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January 10, 2020 7 min read

The sustained gamer posture could potentially compress sensitive structures about the neck, shoulders, and the armpit, resulting in a variety of neurologic and vascular symptoms, typical of the Thoracic Outlet Syndrome(TOS). You may not have heard of the TOS, but if you spend most of your time working at a desk,  have a job that requires overhead lifting, or an avid gamer who sits all day in front of a video game, you could be suffering from this condition especially if you’re already experiencing intense shoulder pain, bizarre sensations of numbness and tingling, weakness in your arms and handgrip, and unusual appearance of pronounced, bright red veins in the neck.

Thoracic outlet syndrome is a term used to describe a variety of conditions caused by compression of the nerves and blood vessels in the space between your collarbone and first rib, known as the thoracic outlet, resulting in various symptoms depending on which structure is affected. Mostly the nerves are affected, with over 90% of cases being attributed to nerve damage. Common neurological symptoms include general shoulder and neck tension, tingling in the hands and arms, muscle wasting and weakness, and decreased handgrip strength.

Relevant Anatomy: The Thoracic Outlet

The thoracic outlet comprises the space from just above your collar bone, or the supraclavicular fossa, all the way to your armpit or axilla. The symptoms of TOS arise from the compression of the brachial plexus nerves, subclavian artery and vein, and axillary artery and vein within the thoracic outlet. Three areas are described where compression of neurovascular structures can occur:

  • The Interscalene Triangle is located between the anterior and middle scalene muscles, with the first rib below. The brachial plexus and subclavian artery pass through this space, underneath your collarbone, and into your armpit.
  • The Costoclavicular Spacelies between the clavicle and the first rib, bordered in front by the subclavius muscle and scalene muscle at the back. The brachial plexus, subclavian artery, and subclavian vein pass through this compartment, and may be compressed by scalene and pectoralis minor muscles.
  • The Subcoracoid or Sub-pectoralis Minor Space lies beneath the coracoid process and underneath the pectoralis minor. The pectoralis minor forms the anterior border of this space, and the ribs form the posterior boundary. The brachial plexus passes through the subcoracoid space and the axillary artery and vein as the continuation of the subclavian artery and vein.

Causes Of Thoracic Outlet Syndrome

Thoracic outlet syndrome is a fairly common condition that can be caused by poor postures, such as seen in gamers who are fully absorbed and hunched over their computers while playing video games. Such a posture can cause tightness in the muscles that are often associated with the occurrence of TOS. Other common causes include:

  • Poor posture (slouching with forward head, flexed neck, rounded shoulders, and rounded upper back), such as when looking down at video games or smartphones frequently, sitting at the keyboard for long hours, or carrying too heavy bags
  • Traumatic injury, such as a car accident
  • Repetitive stress injuries, such as jobs or sports-related activities requiring repetitive overhead motions of the arms and shoulders
  • Anatomical defects (having an extra rib, which reduces the space)
  • Pregnancy

What are the Types of Thoracic Outlet Syndrome and Their Symptoms?

NEUROGENIC TOS:The most common type of TOS, occurring in 95% of all cases, results from the compression of the collection of nerves, the brachial plexus, is compressed. Symptoms of Neurogenic Thoracic Outlet Syndrome:

  • Pain and weakness in the arm
  • Numbness and tingling sensation in the arm, particularly the fingers
  • Muscle atrophy or the shrinking of the pad of the thumb

VENOUS TOS: This occurs when a vein is compressed, leading to upper body deep vein thrombosis, known as effort thrombosis or the Paget-Schroetter syndrome. Five percent of reported TOS cases are venous in origin. Symptoms of Venous Thoracic Outlet Syndrome:

  • Edema or swelling of the arm, hand, or fingers
  • Bluish discoloration of the hand or arm (cyanosis)
  • Painful tingling sensation in the hand and arm
  • Blood clot (deep vein thrombosis) in veins in the upper body

ARTERIAL TOS: Results from subclavian artery compression. Only about 1 percent of cases are arterial. Symptoms of Arterial Thoracic Outlet Syndrome:

  • Cold and pale hands, absence of a pulse in the affected arm
  • Pain in the hand and arm, particularly with overhead
  • Embolism (blockage) of an artery in the hand or arm
  • Aneurysm of the subclavian artery

How To Attack Thoracic Outlet Syndrome?... The Rehabilitation Protocol

Mild symptoms can be managed with pain medications and physical therapy, while in cases of severe neurologic dysfunction or acute vascular insufficiency, a surgical procedure may be necessary. Ifyou’ve been experiencing vascular symptoms of venous or arterial TOS for an extended period, it is important to see a doctor because such cases are usually critical, and individuals who are diagnosed with these types of TOS have surgery as the only option. For those who may have had some slight symptoms, particularly those that involve neurologic TOS, the following should be helpful. A combination of strengthening, stretching, and postural adjustments are essential in managing the symptoms of TOS.


The scalene and pectoralis minor are the two muscles often associated with the onset of TOS. Individuals with TOS often exhibit a flexed head position, depressed and rounded shoulders, and protracted scapula. This position could reduce the costoclavicular space, compressing the neurovascular bundle in the subpectoral region, and shortening of the sternocleidomastoid muscle. The shortened sternocleidomastoid may cause the scalenes and pectoralis muscle groups to become tight, resulting in improper head and neck alignment and postural dysfunction.

SCALENE MUSCLES:The tightness of scalene muscles may be due to long-term faulty posture. Gamers often assume a forward-head, rounded shoulders, and rounded upper back, causing tightness to the associated musculatures. Specifically, tightness of the scalene muscles can pull on the first rib, compressing related neurovascular tissues, and causing TOS symptoms.

There are three scalene muscles — anterior, middle, and posterior scalenes. The main functions of these muscles are flexion, lateral flexion, and rotation of the neck.  

  • The anterior part produces neck flexion when activated bilaterally, and lateral flexion to the same side and neck rotation to the opposite side when contracted unilaterally. It also elevated the first rib.
  • the middle and posterior parts produce neck lateral flexion and elevates the first rib and second rib, respectively.


  1. Sit straight on a chair and stabilize your shoulder down on the right side by holding onto the edge of the chair.
  2. Slightly rotate your head towards the right side, then tilt your head back and to the left.
  3. Hold for 10 seconds before returning to the starting position. Repeat on the other side.


  1. Sit straight on a chair and stabilize your shoulder down on the right side by holding onto the edge of the chair.
  2. Place left hand overhead and gently pull your neck towards the left by bringing your left ear to your left shoulder.
  3. Hold for 10 seconds before returning to the starting position. Repeat on the other side.


  1. Sit straight on a chair and stabilize your shoulder down on the right side by holding onto the edge of the chair.
  2. Slightly rotate your head towards the left side, then place you left hand overhead and gently pull your neck forward and to the left towards your left armpit.
  3. Hold for 10 seconds before returning to the starting position. Repeat on the other side.

PECTORAL MINOR:Focus should be turned on the pectoralis minor muscle, as tightness or spasm of these structures can compress the neurovascular structures along the front of the shoulder. If the pec minor muscle is tight or shortened, it causes the scapula to tilt forward and rotate downward, causing adduction of the shoulder. The doorway pectoralis minor stretching is considered the best way to stretch this muscle.

  • Stand in an open doorway. Raise both arms up to the side at a 90-degree angle with palms forward, resting palms on the door frame.
  • Slowly step forward with your one foot and then feel the stretch in your chest.
  • Hold for 30 seconds, then back to starting position. Repeat three times.


The dynamic stability of the shoulder depends on the surrounding muscles. It is important to strengthen the scapular muscles, starting with the middle and lower trapezius and rhomboids, to stabilize the shoulder during shoulder motions, then progressing to include the serratus anterior muscle. Strengthening the muscles of the neck and shoulders should be a focus (cervical extensors, rhomboid major and minor, and lower trapezius), and should be supervised by a physical therapist for proper execution.


The correction of postural faults and poor body mechanics is a critical part of TOS management as this could be the cause, aggravating factor, or the limiting element in rehabilitation. For example, a common postural deviation that can aggravate this condition is the sagging or dropping of the shoulders; in other words, the rounded shoulder, slouched position. A forward head indicates excessive tension in the scalene muscles. The individual must develop a greater awareness of his postural attitude.

Self-Help Remedies for Thoracic Outlet Syndrome

If it’s confirmed that you are suffering from TOS and you want to try some strategies to manage it, the following remedies may alleviate your symptoms. It is important, though, that you ask for a physical therapist's advice before testing out anything:

  • Always check your posture:Make sure that you don’t slouch. If you can’t leave your seat because of an important game, try to purchase an ergonomic chair to optimize your posture as you focus on the game.
  • Gentle Stretching:This helps in preventing tightness in the associated muscles, promote circulation to the nerves, and relieve muscle tension. See recommended stretches.
  • Massage with Trigger Pointing: Massage promotes blood circulation, breaks adhesions, and releases muscle tension. This can be accomplished with Recovapro, although appropriate precaution must be observed, particularly in targeting the scalene muscle in the neck, where nerves and blood vessels are superficial. It is recommended that treatment must be supervised by a physical therapist. When working up the chest part, please follow the procedures presented in this video: HOW TO TREAT CHEST WITH RECOVAPRO
  • Stress Management: Stress can cause unnecessary tension and strain in the neck and shoulder muscles. These tight muscles can contribute to a small thoracic space and pinch all those vital tissues. Practice stress management techniques such as deep breathing, daily exercise, and adequate sleep.