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The Thoracic Outlet & Its Syndrome
Thoracic Outlet Syndrome: The syndrome that describes the downfall of function at the passageway of vessels at the anterior region of the body where the neck becomes the shoulder. It’s kind of an odd naming, if you think about it. There’s some chaos at the base of the neck that effects what the shoulder, arm, hand and fingers feel like. So why isn’t it called Shoulder Passageway Syndrome? Or Neck Chaos Syndrome? More importantly, what the heck can we do as massage therapists to help?
Excellent question. First of all, TOS got its name from the fact that the “outlet” - a place or opening through which something is let out - in question lives at the top of the “thoracic” cavity - on the superior and anterior aspect of the ribcage. And secondly, the thing that is trying to get out can no longer get out. It has become “syndromatic” so to speak - which kind of like symptomatic but with syndromes instead of symptoms.
Let it be known that there is a technical Thoracic Outlet - but it is not wholly related to TOS. The anatomically correct thoracic outlet is the round space defined by the first thoracic vertebrae at the back, the first ribs at the sides, and the top of the manubrium at the front. It is the outlet through which vessels pass their important contents from the thoracic region up to the head and neck - like arterial blood to the brain. But this is also simultaneously the thoracic inlet because - well - it’s also the space through which vessels pass important stuff into the thoracic cavity - like air to the lungs.
But the outlet associated with the syndrome is not the thoracic outlet as I just defined. What we are looking at is more like a pasta machine designed to roll out linguini sized pasta but has gotten sticky and laden with residue over time and the pasta it produces now looks more like capellini. So let’s take it apart, break it down, and put it back together again.
The outlet: The portion of the neck and shoulder that defines this outlet is specifically the narrow passageway between the clavicle and the Pectoralis Minor and the 1st and second ribs. The vessels that are trying to get through here are the subclavian artery, vein and nerve.The scalenes also play a role in this, in the same way a chef might over knead the dough before putting it through the machine, but they are not technically part of the outlet.
The issue: Our arms, you see, spend most of their lives hanging down from the shoulder. They are designed to do a lot more than that. But they often don’t. They make themselves at home close to the ribcage, with the occasional excursion forward or backward or possibly even an exciting trip towards the ears. This puts the responsibility of preventing the arm from falling to the floor on the scalenes and surrounding neck muscles. Combine this with the modern purse, backpack, grocery bag or general weight that comes with living, and the tension overload starts to, well, overload.
The syndrome: For all intents and purposes, the tissues are tired. The scalenes are in a constant state of trying to hold up the ribcage. The clavicle is slowly, quietly giving in to gravity. And the Pec Minor is shrinking, as we all do, with age. This makes the space through which the subclavian vessels are attempting to pass through a whole lot smaller, limiting blood flow and nerve flow and, let’s face it, really good pasta.
The work: Bodywork for TOS becomes about softening the pull that has worn out the tissues involved. Approaching inflammation and exhaustion takes a steady, gentle approach. With your client supine, start by offering bolsters under the neck, shoulder and arm to ensure a neutral position that allows your client to actually let go. Then, with the grace of a pastry chef, slide their shoulder towards their ear so that the tug of gravity is eased.
With flat finger and thumb pads, gently secure your client’s clavicle and begin to slide it superiorly and inferiorly. Repeat this along the length of the clavicle, respecting its relationship to the Pec Major and the SCM more medially, and the Upper Traps more laterally. This will only offer a couple millimeters of passive range of motion, but it will result in a relatively expansive feeling of space.
Keeping the shoulder in an elevated position, curl your fingers over the middle, superior aspect of the clavicle and palpate the insertion of the anterior and middle scalenes at the first rib. Maintaining a gentle compression, have your client take a deep breath in followed by a long exhale. Sink in, create a positional release, and offer some relief to the tissues that are tired, overloaded, and well deserving of a break.
Finally, as always, connect your work from the neck, though the shoulder, and down to the arm and the hand. Keep their “thoracic outlet neck shoulder pasta machine” fluid and free. And give your client the ability to go home and make some fresh linguine without any pain. In the meantime, I’ll be working on a petition to have TOS renamed to Capellini Syndrome.
