Case Study – Thoracic Outlet Syndrome (TOS)

October 1, 2013 | By | 1 Reply

– Dr. Niriksha Khasgiwala


32 years old Female Rita Gulati (name changed) came to us with complains of:

  • Severe pain in the neck radiating to the right arm.
  • Associated with constant tingling and numbness in the right palm and fingers since 2 months.
  • Working in front of the computer for 10-12 hours and carrying her 2 year old son was making her pain unbearable.
  • The intensity of pain was so high that she couldn’t even tolerate holding a light sling bag/purse or even slightly fitted strappy clothes on her shoulder.
  • She had to quit driving as keeping hands on the steering wheel was an effort.

Thoracic Outlet Syndrome (TOS)


  • Slightly overweight lady with extremely rounded shoulder and poking chin posture.
  • Both her shoulder blades were jutting out wid flat upper back musculature.

Thoracic Outlet Syndrome (TOS)

  • Side bend and rotation of the neck on both sides were severely restricted and painful(Tight Scalene Muscles)

Thoracic Outlet Syndrome (TOS)

  • Right arm weaker than left
  • All Thoracic Outlet Syndrome(TOS) special tests +ve.


  • Vit D3 and B12 were normal
  • Cervical Xray – Showed loss of curvature(concavity)
  • Cervical ribs(Extra pair of ribs arising from cervical vertebra) – There are normally 12 pairs of thoracic ribs, if anyone has a pair of extra ribs they are called cervical ribs(13th). It sits at the top of the ribcage thus compressing the neurovascular structures underneath.
  • Cervical MRI – Multilevel C4-C5 C5-C6 C6-C7 disc protrusion

Thoracic Outlet Syndrome (TOS)Thoracic Outlet Syndrome (TOS)


  • Went to the orthopaedic doctor who gave her medicines which helped her pain slightly and that too temporarily.
  • She had taken IFT current for 2 sessions at a local physio which made the pain worse.
  • On a friends recommendation she came to Physio Rehab.
  • Keeping in mind her severity of pain,investigations and clinical evaluation we charted out a plan of care for her.


  • Scapular Stabilization and Neck Rehab

Thoracic Outlet Syndrome (TOS)

  • Decompressions Exercises like shoulders shrugs for axial elongation will also be of help
  • Ergonomic advice for office as well as in terms of handling her child

Thoracic Outlet Syndrome (TOS)

  • Neural Mobilization to reduce tingling and numbness

Thoracic Outlet Syndrome (TOS)

  • Stretching the shortened muscles around the neck and chest (Upper Trapezius/Pectorals)

Thoracic Outlet Syndrome (TOS)Thoracic Outlet Syndrome (TOS)

  • Core Strengthening and general fitness as work was very sedentary

After 8 sessions of the above rehab plan she was around 50-60% better with respect to intensity of pain with occasional tingling numbness but post which there was a plateu as she got better but still had some pain which kept bothering her.
We re-evaluated her thoroughly and found that her thoracic spine was moderately stiff and cervical facets are extremely hypomobile (stiff) which was one of the reasons of the muscles being so tight and along with that she also had a pair of cervical ribs which was again compressing on the nerves around the neck. (Thoracic Outlet Syndrome=TOS)

Thoracic Outlet Syndrome (TOS)

So her pain due to the inflammation of disc got resolved with the initial treatment but now the lingering pain was due to TOS so we gave her a Home exercise programme which would help her maintain the strength and in the clinic we focused more on:

  • Manual Therapy-Mobilization of the cervical facet joints and first rib mobilization

Thoracic Outlet Syndrome (TOS)

  • Dry Needling of the Upper Trapezius Muscle/Muscle energy technique for scalenes

Thoracic Outlet Syndrome (TOS)

  • Opening up of her thoracic spine with mobilization/bolster

Thoracic Outlet Syndrome (TOS)

After 8 sessions twice/week of this tailor made combined rehab she has no pain at all. She is glad that the constant irritating tingling and numbness is no more there. She has resumed driving now. She says, “I can now carry my child with ease and not dragging myself to do it as earlier and working at office has become much more efficient as there is no nagging pain anymore”.

Thoracic Outlet Syndrome (TOS)

She still comes to Physio Rehab once a week but not for pain relief or her neck stiffness. She comes for maintainance and fitness in the form of core strengthening with Mat Pilates.

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Category: Case Studies

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  1. Atishay Gupta says:

    Hi there,
    I am from Hyderabad. Software engineer. Fav hobby- basketball after work.
    I have been having all the symptoms as above on my right side. But also Vit D n B12 deficiency.
    I have undeveloped cervical ribs too. c3-c4 left paracentral disc bulge. Loss of lordosis.

    Had left shoulder disclocation thrice in last five years while playing basketball. But after the last one in April 2016 my left traps n rhomboids pained a lot. And slowly my right shoulder pain gradually increased. Initially it felt like tendonitis but then after the left shoulder Arthroscopic surgery the pain in right side increased more.

    I too get sever pain from IFT. Poking chin posture. Work on computer for not more than 4 hours since the last one year. All the areas of pain are same as described in the above case study.

    But the adsons test is negative. ENMG is normal.

    One of the vascular surgeon says clinically no TOS but symptoms could suggest so.

    Apart from the above symptoms, my major complaint is burning sensation during the day n tingling only at night.. Like my Thoracic Outlet is set on fire. Shoulder, back of armpit, traps and neck are in spasm all the time.

    If you could help me find a physio in Hyderabad I would be very grateful!


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