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Onset of symptoms of thoracic outlet syndrome (TOS) is usually very vague. Initially the patient may ignore the symptoms because they are mild and/or intermittent. As time progresses, symptoms may increase in frequency and intensity to the point where the patient seeks medical attention, typically when they achieve no relief from moving their arm, changing position, or taking over-the-counter medication. The patient may or may not remember a precipitating event, such as trauma.

Symptoms that patients typically describe when they seek medical care include:

• Neck/shoulder pain that may spread to the upper arm and forearm
• Pain radiating down the arm
• Dull, aching pain in the shoulder and/or arm
• Numbness/weakness along the forearm, hand, and little finger
• Paresthesia (burning, prickling or tingling sensation)
• Headache involving the occipital (back of the head) or orbital (around the eyes) areas
• Anterior chest wall pain (pseudoangina)

Clear cut cases of vascular TOS are somewhat easier to identify than neurogenic TOS. Symptoms with which the patient may present to the physician (in addition to those listed above) that are indicative of vascular TOS include:

• Swelling of the arm/hand
• Coldness in the hand/finger
• Bluish color of the hand/finger
• Wasting (atrophy) of the hand (in severe, chronic cases of TOS)

Neurogenic signs are much harder to diagnose definitively as thoracic outlet syndrome. In severe cases, (e.g., hand muscle atrophy), it may be possible to clearly identify compression of the brachial plexus and, although surgery is performed, it does not always resolve the symptoms. For patients who present with sensory symptoms, (e.g., paresthesia, numbness, or pain) there is no test to definitively reach a diagnosis of TOS. Therefore, some health care providers feel that thoracic outlet syndrome is overdiagnosed while others think it is underdiagnosed. Both, however, agree that:

• No single test is reliable to definitively determine a diagnosis of TOS
• Electrodiagnostic studies are typically normal
• Surgery results in little improvement of symptoms

Symptoms follow the pattern of deterioration of the nerve. The aching is related to the muscles that are innervated by the compressed nerve. The compression of nerves is accompanied by complaints of intermittent paresthesia and, finally, numbness. When tested, patients will initially exhibit symptoms only during provocative tests of arm positions and, as the deterioration continues, patients can maintain the elevated position for less and less time due to intense discomfort. Deterioration to the point of muscle atrophy of the hand is rare.

Symptoms of Neurogenic Thoracic Outlet Syndrome

• Pain in the neck on the affected side. The pain may radiate up to the head and cause hemicranial headaches (headache on one side of the head) or headaches in the occipital region (lower back of the head). Pain may also radiate into:

  • mandible (jaw)
  • face
  • temple

• Pain that may radiate posteriorly to the back, across the shoulders, upper chest, and down the outer arm

• There may be numbness and tingling of the ear, cheek, back of the shoulder, or outer arm
• Discomfort around the shoulder, front and/or back