Key Point

• Tension overload can limit blood flow and nerve flow. Working this area can lead to much-needed relief.

Thoracic outlet syndrome (TOS) 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 name, if you think about it. There’s some chaos at the base of the neck that affects what the shoulders, arms, hands, and fingers feel like. So why isn’t it called shoulder passageway syndrome? Or neck chaos syndrome? More importantly, what can we do as massage therapists to help?

TOS got its name for two reasons: First, from the fact that the outlet lives at the top of the thoracic cavity on the superior and anterior aspect of the rib cage. And second, the thing that’s trying to get out can no longer get out. It has become “syndromic,” so to speak, which is kind of like symptomatic but with syndromes instead of symptoms.

Let it be known there is a singular thoracic outlet, but it’s 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 to the head and neck, like arterial blood to the brain. But this is also simultaneously the thoracic inlet because 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 linguine-sized pasta that has gotten sticky and laden with residue over time, so the pasta it produces now looks more like angel hair. So, let’s take it apart, break it down, and put it back together.

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 first and second ribs. The vessels trying to get through here are the subclavian artery, vein, and nerve. 

The Issue

Our arms 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 rib cage, with the occasional excursion forward or backward or possibly even an exciting trip toward 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 rib cage. The clavicle slowly, quietly gives in to gravity. And the pec minor shrinks—as we all do—with age. This makes the space through which the subclavian vessels attempt to pass a whole lot smaller, limiting blood flow and nerve flow.

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 let go. Then, slide the client’s shoulder toward their ear so 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 sternocleidomastoid more medially and the upper traps more laterally. This will offer only 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. While you maintain a gentle compression, have your client inhale deeply followed by a long exhale. Sink in, create a positional release, and offer some relief to the tissues that are tired, overloaded, and need a break. 

Finally, as always, connect your work from the neck through the shoulder and down to the arm and the hand. Keep the client’s thoracic-outlet-neck-shoulder area fluid and free and soon they will have the ability to resume their favorite activities with the fluidity of a freshly stretched TOS.