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Neurogenic TOS Symptoms

Neurogenic TOS is when the brachial plexus nerves are compressed within the scalene triangle and/or the costoclavicular space.  It is a nerve compression syndrome which is a condition wherein nerves are being compressed or pinched/squeezed by other internal body structures resulting in nerve damage or dysfunction leading to symptoms.  Carpal tunnel syndrome is also a nerve compression syndrome.  The difference is that, with carpal tunnel, one nerve is compressed lower down in the arm by the wrist, and with NTOS, there are several different nerves being compressed up near the neck and chest.  Since the brachial plexus supplies the nerves to the chest, most of the upper back, shoulder, arm, and hand, symptoms can be experienced in any of these places.  NTOS can cause several different types of symptoms including nerve symptoms, muscle symptoms, and even symptoms that affect blood flow.  


Symptom Features:

  • Majority of patients are female (approx. 60-70%)

  • Most frequently presents in patients ages 20-40, but can & does occur outside of this range

  • Usually presents on 1 side of the body at least initially, and typically the side of the body with the dominant arm is the side to first show symptoms

  • tend to start gradually and worsen over time but sudden onset can also occur

  • can vary throughout the day or from day-to-day in location, type, and severity especially early on in the condition

  • tend to worsen during sleep with many patients having trouble falling asleep, waking up during the night due to symptoms, or having symptoms upon waking in the morning.  Sleeping positions which can exacerbate symptoms are sleeping with the arm overhead, sleeping on the back, and sleeping on the affected side

  • Can range from mild and mostly positional to constant severe and debilitating pain that can result in patients not being able to work, socialize or take care of themselves which can also have a severe impact on the mental health of the patient

  • Some symptoms worsen with certain TOS-aggravating activity such as heavy lifting or heavy use of the arms, pushing or pulling too much weight, repetitive use of the arms, overhead use of the arms, keeping the arm in an outstretched or awkward position for prolonged periods of time, and anything that involves fine motor skills/fine finger movements.  Such activity examples include:

  • driving

  • brushing teeth

  • talking with the phone up to ear

  • brushing, washing, blow drying, or styling hair

  • typing/texting

  • using a mouse

  • vacuuming

  • folding laundry

  • sewing

  • writing

  • throwing

  • playing an instrument such as guitar or violin


Common Symptoms:

  • Pain in shoulder, arm and/or hand.  Pain can be any type such as dull, sharp, shooting, stabbing, squeezing, aching, burning, electrical zaps

  • Numbness or tingling in shoulder, arm and/or hand.  Most commonly in the pinky and ring fingers, but it can involve any or all the fingers.

  • Hypersensitivity of the skin of the shoulder, arm and/or hand

  • Pain radiating down the arm to the hand particularly when turning the neck toward the affected side

  • Feeling of fatigue or heaviness in the arm especially when elevated

  • Feeling of hot or cold sensations within the shoulder, arm, and/or hand

  • Temperature and color changes of the hand (cold & bluish purple) or (hot & red) especially when arm is elevated or hanging straight down (Click here to learn more about the role of NTOS in these types of symptoms)

  • Swelling of the hand and/or fingers

  • Loss of hand dexterity such as inability to grip or pinch objects and easily dropping things

  • Enlarged or bulging veins in the arm and/or hand

  • Atrophy and weakness in the muscles of the fleshy base of the thumb (Gilliat-Sumner Hand)

  • Claw hand (characterized by curved or bent fingers, making the hand appear claw-like)

  • Muscle spasm and twitching in the arm and/or hand

  • Swelling at the base of the neck just above the collarbone

  • Neck muscle spasm, tension, tightness, and pain particularly on the sides and back of the neck including in the form of trigger points with specific pain patterns radiating to other parts of the body.

  • Tenderness in the base of the front of the neck just above the collarbone that might also reproduce symptoms radiating down the arm

  • Headaches in the back of the head (occipital headaches) which can wrap around the back of the head to above the eye.

  • Collarbone pain

  • Shoulder blade pain (often sharp or knife-like)

  • Winged shoulder blade (shoulder blade is prominent & sticks out from the back instead of lying flat)

  • Upper back muscle spasm, tightness, and pain particularly in upper trapezius, rhomboid, levator scapulae, and muscles that surround the shoulder blade

  • Pain in the chest, breast and armpit can also go along with NTOS in the form of Pec Minor Syndrome.  Click here to learn more about the symptoms of Pec Minor Syndrome.

  • Rarely, patients with NTOS will also have VTOS.  Click here to learn more about the symptoms of VTOS.

  • Rarely, patients with NTOS will also have ATOS.  Click here to learn more about the symptoms of ATOS.

Less Common Symptoms:

  • Pain, numbness or tingling in the jaw or face

  • Migraine headaches (although no known connection to NTOS)

  • Atrophy or wasting of the muscles in the upper back, shoulder, arm, and/or hand (aside from what is mentioned above)

  • Decreased range of motion in the shoulder and arm

  • Decreased range of motion in the neck (mainly due to muscle spasm)

  • Ear pain or tinnitus (ringing or pulsing in the ear)

  • Dizziness

  • Fainting or passing out particularly with neck or head movement

  • Shortness of breath (due to compression of the phrenic nerve)

  • Heart palpitations or fast heart rate (due to compression of the vagus nerve)

clavicle pain
woman with shoulder pain
elbow pain
wrist pain

Additional Information Related to the Role of NTOS in Causing Vascular Symptoms

Symptoms related to blood flow changes such as changes in temperature and color and swelling are actually quite common in patients with NTOS.  These symptoms are often assumed to be caused by Arterial or Venous TOS, but typically, this is not the case.  It’s actually caused by a sympathetic induced vasoconstriction. The sympathetic nervous system controls the blood vessels including how constricted (closed down) or how dilated (opened up) they are. The brachial plexus nerves contain fibers by which they communicate with the sympathetic nervous system. Therefore, when the nerves are compressed, these fibers are compressed and can cause the sympathetic nervous system to become overactive.  Being overactive means that it can tell the vessels to overconstrict which reduces blood flow resulting in coldness and/or blue/purple/mottled discoloration. It can also tell them to open too wide resulting in swelling, redness, bulging veins, etc. Arm elevation and arm hanging down positioning further irritates the nerves by either compressing them more or stretching them which can enhance these vasoconstriction symptoms.



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