Thoracic Outlet Syndrome: another source of neck and arm pain.

It’s well known that pain in your neck, radiating down the arm can be a result of an irritated nerve root in your neck. What’s often overlooked, is that compression can occur further down the nerve continuum as they bundle together and exit the neck. These nerve bundles are partnered with major blood vessels as they travel through the shoulder and further into the upper arm. As they exit the neck, these neurovascular structures become susceptible to compression. Knowing this, we now consider the possibility of compression of not just the nerves, but the blood vessels too.

Thoracic Outlet Syndrome (TOS) is a complex presentation of signs and symptoms that result from compression of the neurovascular bundle as it emerges from the thorax and enters the upper limb. The thoracic outlet is the space bordered by the scalene muscles, first rib, and clavicle. The neurovascular structures pass from the neck and thorax into the axilla (arm pit region), and continue to branch further into the upper arm, to forearm, and hand. TOS is more common in women, particularly those with poor muscular development, poor posture, or both.

In the office, we assess and diagnose injuries related to repetitive upper extremity use or trauma. Swimming, baseball, tennis, and volleyball, are common sports that may bring on symptoms of TOS. Functional and biomechanical assessment of these patients who engage in repetitive and extreme abduction (out to side) and external rotation (outward rotation) of the shoulder, often demonstrate TOS signs and symptoms. Other patient populations who may develop TOS include those who are in sustained poor postures in their activities of daily living and work, and tend to develop shortened chest and shoulder structures, and weak/lengthened neck and upper back structures.

Anatomically, TOS can be a result of bony and soft tissue factors. Bony causes often involve rudimentary or “extra” ribs which increases the risk of compression, e.g. cervical rib. Soft tissue factors can include muscular tightness or hypertrophy related to sport. Trauma or mechanical stress to the neck, shoulders, upper back, or upper extremities can bring on signs and symptoms.

The common presentation of TOS includes a high degree of variability. Most people describe a vague and often confusing source. Pain can originate from the root of the neck and radiate to the entire arm. Strength loss can occur. Depending on the structures being compressed, people can also experience numbness, swelling, tingling in the arm and hand, heaviness in the arm, loss of movement, rapid fatigue, dull aching, cold and discolouration.

Our challenge as physical therapists is to distinguish by specific testing, whether or not you present with a true TOS. From the comprehensive list of signs and symptoms above, we can easily see how TOS can mimic neck injury (disc, nerve root pain), and even shoulder and elbow injury.

Physical therapy treatment addresses postural abnormalities and muscle imbalance, in order to assist in alleviating symptoms by relieving pressure on the thoracic outlet. We work to minimize tension directly around the nerve entrapment points. Manual therapy and exercise strategies would assist in correcting muscles that have shortened or lengthened because of poor posture. It is also important to take into consideration a patient’s activities of daily living, work environment, sleep positions, etc. Surgical intervention is often considered in severe cases of blood vessel compression and compromise.

Symptoms often resolve with conservative physical therapy in 90% of individuals, with good ability to return to previous lifestyle with little difficulty.

Vince Cunanan is a registered physiotherapist and associate at Sun City Physiotherapy. He can be contacted at our Downtown St. Paul Street location or email

Cervical Radiculopathy

Ever had pain radiating from your neck to your shoulder and down your arm? Perhaps losing strength in your arm or a feeling of numbness or tingling in the fingers? Chances are that you have irritated a nerve in your neck and that nerve is sending these painful or distressing symptoms down your arm.

The neck, or cervical spine, is comprised of the top seven vertebrae of the spine. These vertebrae form a solid yet fluid structure – solid to encase the spinal cord which runs down the centre of the spine, and fluid as the vertebrae move on each other as the neck bends and rotates. In between each vertebrae there is a opening called the intervertebral foramen, and it is here where the nerves that branch off the spinal cord exit the spine. These are called the nerve roots and the ones from the lower half of the cervical spine combine to form a group of nerves that travel into the arm, giving us sensation and muscle power.

Each nerve will follow a specific pathway from the neck to the arm, and nerves like to have space to slide and glide along that pathway. If at any point the nerve is compressed or pinched, then the nerve signal can be affected and as a result we can experience some of the symptoms mentioned above – pain, altered sensation, or reduced power in the arm.

There are certain areas where the nerve is more likely to become pinched in the neck. The intervertebral foramen that it travels through to exit the spine is the first. Anything that encroaches on the foramen such as a disc bulge or a bone spur can reduce the space available for the nerve causing compression. Then once it is through the foramen, the nerve travels between some tightly packed muscles in the neck so any increase in tension in these muscles can also cause compression of the nerve as it moves through this area.

If these symptoms ring a bell with you, a physiotherapist can perform a series of tests that will determine exactly which nerve is irritated and exactly where it is getting pinched. The location of your symptoms or the specific muscles that have lost power will help to determine the area of your neck that needs to be treated. There are several treatment options to resolve your symptoms, and which treatment will be most effective for you will depend on the findings from the assessment. Some common techniques used to treat cervical radiculopathy are manual therapy to create more space for the nerve, traction to take the pressure off the nerve, and acupuncture to stimulate the nerve in order to fully restore the nerve signal. Once there is no compression on the nerve and any inflammation around it has settled, then your arm symptoms should subside and full function should be restored.

Classification of Whiplash Injuries

Classification of Whiplash Injuries

[et_pb_dcsbcm_divi_breadcrumbs_module hide_homebreadcrumb=”off” homebreadcrumbtext=”Manual Therapy” separator=”sep-raquo” hide_currentbreadcrumb=”off” homebreadcrumborientation=”left” admin_label=”Divi Breadcrumbs” _builder_version=”3.20.1″ saved_tabs=”all” global_module=”3160″][/et_pb_dcsbcm_divi_breadcrumbs_module]

Classification of Whiplash Injuries

Motor vehicle accidents (MVA) are sometimes an unfortunate consequence of modern reliance we have on automobile transportation. Previous to the invention of the car, there was “railroad neck”, and also a whiplash variation termed “roller-coaster neck”. Motor Vehicle accidents are sometimes termed “motor vehicle crashes” to suggest the preventable nature of some accidents. When a crash does occur, there is usually a chain of events including visits to the auto body shops, ongoing communication with insurance claims agents, and visits to many different health care professionals.

Despite advancement in sophisticated safety equipment for cars, bodily injury can sometimes result from accidents. Although the impact can occur in less than a second, the resulting injuries can persist for weeks or months. The neck (cervical spine) is the most common area of involvement, however, the mid back or low back can also sustain trauma. The shoulder or chest area can also be bruised by the restraint effect of the seat belt.

Injuries to the cervical spine are termed “whiplash-associated disorder’ or WAD for short. As with most conditions and injuries, there is a spectrum of severity. Following much consultation, the Quebec Task Force on Clinical Classification of WAD developed a five point scale of severity in 1995, which is well recognized within the health care and insurance fields. With Grade 0, or WAD 0, there are no physical signs, and the person does not complain of symptoms or usually seek help. At the other extreme end of the spectrum is the most severe WAD IV injury in which X-rays indicate a fracture or dislocation and require urgent medical attention. WAD classification is determined by a detailed and comprehensive clinical examination. Fortunately, most of the whiplash injuries sustained in a crash are classified as WAD II or III, and are commonly treated in physiotherapy practice. Clinical features include pain, and limited range of motion due to muscle spasm, sprained ligaments, and inflamed joints. Irritation of the neurological system can manifest as symptoms of numbness or tingling extending into the upper or lower extremities.

Physical therapists are very familiar with performing a detailed assessment and can help with determining the degree of injury that a person has sustained. A physiotherapy treatment plan is determined based on the degree of injury and time since the accident. Early in treatment when the condition is still very acute, it is common to suggest use of ice to decrease inflammation and pain relieving physical electrical modalities can also be used. As the person’s symptoms decrease, gentle mobilization, range of motion exercises, and progressive strengthening exercises are commonly introduced. Progress with treatment is individual and dependent on many factors. There are numerous practice guidelines, however, which suggest a return to normal daily activities as soon as possible, and treatment that promotes return of function is most helpful. A physical therapist is well trained to help assess your whiplash condition and provide an individualized treatment plan.


Sun City Physiotherapy Locations


1468 St. Paul Street, Kelowna, BC
Phone: 250-861-8056
more info


103-437 Glenmore Road, Kelowna, BC
Phone: 250-762-6313
more info

Lake Country/Winfield

40-9522 Main St., Lake Country, BC
Phone: 250-766-2544
more info

Lower Mission

3970 Lakeshore Road, Kelowna, BC
Phone: 778-699-2006
more info