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• Pain radiating down the arm and into the hand
• Dull aching pain in the arm
• Weakness, tingling or numbness in the fingers
• Pain spreading up the side or back of the neck and to the back of the head (occipital area)
• Severe headaches which may radiate over the top of the skull (headaches are usually related to arm movement)
• Paresthesia may occur in the presence of pain or alone
• Arm may feel like it's "going to sleep" when elevated

Symptoms typically intensify following exertion (e.g., after exercise) and/or elevation of the affected arm. Some patients report that symptoms are worse at night following a day of heavy use of their arm. Symptoms can also be initiated following positional changes of the arm, including:

• Reaching out for something
• Activities during which the arm is raised for an extended period as in painting, using a hair dryer, applying makeup, or changing overhead bulbs.
• Heavy lifting in which the arm is pulled downward
• Sleeping with the arm above the head and elbows flexed

As thoracic outlet syndrome advances, the patient may experience weakness of the hand and loss of dexterity. In advanced cases, there may be muscle atrophy and reduced use of the arm but no paralysis. It is rare that TOS deteriorates to this extreme situation.

Symptoms of Vascular TOS

Arterial TOS

In arterial TOS, the patient may also not be mindful of early symptoms. The patient may complain of heaviness or weakness of the arm and may experience numbness or paresthesia. Patients may also experience headaches at the back of the head (occipital) or in and around the eyes (orbital). Typically, symptoms are exacerbated by using the arm especially if it involves any overhead positions. Later symptoms associated with arterial TOS include:

• Pallor (paleness of the limb)
• Erythema (skin turns red)
• Affected arm may be cold
• Fatigue of the arm with exercise

Early emboli (clots no longer attached to the wall of the blood vessel and can travel in the blood stream) usually do not lead to significant complications. But chronic embolic episodes can lead to ischemia (lack of oxygen supply) of the limb and progression of tissue damage. If the diagnosis is delayed over a long period, severe symptoms can develop (e.g., limb-threatening ischemia and other thromboembolic complications). At this point, surgical management becomes difficult, especially if the clots have traveled down the arm and are blocking smaller blood vessels. Advanced cases that cannot be managed by surgery may result in amputation of the limb. This is very rare.

Venous TOS

The unique symptoms associated with venous TOS include:

• Swelling of the entire affected arm, forearm, and hand
• Edema
• Cyanosis
• Venous distention
• Discomfort of the arm that is aggravated with activity or exercise

Patients may or may not experience pain with this condition. The affected limb may have a diameter 1-3 inches greater than the unaffected arm. Visible superficial veins may also be present. Venous thrombosis may develop at the location of the compression. The diagnosis of venous TOS is often delayed until there is evidence of thrombosis (sudden edema with cyanosis and limb discomfort) at which point treatment must be initiated immediately in order to prevent complications.