate tests to diagnose and differentiate TOS. Check out the following video that reviews the current best practice assessment of TOS.


Here’s the conclusion from the Journal of Sport Rehabilitation:

“There is moderate evidence to support the use of the costoclavicular maneuver (AKA Halstead or exaggerated military brace test), Wright’s testCyriax Release test, and supraclavicular pressure test to have good diagnostic accuracy for the provocation of symptoms in patients presenting with upper extremity pathology. The use of the Adson’s test and Roos test should be discontinued for the differential diagnosis of thoracic outlet syndrome.” (1)

Most patients presenting with TOS are between the ages of 20-60, with a peak incidence in the fourth decade (2). TOS is more common in women with some estimates as high as 9:1.

Anatomical predisposing factors for costoclavicular TOS include tightening or thickening of the fascial band that connects the first rib to the clavicle, and the presence of a cervical rib (3).  Cervical ribs are present in approximately 1% of the population and are bilateral in 80% of cases.  Although cervical ribs can be a causative factor for costoclavicular TOS, less than 10% of patients with cervical ribs will experience TOS complaints. (4)

Symptoms of TOS include pain, paresthesias, and motor weakness.  Neck, arm and hand pain is often insidious in onset and aggravated by elevation of the arms or excessive head and neck movement. Pain and paresthesia predominately involve the C8/T1 segmental level. (5) Symptoms follow an ulnar nerve distribution in 90% of cases. (6) Motor deficits, especially diminished grip strength, are possible, but reflex changes are suggestive of more central pathology. (7)

In the absence of acute or threatening neurovascular problems, conservative care should be the treatment of choice for TOS. (8) The treatment pathway for TOS is based upon the specific site(s) of neurovascular compression, but clinicians should keep in mind that TOS is often multifactorial in origin and successful management needs to address each component.

Joint manipulation may be indicated for restrictions in the cervical spine, first rib, cervicothoracic junction, shoulder, elbow, hand, and wrist.  Stretching and myofascial release techniques should address problems in the paracervical, scalene, and pectoral muscles as well as distal sites of potential “double crush” involvement, i.e., cubital tunnel, carpal tunnel, etc. Retraining proper diaphragmatic breathing and correction of a forward head/ forward shoulder posture are critical.  Nerve mobilization, particularly for the ulnar nerve, will likely play a role in recovery. (9)

Lifestyle modifications may include avoidance of repetitive postural stress and workstation modification.  Patients should avoid carrying heavy loads, especially on their shoulder, i.e., carpet rolls.  Briefcases, laptop cases or heavy shoulder bags should be lightened.  Bra straps may need additional padding or consideration of replacement with a sports bra.

The best news is that ChiroUp automates the delivery of evidence-based chiropractic care. As a subscriber, your TOS condition reference protocol has already been updated to include the latest tests, and your lay condition reports include the most appropriate exercises and ADL’s. (View sample report below)


We are honored to be your partner in delivering clinical excellence. If you’re not yet part of the ChiroUp team, click here to start your free trial today and join us in becoming the undeniable best choice for patients and payors!



  1. Horris HB et al. The Diagnostic Accuracy of Clinical Diagnostic Tests for Thoracic Outlet Syndrome. Journal of Sport Rehabilitation, 2017, vol. 26, issue 5, p 459
  2. Sucher, BM, Physical Medicine and Rehabilitation for Thoracic Outlet Syndrome. medscape.com (2013)
  3. Brewin J, Hill M, Ellis H. The prevalence of cervical ribs in a London population. Clin Anat. Apr 2009;22(3):331-6.
  4. Elsiveeer, Thoracic Outlet Syndrome, www.clinicalkey.com (2013)
  5. Lindgren, K.A. Lindgren Conservative treatment of thoracic outlet syndrome: a 2-year follow-up Archives of Physical Medicine and Rehabilitation, 78 (4) pp. 373–378
  6. Thoracicoutletsyndromes.com (2013)
  7. Watson LA, Pizzari T, Balster S. Thoracic outlet syndrome part 1: Clinical manifestations, differentiation and treatment pathways. Manual Therapy 14 (2009) 586–595
  8. Sharp WJ, Nowak LR, Zamani T, Kresowik TF, Hoballah JJ, Ballinger BA, et al. Long- term follow-up and patient satisfaction after surgery for thoracic outlet syndrome. Annals of Vascular Surgery 2001;15(1):32 e 6.
  9. Mackinnon SE, Novak CB. Thoracic outlet syndrome. Current Problems in Surgery 2002;39(11):1070 e145

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