Thoracic Outlet Compression Syndrome TOCS

When your body is in healthy balance and alignment, your nerves, muscles, bones and joints cohabit your body in perfect harmony, allowing for pain-free fluid movement. But when things don’t line up the way they should, you may experience pain and tightness in your muscles and joints that keeps your from performing at your best.
The thoracic outlet is a space between your first rib and collarbone that provides a passageway for muscles, nerves and blood vessels. When this crowded passageway becomes narrowed, it places pressure on your nerves and blood vessels, reducing circulation to your arm, causing pain and inhibiting movement.

Symptoms of TCOS

Depending on the affected structures, TCOS can create a number of symptoms anywhere from the head, neck and shoulder to the arm, hand and fingers.
Common symptoms include:
  • Muscle weakness
  • Numbness and tingling
  • Pain in the side of the neck and head
  • Headache

Causes of TCOS

TCOS is most commonly seen in athletes, especially in sports that require repetitive arm and shoulder movements like swimming, tennis, baseball and golf. In non-athletic populations, TCOS is uncommon, and seem mostly in de-conditioned middle aged women with poor posture.
Other less common causes include:
  • sleep disorders
  • Stress
  • carrying heavy loads
  • whiplash or other trauma
  • overdeveloped muscles from bodybuilding or weightlifting
  • poor postural habits

Diagnosis of TOCS

TCOS can be difficult to diagnose because numerous other conditions can cause similar symptoms. Diagnostic ultrasound combined with testing and patient history can provide a reliable diagnosis. Tests include assessments of muscle strength, and testing of sensations in the arm and hand, with the arm held in a range of positions.
In neurogenic TOCS, different symptoms can present, depending on the location of nerve compression:
  • Compression of the upper brachial plexus may cause symptoms in the side of the head and neck, including the ear, jaw, face, temple and back of the head. Upper plexus compression may affect the forearm and arm, but not the hand.
  • Lower plexus compression tends to affect the arm and hand. You may experience some numbness or tingling in the ring and little fingers.
Ultrasound provides a reliable means of diagnosing TOCS when combined with testing and patient history. Tests include assessments of muscle strength and arm sensation, with the arm held in neutral positions and in positions where the patient experiences maximal symptoms.
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Treatment

Physical therapy is the most effective way to resolve TCOS. Your therapist may include strengthening, stretching and postural correction exercises, with the goal of realigning the structures that support the collarbone, to open up the thoracic outlet space.
For general population patients, long-term lifestyle changes may help prevent the recurrence of TCOS, including weight loss, improved workspace ergonomics and increased physical activity. Athletes may benefit from sport-specific rehabilitative training.
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TCOS treatment at NYDNR

The physical therapy team at NYDNR takes a holistic whole-body approach to treating TCOS. We understand that your symptoms are unique to you and your lifestyle, and we design individualized treatment plans for every patient, based on your unique needs.
130 West 42 Street Suite 1055, New York NY 10036
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In this instance, an athlete was originally diagnosed with minor quadriceps muscle strain and was treated for four weeks, with unsatisfactory results. When he came to our clinic, the muscle was not healing, and the patients’ muscle tissue had already begun to atrophy.

Upon examination using MSUS, we discovered that he had a full muscle thickness tear that had been overlooked by his previous provider. To mitigate damage and promote healing, surgery should have been performed immediately after the injury occurred. Because of misdiagnosis and inappropriate treatment, the patient now has permanent damage that cannot be corrected.

The most important advantage of Ultrasound over MRI imaging is its ability to zero in on the symptomatic region and obtain imaging, with active participation and feedback from the patient. Using dynamic MSUS, we can see what happens when patients contract their muscles, something that cannot be done with MRI. From a diagnostic perspective, this interaction is invaluable.

Dynamic ultrasonography examination demonstrating
the full thickness tear and already occurring muscle atrophy
due to misdiagnosis and not referring the patient
to proper diagnostic workup

Demonstration of how very small muscle defect is made and revealed
to be a complete tear with muscle contraction
under diagnostic sonography (not possible with MRI)

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Complete tear of rectus femoris
with large hematoma (blood)

image

Separation of muscle ends due to tear elicited
on dynamic sonography examination

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