Thoracic outlet syndrome (TOS) is an umbrella term for three related syndromes that cause pain in the arm, shoulder, and neck. The three types are neurogenic TOS caused by compression of nerves, vascular TOS caused by compression of arteries or veins, and nonspecific TOS of unknown cause. Common symptoms include pain, numbness, tingling, and fatigue in the affected arm. Risk factors for TOS include repetitive overhead activities like in tennis players. Diagnosis involves physical exams like the Roos stress test. Treatment involves stretches and strengthening exercises to relieve compression and promote proper posture. A typical treatment plan progresses from stretching to address tightness, to strengthening exercises to prevent future issues.

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1. injury or condition - Thoracic Outlet Syndrome
a. TOS is an umbrella term that encompasses three related syndromes that cause
pain in the arm, shoulder, and neck: neurogenic TOS (caused by compression of
the brachial plexus), vascular TOS (caused by compression of the subclavian
artery or vein) and nonspecific or disputed TOS (in which the pain is from
unexplained causes).
b. Neurogenic (neurological) thoracic outlet syndrome. This form of thoracic
outlet syndrome is characterized by compression of the brachial plexus. The
brachial plexus is a network of nerves that come from the spinal cord and control
muscle movements and sensation in the shoulder, arm and hand. In the majority
of thoracic outlet syndrome cases, the symptoms are neurogenic.
c. Vascular thoracic outlet syndrome. This type of thoracic outlet syndrome
occurs when one or more of your subclavian vessels (the arteries and veins under
the clavicle) are compressed.
d. Nonspecific-type thoracic outlet syndrome. Also called disputed thoracic outlet
syndrome or common thoracic outlet syndrome, some doctors don't believe it
exists, while others say it's a common disorder. People with nonspecific-type
thoracic outlet syndrome have chronic pain in the area of the thoracic outlet, but
the specific cause of the pain can't be determined.
e. Roos stress test. From a sitting position, your doctor will ask you to hold both
elbows at shoulder height while pushing your shoulders back. You will then
repeatedly open and close your hands for several minutes. If your symptoms are
present after the test, or if you feel heaviness and fatigue in your shoulders, this
can indicate the presence of thoracic outlet syndrome.
2. Mechanism of injury or etiology - tennis players
a. Pectoralis minor tightness

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b. Compression beneath the tendon of the pectoralis minor under the coracoid
process-may result from repetitive movements of the arms above the head
(shoulder elevation and hyperabduction).
3.
4. signs and symptoms -Thoracic outlet syndrome symptoms can vary, depending on
which structures are compressed. When nerves are compressed, signs and symptoms of
neurogenic thoracic outlet syndrome often include:
a. Vascular symptoms
i. Swelling or puffiness in the arm or hand
ii. Bluish discoloration of the hand
iii. Feeling of heaviness in the arm or hand
iv. Pulsating lump above the clavicle
v. Deep, boring toothache-like pain in the neck and shoulder region which
seems to increase at night
vi. Easily fatigued arms and hands
vii. Superficial vein distention in the hand
b. Neurologic symptoms
i. Paresthesia along the inside forearm and the palm (C8, T1 dermatome -
the lateral wall of each somite in a vertebrate embryo, giving rise to the
connective tissue of the skin..)
ii. Muscle weakness and atrophy of the gripping muscles (long finger
flexors) and small muscles of the hand (thenar and intrinsics)
iii. Difficulty with fine motor tasks of the hand
iv. Cramps of the muscles on the inner forearm (long finger flexors)
v. Pain in the arm and hand
vi. Tingling and numbness in the neck, shoulder region, arm and hand
5. Management plan -
a. Phase 1.

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i. goals: stretching exercises for the chest to promote space in the thoracic
outlet
ii. Estimated Length of time of phase: 3 weeks
iii. exercise rehabilitation:
1. stretching
a. hands behind your head chest stretch
i. Sit in a sturdy backed chair with the hands clasped
behind the back of the head. Bring the elbows back
as far as possible during a slow, deep breath in.
While exhaling slowly bring the elbows together
letting the head bend forward slightly
b. assume the position
i. stand facing a corner or a doorway with the arms in
a "U" or a "V" against the wall or door posts. With
the knees bent lean slightly forward from the
ankles.
c. just need a nap
i. Sit in a sturdy chair next to a table with the arm
placed as demonstrated, palm down. Slide the arm
forward while bending at the waist as far as
ii. is possible without pain. Eventually the head
should be level with the side of the table.
b. Phase 2
i. goals:promote proper posture in shoulders and strengthen the pec
minor
ii. Estimated Length of time of phase 4 weeks
iii. exercise rehabilitation:
1. stretching

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a. Pectoralis Minor
i. Lie on your back with knees bent.
ii. Keep your arms comfortably at your sides .
iii. Actively pull your shoulder blades together and feel
your shoulders flatten toward the floor.
iv. Try and pull your shoulder blades down toward
your feet as well. Hold this.
v. Bring your elbows out from your sides and let your
hands fall back with your elbows at 90 degrees.
vi. Again, pull your shoulder blades down and back to
bring your shoulders closer toward the floor.
b. Posterior Joint Capsule
i. Lie on your right side on your right shoulder.
ii. Position your right shoulder in approximately 30
degrees of flexion (your elbow should be about a
third of the way up to shoulder level).
iii. Bend your elbow to 90 degrees such that your hand
is pointing toward the ceiling.
iv. Grab your right forearm and bring your hand down
toward the floor.
c.
2. strengthening
a. Partner Standing Row with Resistance Tubing
i. Step 1 - Starting Position: You and a training
partner should have specialized resistance x-pattern
resistance tubing with four handles so that two
people can use it at the same time; or take 2 pieces
of standard resistance tubing with handles and cross
them to interlink them and create a 4-handled

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pattern. You and your training partner should stand
facing each other with your feet hip-width apart and
the right foot slightly in front of the left to create
additional stability; your knees and hips should be
slightly bent so that you each can sink into your
hips and contract your abdominals (bracing) for
additional stability. You and your partner should
each position your body with the spine in neutral
(normal-to-flat), shoulders blades pulling down and
back toward the hips (no shrugging). You and your
partner should each keep your chest held up and
out, with your heads in line with your spine or
slightly lifted. Hold the handles firmly in both
hands, palms are facing the ground. Pull back
slightly to create opposing lines of pull.
ii. Step 2 - You and your partner should each maintain
an abdominal contraction with your feet planted on
the floor to create stability through the hips and
core. Both you and your partner pull back on the
handles, at the same time. The pulling motion
should be initiated from the shoulder blades. Pull
the handles toward your rib cage. Keeping the
elbows wide, engage the upper back and shoulder
muscles.
iii. Step 3 -Once you and your partner have pulled the
handles back, both partners should hold the
shoulder blades back and down. Holding this
engagement in the shoulder blades, each partner

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straightens his or her right arm, as though you are
"punching" toward your partner. Keep the left arm
pulling back.
iv. Step 4 - Pull the right arm back. Hold the
contraction once again. Without allowing any
movement in the right shoulder, reach the left arm
forward. Keep the abdominals braced and alternate
the arm movements. You and your partner should
work together to provide resistance to one another
while simultaneously pulling back on the bands to
maintain tension in the band.
v. Step 5 - Exercise Variation: Start with slow, steady
consistent movements to become used to providing
manual resistance through the tension of the rubber
tubing.
b. Stability Ball Dumbbell Press
i. Step 1 - Starting Position: Sit on the stability ball
holding each dumbbell with your thumbs wrapped
around the handles and your feet flat on the floor.
Slowly begin walking your feet forward as you tuck
your tail under, lowering your spine onto the ball as
you walk your feet away from the ball until your
head, shoulders and upper back are resting on the
ball. Feet should be parallel and shoulder width
apart. Knees are bent to about 90 degrees with your
thighs and torso at or nearly parallel to the floor.
Distribute your weight evenly through your feet.

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ii. Step 2 - Pull your shoulders down and back until
you feel your shoulder blades hugging the ball.
position arms so they look like a Position the
dumbbells near your chest and armpits with your
palms facing forward. Keep the wrist in a neutral
position (straight, not bent). keeping palms and
wrist in same place, bending at the elbow bring both
arms to a 90 degree angle.
iii. Step 3 - Upward Phase: Exhale, engage your
abdominal/core muscles ("bracing") to stabilize
your spine. Slowly press your shoulders upward to
the ceiling. contracting on using your shoulder and
upper back muscles only. Keep your feet pressed
into the floor and your hips pushed up towards the
ceiling to maintain stability and control during the
exercise.
iv. Step 4 - Downward Phase: Inhale and slowly lower
your shoulders using your upper back muscles until
your scapulas are hugging the ball. Try to keep your
arms and shoulders in a straight line, perpendicular
to your trunk and parallel with ground. Your head,
shoulders and upper back should be resting on the
ball, and your torso and thighs should be parallel
with the floor at all times.
3. sports related exercises
a. High Knee Running, Without Arms – Run Form Drills
i. Start by standing at the doubles sideline and raise
up onto the balls of your feet.

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ii. Alternate lifting the left and right knees up high
while moving forward slowly.
iii. Put the foot down under the body. A cue to avoid
“breaking” or putting the foot
iv. down too far forward is “Keep Your Nose Over
Your Toes.”
v. Lean slightly forward when performing this
exercise.Do not twist at the hips or
vi. shoulders or use the arms.Keep the upper body
relaxed.
b. Spider Drill - Agility and Movement Training
i. Start at the center mark on the baseline facing the
net.Turn and sprint right to the corner formed by the
baseline and the singles’ sideline. Decelerate and
touch the corner with your foot. Sprint back to the
center mark, get under control and touch it with
your foot.
ii. Sprint to the corner formed by the right singles
sideline and the service line. After getting under
control, touch the corner and sprint back to the
center mark.
iii. Next sprint to the “T” and back to the center mark.
iv. Then sprint to the corner formed by the left singles
sideline and the service line.
v. Finally, sprint to the corner formed by the left
singles sideline and the baseline.
vi. Have players rest 30 seconds, and repeat in the
other direction.

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4. Phase 3
i. goals - dynamic movement to gain function hips
and legs
iv. Estimated Length of time of phase: 5 weeks
v. exercise rehabilitation:
1. stretching
a. same as phase 2
2. exercise
a. Inchworms
i. Starting Position: From a standing position with
your feet together or slightly apart, engage ("brace")
your abdominal muscles to stabilize your spine.
ii. Step 2 Gently exhale and bend forward from your
hips ("hip hinging"). Try to keep your knees straight
(but not locked). Slowly lower your torso towards
the floor until you can place your fingers or palms
of your hands on the floor in front of your body. If
your hamstrings are tight, you may need to bend
your knees slightly. Try to keep the spine flat.
iii. Step 3 Slowly begin to walk your hands forward,
away from your feet. Your heels will begin to rise
off the floor. Continue walking your hands forward
until you reach a full-push-up position where your
spine, hips and head are level with the floor (plank
position).
iv. Step 4 Perform one full push-up, bending the
elbows and lowering your chest and hips

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simultaneously to the floor. Maintain a rigid torso
and keep your head aligned with your spine. Do not
allow sagging in the low back or ribcage. Keep the
hips level. Do not allow your hips to hike upwards
during this downward phase. Continue to lower
yourself until your chest or chin touches the floor.
Allow your elbows to flare outwards during the
lowering phase.
v. Step 5 Press up to plank position keeping the torso
rigid and your head aligned with your spine. Do not
allow sagging in the low back or ribcage. Keep the
hips level. Do not allow your hips to hike upwards
during this phase. Continue pressing until the arms
are fully extended. Slowly begin walking your feet
forward towards your hands, taking steps without
moving your hands. Maintain a flat spine
throughout and continue walking until your feet are
close to your hands.
vi. Step 6 Repeat this movement and continue for 10 -
15 yards (9-13 m).
vii. Exercise Variation: You can progress this exercise
by adding multiple push-ups in the lowered
position.
b. Single-arm, Single-leg Romanian Dead Lift
i. Starting Position: Stand with your feet together,
holding a dumbbell in your left hand. Brace your
abdominal / core muscles to stabilize your spine.
Pull your shoulder blades down and back without

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arching your low back. Maintain these engagements
throughout the exercise.
ii. Step 2 Downward Movement: Inhale and slowly lift
your left leg a few inches off the floor as you begin
to bend forward at the hips. Balance on your
standing leg. Try to keep the torso absolutely rigid
with no sway, shift or rotation. Keep the back flat
and the head aligned with your spine.
iii. Step 3 As you bend forward allow your left
(dumbbell) arm to straighten toward the floor. Do
not allow the torso to rotate or the shoulder to droop
toward the floor. Continue bending forward,
allowing only a slight bend in the knee until your
torso is at, or near horizontal to the floor and your
arms hang straight down from your shoulder.
Maintain your balance by keeping your weight into
the heel of the standing foot. Try to straighten your
standing leg and point the toes to help with control
through the movement
iv. Step 4 Upward Movement: Exhale and slowly bring
your torso back to a vertical position with your left
arm (holding the dumbbell) at your side. Step
v. Exercise Variation: As this technique is mastered,
the exercise intensity can be progressed by: (1)
Switching the stance (supporting or balance) leg
(i.e., holding a dumbbell in the left arm and lifting
the right leg rather than the left leg). This increases
the need for balance and stabilization within the
body; (2) using heavier resistance; (3) bending over
and / or lowering the hips closer to the ground by
increasing your knee bend; and (4) standing on
unstable surfaces (e.g., Airex pad).
3. sports related exercises

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a. Medicine Ball Tennis - Agility and Movement Training -
Improve movement, agility and footwork and Improve core
strength and leg strength
i. This game is played by two or more players.
ii. The game only uses the service boxes and is played
and is scored like a tie-breaker.
iii. Instead of a racquet and tennis ball, a medicine ball
is used in this game. Players catch the ball and toss
it from the same side.
iv. Make sure the player loads the outside leg behind
the ball when they catch it so they can store energy
in the muscles and use the entire kinetic chain.
v. The athletes must let the ball bounce once.
vi. Play until 7.
b. criteria to return to sport or activity
i. preform all exercises with little effort and no pain