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Research-Based Massage for Thoracic Outlet Syndrome (2 CE Hours)

This course is approved by the Texas Department of State Health Services DSHS for Continuing Education for Massage Therapists CE0009 and by the NCBTMB for Nationally Certified Massage Therapists for 2 CE Hours.

This article reviews the latest clinical research that has reported the effectiveness of massage therapy for the treatment of Thoracic Outlet Syndrome. 

Learning Objectives: After reading this course, you will...

  1. be able to describe the research-based anatomy associated with thoracic outlet syndrome.
  2. be able to list the types of symptoms associated with thoracic outlet syndrome that can be influenced positively by massage therapy, according to the research.
  3. be able to list specific massage therapies that have evidence to support their use on thoracic outlet syndrome.
  4. be able to explain the efficacy of massage therapy in the treatment of symptoms of thoracic outlet syndrome.
  5. be able to describe what type of massage is best in the treatment of thoracic outlet syndrome.
  6. be able to list the contraindications for massage therapy with thoracic outle syndrome.


Introduction to Research-Based Massage for Thoracic Outlet Syndrome

Thoracic outlet syndrome (TOS) is characterized by the extrinsic compression of neurovascular structures in the posterior triangle of the neck and between the clavicle and first rib. (1) There are three subcategories of TOS: neurogenic, which involves compression of the brachial plexus, arterial, which involves compression of the subclavian artery, and venous, which involves compression of the subclavian vein. (1)

Research-Based Categorization of Thoracic Outlet Syndrome

Neurogenic  TOS

The brachial plexus (Cervical nerve roots C5-T1) exits through the interscalene triangle, which is in the posterior triangle in between the anterior and middle scalene muscles and the clavicle. (2) The site of compression is normally here but may also occur in the costoclavicular space between the clavicle and first rib or in the subcoracoid space under the pectoralis minor. (2)

Eighty-five to ninety-five percent of all TOS cases are neurogenic TOS.(1) Neurogenic TOS can be caused by injury, repetitive stress of scaleni muscles, or fibrosis of surrounding tissue that is sometimes complicated by congenital anatomic anomalies such as anomalous scalene musculature, aberrant fascial bands, or cervical ribs.(1)The patient with neurogenic TOS presents with pain and paresthesia (nerve symptoms) that can affect the neck, upper back, shoulder, arm and hand. (1) The symptoms tend to be variable changing in response to neck, shoulder and/or arm movements. (1) On physical exam, tenderness upon palpation of the supraclavicular area in the interscalene triangle which reproduces referred nerve symptoms or palpation of the costoclavicular or subcoracoid space. (1) It is hypothesized that mechanisms of nerve compression in the costoclavicular space are related to either compression of the clavicle down onto the first rib (as in wearing a heavy backpack or purse) or elevation of the first rib up into the clavicle (as in forced inhalation).  In the subcoracoid space, compression is theorized to take place as the pectoralis minor becomes taught in movements, especially shoulder abduction and flexion.  (2)  Several special tests have been developed to localize the area of compression. Adson’s test is designed to reproduce compression in the interscalene triangle by moving the head and neck. 


The military brace test is designed to reproduce compression on the brachial plexus in the costoclavicular space, between the clavicle and the first rib.


The hyperabduction test is designed to reproduce compression in the subcoracoid space under the pectoralis minor.


Venous TOS

Three to fifteen percent of TOS cases are venous TOS, which involves compression of the subclavian vein in the costoclavicular space. (1,2) It is theorized that vascular compromise can have two manifestations, either compression of the vein with overhead reaching or rubbing of the vein on the clavicle, which triggers an intravascular thrombotic reaction (Paget-von Schroetter syndrome). (1) This condition is characterized by swelling of the arm, cyanotic (blue) discoloration of the skin and pain. (3)

Arterial TOS

One to five percent of TOS cases are arterial TOS. Usually, this form of TOS occurs due to compression of the subclavian artery in the region of the interscalene triangle. One research study found that most of cases of arterial TOS involved a bony anatomic anomaly such as a cervical rib or anomalous first rib.(9) Symptoms include arm pain, paresthesia, weakness, coolness, palor, and diminished brachial and/or radial pulse.(2) In arterial TOS, a post-stenotic aneurism or embolism can cause ischemic damage to the upper extremity. Therefore, arterial TOS is considered the most threatening form of Thoracic Outlet Syndrome. (2)

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