Compression of the lower cord of the brachial plexus of nerves as it passes between the first rib and clavicle, due to a lowering of the shoulder girdle, the presence of an abnormal seventh cervical rib, enlarged seventh cervical transverse process, or strong fibrous band.


Pins, needles, numbness, and pain in one or both hands, occurring two to three hours after falling asleep, which usually wakes the patient, due to discomfort. Wasting of small muscles in hands may occur, as well as coldness or swelling.

Etiologic Considerations

Lowering of the shoulder girdle

• Muscle weakness in middle age (weakness of shoulder elevator muscles, upper trapezius, and levator scapulae) • General fatigue • Carrying excess heavy weights • Overuse of arms • Poor posture

Seventh cervical rib abnormality

Enlarged seventh cervical transverse process

Strong fibrous band


Thoracic outlet syndrome is a fairly common problem, occurring due to compression of the lower branch of the brachial plexus of nerves that exit from the lower cervical vertebrae to pass underneath the clavicle and on into the arm. The lowest cord of the brachial plexus lies in close proximity to the first rib, where it is subject to compression between the first rib and the clavicle, if the muscles that help support the shoulder girdle in elevation become weakened. This is the common adult-onset syndrome, which usually progresses gradually, causing pins and needles sensations and numbness and pain in one or both arms. The discomfort usually occurs in the middle of the night.

Other structures in the region, such as an abnormally developed transverse process, cervical rib, or a hard fibrous band, may compress the lower brachial nerves or, in some cases, restrict blood flow in the subclavian vessels and cause circulatory symptoms similar to Raynaud’s disease, with resultant coldness, pallor or redness, and some swelling.

Cervical rib syndrome or that of an enlarged transverse process usually differs from thoracic outlet syndrome. These conditions are more frequent in younger persons, and the pain or paresthesia occurs shortly after heavy lifting, wearing a heavy coat, or simply having the arms hang in a dependent position. Nocturnal pain is not usually present. In most cases, X-rays will clearly show the abnormal bony development of the seventh cervical vertebra; however, even a strong fibrous band in this area may cause compression and will not be noticeable with a routine X-ray.

Typical adult-onset thoracic outlet syndrome is almost always caused by poor muscular tone. The average patient is middle-aged, with a lowered shoulder girdle, due to the cumulative effect of weakness of the upper trapezius and levator scapulae muscles along with gradual reduction of disc space (normal with the aging process), and consequent changes in spinal curves. The patient complains that he or she is awakened by pronounced pins and needles sensations, numbness, and pain in one or both hands, two to four hours after having fallen asleep. Getting up into a sitting or standing position helps relieve the disagreeable symptoms. These symptoms may recur, leaving the hands literally numb on awakening. During the day few symptoms are present unless heavy lifting is performed. In some cases even a heavy overcoat will instigate symptoms of pins and needles. Over time, the symptoms may include the lower arm, upper arm, and even the shoulder, and are usually worse on days where heavy lifting or exertion has been performed.

Nocturnal symptoms are usually the result of prolonged nerve compression occurring during the day and are a nerve recovery phenomenon. Only when the nerve compression caused in the shoulder weight-bearing position is relieved, in this case by lying down to sleep, can the nerve recover. This recovery takes time in the case of a prolonged compression, which is the reason it takes several hours before symptoms are sufficiently strong to wake the patient.


The basis for therapy in the muscle-weakness type of thoracic syndrome relies on muscular and postural reeducation. The following exercises must be repeated twice daily until the muscles gain strength. The number of repetitions may be increased, as well as the weights used.

Shoulder shrugs*: Stand with arms at sides, with a 2-lb weight in each hand, shrug shoulders upward and forward. Hold 1 to 2 seconds and relax slowly. Repeat ten times. Shrug shoulders upward and backward. Hold 1 to 2 seconds and relax slowly. Repeat ten times. Shrug shoulders straight upward. Hold 1 to 2 seconds and slowly relax. Repeat ten times. Gradually increase weights used, when the exercises no longer cause fatigue. The weights used may be the standard barbell type, or sandbags, cans, or jars, as long as the weight is known.

Corner press*: Stand facing the corner of a room, with feet 2 to 3 ft from the wall, one hand on each wall at shoulder height and arms outstretched. Slowly allow the chest to press forward into the corner as you inhale, and press outward back to the original position while exhaling. Repeat ten or more times.

Arm lift*: Stand with arms held out to the sides at shoulder level, palms downward, holding 2-lb weights. Raise arms over the head until back of hands meet, keeping arms straight at all times. Slowly lower arms to shoulder level. Repeat ten times. Increase weights to 5 lbs. and on to 15 lbs. as muscles become stronger.

Neck exercise*: Stand erect with shoulders very slightly shrugged. Slowly bend head to right, attempting to come as close to your shoulder with the ear as possible, without shrugging the shoulder. Repeat to the left.

Upper trunk raise*: Lie face down with a small pillow under the chest and hands clasped behind the small of your back. Raise the head and chest as high as possible off the floor, pulling the shoulders backward while keeping the chin close to the chest. Inhale while going up. Hold 3 to 5 seconds, exhale as you return to the starting position. Repeat ten to twenty times.

Spinal Manipulation

Twice a week initially; later one to four times per month.


  • Swimming: Three times per week.
  • Medicine ball throwing: Keep ball shoulder-high or higher.
  • Evening armchair sitting: Sit with elbows supported on an armchair and shoulder girdle elevated for 20 to 40 minutes each evening to allow for nerve recovery while awake. Continue session until usual nighttime symptoms of pins and needles appear and then cease. This will prevent nighttime symptoms from occurring.
  • Avoid heavy lifting and heavy overcoats.
  • Lifting advice: Shrug shoulders first prior to lifting and keep in a partly shrugged position while lifting proceeds. This will prevent nerve compression.
Suitable Treatments
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Excerpts from Better Health Through Natural Healing 3rd Edition

First published in 1985, Better Health through Natural Healing has become one of the most successful and authoritative resources of its type, with more than 1.5 million copies sold worldwide. Since the original publication of this comprehensive guide, alternative therapies have become more and more accepted by the mainstream, and patients and practitioners of the wider medical community are embracing complementary medicine as an effective treatment option for a range of medical conditions.

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