Thoracic outlet syndrome can cause neck, shoulder, chest, arm, or hand pain with numbness, tingling, weakness, heaviness, coldness, swelling, or symptoms that worsen with overhead activity.
Thoracic outlet syndrome (TOS) occurs when nerves or blood vessels are compressed as they travel between the neck and shoulder, leading to pain, numbness, tingling, weakness, or circulation problems in the arm. Dr. Siefferman explains how thoracic outlet syndrome is diagnosed, the different types of TOS, and the personalized treatment options available to relieve compression and restore function.
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Hi, I’m Dr. Jason Siefferman, medical director at Manhattan Pain Medicine. Thoracic outlet syndrome refers to anything affecting the blood vessels or the nerves where they exit from the thorax going into the arm. Typically, this occurs in one of three places. Either between the anterior and middle scalene muscles, between the clavicle and the second rib, or under the pectoralis minor. The general symptoms of thoracic outlet syndrome are weakness, numbness with overhead use of the arms because this position typically occludes the blood vessel or the teeny tiny blood vessels to the nerves which makes the nerves go numb and it makes the arm feel weak.
When we see this situation, we want to understand what else is going on. Is the person hypermobile? Is there a pain in the neck that the scalenes are hyperactive trying to guard and then as a result closing off that space? Is there a primary shoulder issue which is causing the shoulder to be guarded by pulling the shoulder blade forward? Whatever the primary issue is, that’s what we first must treat to try and correct the biomechanics.
There’s often more than one thing going on that leads to this. We identify those issues. We get them treated. It’s often done in combination with physical therapy. Often we will also use botulinum toxin in this situation both to weaken and soften the scalene muscles or the pec minor or the subclavius and to shrink those muscles because there’s a limited amount of space where the brachial plexus courses between these muscles and if the muscles have grown too large they occupy too much space that can also be the reason for thoracic outlet. So the botulinum toxin not only weakens and softens the muscles but it also helps shrink them so there’s more room. If this is adequate, and it often is, patients do very well. Otherwise, we work with a surgeon who may consider a first rib resection.
Thoracic outlet syndrome, often called TOS, refers to a group of conditions involving compression or irritation of nerves or blood vessels in the space between the neck, collarbone, first rib, and shoulder. Symptoms may include neck pain, shoulder pain, upper chest discomfort, arm or hand numbness, tingling, weakness, heaviness, coldness, swelling, color change, or pain that worsens with overhead activity, posture, driving, typing, exercise, or carrying objects.
TOS can be difficult to diagnose because symptoms may resemble cervical radiculopathy, carpal tunnel syndrome, cubital tunnel syndrome, shoulder impingement, migraine, vascular disease, peripheral neuropathy, anxiety-related symptoms, or nonspecific neck pain.
At Manhattan Pain Medicine (MPM), evaluation begins by identifying the type of TOS, the suspected compression site, the pain generator, and any overlap with cervical spine issues, shoulder mechanics, cervical dystonia, headache, hypermobility, EDS, autonomic symptoms, or complex chronic pain patterns.
At MPM, thoracic outlet syndrome care begins with a diagnosis-first evaluation of the symptom pattern, movement triggers, nerve distribution, vascular symptoms, cervical spine contributors, shoulder mechanics, posture, muscle overactivity, hypermobility, prior testing, and prior response to therapy.
For patients seeking thoracic outlet syndrome treatment in Manhattan, MPM considers whether symptoms may reflect neurogenic TOS, venous TOS, arterial TOS, cervical radiculopathy, peripheral nerve entrapment, cubital tunnel syndrome, shoulder impingement, scapular dyskinesia, cervical dystonia, migraine, autonomic dysfunction, EDS, hypermobility spectrum disorder, or another source.
Care may include movement-based rehabilitation, medication coordination, diagnostic injections, diagnostic ultrasound when appropriate, ultrasound-guided procedures, peripheral nerve blocks, botulinum toxin or chemodenervation in selected cases, and referral to vascular surgery, neurology, orthopedics, or other specialists when needed.
Thoracic outlet syndrome can be difficult to recognize because the symptoms may shift between the neck, shoulder, collarbone area, upper chest, arm, forearm, and hand. Some patients feel numbness or tingling when their arms are overhead. Others notice heaviness, weakness, pain with posture, hand symptoms while typing, or symptoms that worsen with carrying bags or driving.
MPM’s diagnosis-first approach is designed to avoid treating TOS as a single diagnosis with one standard treatment. The evaluation considers whether symptoms are nerve-related, vascular, muscular, cervical, shoulder-related, hypermobility-related, autonomic, or part of a broader chronic pain pattern. This distinction matters because neurogenic TOS, venous TOS, and arterial TOS require different care pathways, and vascular symptoms may require timely vascular evaluation.
Thoracic outlet syndrome sits within MPM’s neurological conditions framework, with strong overlap in Hypermobility, Musculoskeletal issues, Complex Chronic Pain, and Autonomic dysfunction. In selected patients, EDS, hypermobility spectrum disorder, altered shoulder mechanics, cervical instability, muscle guarding, or cervical dystonia may contribute to nerve irritation, compression sensitivity, or persistent neck and arm symptoms.
Some patients with TOS-like symptoms also experience headaches, migraine, dizziness, autonomic symptoms, pain flares, or widespread sensitivity. MPM evaluates these relationships carefully. The goal is not to assume that all symptoms are caused by TOS, but to understand whether nerve compression, vascular compression, cervical mechanics, shoulder mechanics, autonomic dysfunction, or chronic pain sensitization are interacting.
I cannot say enough good things about Manhattan Pain Medicine. From the moment I walked in, I felt truly cared for and taken seriously. Dr. Nino Mikaberidze, Director of Rheumatology, is exceptional — knowledgeable, compassionate, and incredibly thorough. She takes the time to listen, explains every...
The best care I've received as a chronic pain patient. I traveled from out of state to visit Manhattan Pain Medicine because I could not find knowledgeable doctors in my hometown for my hypermobility, and Ehlers-Danlos syndrome symptoms and comorbidities. Let me tell you, it was worth every travel e...
I was injured in a bicycle accident over 8 years ago. I’ve suffered throughout the years since my accident with nothing seeming to work. PT, Yoga, lifestyle changes, NOTHNG! I finally made an appointment with Dr Kane and I’m feeling an improvement in my life. I no longer stay up all night in pain, a...
One of the best experiences, if not the best, I have ever had at the doctor’s office. From the front desk to the nurses to the PA assisting the doctor this was a great experience. Dr.Nino actually listened to me and came up with a game plan. Would recommend this practice to as many people as I could...
I have very unique & severe nerve pain from CRPS which has no known specific cure. Dr. Siefferman has a huge tool box, far greater than the other 23 Drs. I have seen. He saved me from jumping off a bridge and continues to help me with both treatments and advice. Dr. S. is in a different league!
After two years of searching and feeling lost and let down, I finally found real help at Manhattan Pain Medicine. With Dr. Siefferman, Adam Rosenberg, Dr. Mikaberidze, and the whole team, I feel heard, supported and understood. Every symptom is being considered and I’m finally getting answers with m...
Why is Dr Dr. Tayyaba Ahmed one of the top pevic Floor specialists - 1- She wants to know a full history of what led the patient to get to this point. 2 - She listens intensley to the patient 3- She does not rush you 4- Extremely skilled at giving pelvic floor injections 5- I thank my luck stars she...
The staff was friendly and helpful. Dr. Siefferman was thoughtful, listened, asked questions and proposed simple safe ways to come to further conclusions regarding my pain and discomfort. The office staff including Dr. Siefferman is responsive even after the initial in-person visit. Very pleased.
Dr. Siefferman is a brilliant provider. While my pain is still a work in progress, Dr Siefferman always gives me options and explains his reasoning behind things. He listens to my feedback and concerns. I never feel rushed; and am grateful he works to meet me where I am. I highly recommend him.
What a great find! They listen to me, I listen to them and the diagnosis is made and a plan developed to develop an approach to treat all of my chronic pain. I wish I could have discovered this type of treatment sooner. This doctor and group give me hope.
Thoracic outlet syndrome is a group of conditions caused by compression or irritation of nerves or blood vessels in the space between the neck and shoulder. This area includes structures near the collarbone, first rib, scalene muscles, pectoralis minor region, and brachial plexus. Symptoms may include neck, shoulder, chest, arm, or hand pain with numbness, tingling, weakness, heaviness, swelling, coldness, color change, or symptoms that worsen with overhead activity.
TOS may cause pain, tingling, numbness, heaviness, weakness, fatigue, coldness, color change, swelling, or discomfort in the neck, shoulder, collarbone area, upper chest, arm, forearm, or hand. Symptoms may worsen when the arms are raised overhead, while typing, driving, exercising, carrying objects, or maintaining certain postures. The pattern varies depending on whether the nerves, veins, or arteries are involved.
Neurogenic thoracic outlet syndrome involves irritation or compression of the brachial plexus, the network of nerves that travels from the neck into the shoulder, arm, and hand. It is the most common type of TOS. Symptoms may include neck, shoulder, arm, or hand pain, numbness, tingling, weakness, heaviness, or symptoms that worsen with overhead activity or certain positions. Diagnosis requires careful evaluation because similar symptoms can come from the neck, shoulder, elbow, wrist, or peripheral nerves.
Neurogenic TOS involves nerve irritation or compression and may cause pain, numbness, tingling, weakness, or heaviness. Venous TOS involves vein compression and may cause arm swelling, discoloration, heaviness, visible veins, or clot-related symptoms. Arterial TOS involves artery compression and may cause coldness, color change, circulation changes, hand symptoms, or pulse changes. Venous and arterial TOS require vascular evaluation, especially when symptoms are sudden, severe, or progressive.
Diagnosis begins with a detailed history, symptom trigger review, physical examination, neurologic assessment, vascular screening, posture and movement assessment, and review of prior imaging or testing. Depending on the symptoms, evaluation may include cervical spine imaging, shoulder evaluation, EMG or nerve conduction studies, ultrasound, vascular studies, diagnostic injections, or specialist consultation. Because TOS can mimic several other conditions, diagnosis should be based on the full clinical pattern rather than one test alone.
In selected patients, EDS or hypermobility spectrum disorder may contribute to thoracic outlet symptoms through joint laxity, altered shoulder mechanics, cervical instability, muscle guarding, postural compensation, or increased nerve sensitivity. However, hypermobility should not be assumed to be the only cause of symptoms. MPM evaluates whether TOS, cervical spine issues, shoulder mechanics, peripheral nerve entrapment, autonomic dysfunction, or chronic pain sensitization may be contributing.
Botulinum toxin or chemodenervation may be considered in selected neurogenic or muscle-driven TOS patterns, particularly when scalene, pectoralis minor, or related muscle overactivity is suspected. It is not a universal treatment for TOS, and response varies. Treatment requires careful diagnosis, target selection, dosing, risk discussion, and follow-up. It should not be presented as a cure or replacement for vascular or surgical evaluation when those are needed.
Surgery may be considered when symptoms are severe, persistent, progressive, associated with vascular compression, blood clots, structural compression, or significant neurologic impairment, or when appropriate nonsurgical care has not helped. Venous or arterial TOS often requires vascular specialist evaluation. Neurogenic TOS may require surgical evaluation in selected cases when symptoms remain disabling despite careful conservative and interventional care.
Before care begins, our team helps patients understand the practical side of treatment, including insurance verification, out-of-network benefits, cost-share estimates, self-pay options, and billing questions. We believe patients should have as much clarity as possible before moving forward.
Thoracic outlet syndrome is a group of conditions involving compression or irritation of nerves or blood vessels as they pass through the thoracic outlet, the space between the neck, collarbone, first rib, and shoulder. Because important nerves, veins, and arteries travel through this region, symptoms can vary widely.
Some patients experience neck and shoulder pain with numbness, tingling, weakness, heaviness, or fatigue in the arm or hand. Others notice symptoms that worsen when the arm is raised overhead, when carrying a bag, while typing, while driving, during exercise, or with certain postures. When blood vessels are involved, symptoms may include swelling, discoloration, coldness, heaviness, visible veins, circulation changes, or clot-related concerns.
Thoracic outlet syndrome is usually described as neurogenic, venous, or arterial.
Neurogenic TOS involves irritation or compression of the brachial plexus, the nerve network that travels from the neck into the shoulder, arm, and hand. It may cause pain, numbness, tingling, weakness, heaviness, or symptoms that worsen with arm position.
Venous TOS involves compression of the vein in the thoracic outlet. It may cause arm swelling, discoloration, heaviness, or clot-related symptoms. This pattern requires vascular evaluation.
Arterial TOS involves compression of the artery. It may cause coldness, color change, circulation changes, hand symptoms, pulse changes, or vascular complications. This pattern also requires vascular evaluation.
TOS can be difficult to diagnose because symptoms overlap with many other conditions. Neck and arm symptoms may be caused by cervical radiculopathy, cervical myelopathy, shoulder impingement, rotator cuff disease, carpal tunnel syndrome, cubital tunnel syndrome, peripheral nerve entrapment, peripheral neuropathy, migraine, brachial plexopathy, vascular disease, or complex chronic pain patterns.
Some patients have imaging or nerve tests that do not clearly explain their symptoms. Others may have more than one contributing issue, such as cervical spine irritation, shoulder mechanics, scapular dyskinesia, hypermobility, muscle guarding, and nerve sensitivity. MPM evaluates the full pattern before recommending treatment.
In patients with EDS or hypermobility spectrum disorder, thoracic outlet symptoms may be more complex. Joint laxity, altered shoulder mechanics, cervical instability, muscle guarding, and compensatory movement patterns may increase irritation around the neck, shoulder, and brachial plexus region.
This does not mean hypermobility automatically causes TOS. Instead, it means the evaluation must consider how connective tissue laxity, posture, shoulder stability, neck mechanics, and nerve sensitivity may interact. MPM evaluates these relationships carefully and coordinates with other specialists when needed.
Thoracic outlet symptoms may overlap with headache, migraine, neck pain, cervical dystonia, and autonomic symptoms in selected patients. Muscle overactivity in the neck or shoulder region can contribute to pain, altered movement, nerve irritation, and symptom flares.
Some patients also report dizziness, temperature changes, fatigue, or symptoms that resemble autonomic dysfunction. These symptoms require careful evaluation because they may be related to TOS, POTS-like symptoms, cervical mechanics, vascular issues, medication effects, anxiety physiology, or another medical condition.
MPM begins with a detailed review of the symptom pattern, including location, quality, triggers, arm position, overhead tolerance, vascular symptoms, neurologic symptoms, prior injuries, prior imaging, prior EMG or nerve studies, therapy history, and prior specialist evaluations.
The physical examination may include neck, shoulder, scapular, neurologic, and vascular screening. MPM considers whether symptoms are coming from the thoracic outlet, cervical spine, shoulder, peripheral nerves, muscles, vascular system, or a broader chronic pain pattern. Diagnostic ultrasound, vascular studies, nerve testing, imaging review, or diagnostic injections may be considered when clinically appropriate.
Treatment depends on the type of TOS and the suspected pain generator. For neurogenic TOS, care may include posture and movement retraining, physical therapy, activity modification, medication management, Feldenkrais, peripheral nerve blocks, diagnostic injections, ultrasound-guided procedures, and selected chemodenervation approaches.
Botulinum toxin or chemodenervation may be considered in selected cases when scalene, pectoralis minor, or related muscle overactivity appears to contribute to neurogenic symptoms. These treatments require careful target selection and should not be considered a universal solution.
For venous or arterial TOS, vascular evaluation is important. Pain medicine procedures should not delay appropriate vascular assessment when symptoms include swelling, discoloration, coldness, vascular changes, clot concern, or circulation symptoms.
Referral to vascular surgery, neurology, orthopedics, or another specialist may be needed when symptoms suggest venous or arterial TOS, progressive neurologic deficit, severe persistent symptoms, structural compression, blood clot concern, or failure of appropriate nonsurgical care.
Surgery is not appropriate for every patient. When considered, the decision depends on the type of TOS, anatomy, severity, functional limitation, vascular findings, neurologic findings, prior treatment response, and specialist evaluation.
Patients should seek urgent evaluation for arm swelling, blue or pale discoloration, cold hand, loss of pulse, new severe arm heaviness, sudden weakness, chest pain, shortness of breath, fainting, signs of blood clot, severe neurologic deficit, or rapidly worsening symptoms. Venous and arterial TOS can involve vascular complications and should not be managed as routine musculoskeletal pain.
MPM approaches thoracic outlet syndrome through a diagnosis-first, coordinated model. The goal is to identify whether symptoms are neurogenic, vascular, cervical, shoulder-related, muscular, hypermobility-related, autonomic, or part of a complex chronic pain pattern.
For patients seeking thoracic outlet syndrome treatment in Manhattan, MPM offers a careful pain medicine perspective focused on symptom mapping, nerve and musculoskeletal evaluation, hypermobility-related complexity, image-guided care when appropriate, and coordination with the right specialists. Treatment is individualized and based on the type of symptoms, suspected compression site, risk profile, prior response, and care goals.
