Pain, numbness, tingling or weakness in the shoulder, arm or hand that is worse with overhead activity and has not resolved with neck or shoulder treatment may be coming from the thoracic outlet, the narrow space between the collarbone and the first rib where the nerves to the arm can be compressed. This is thoracic outlet syndrome, and it is frequently missed for years while the neck, shoulder or wrist is treated instead. Dr Lawrence Okiror, Consultant Thoracic and Robotic Surgeon (GMC 6150382), provides specialist assessment of neurogenic TOS at London Bridge Hospital and The Lister Hospital Chelsea: whether it is TOS, and whether surgery is needed, since most people are managed without an operation. Where surgery is the right step, the decompression is removal of the first rib, which he performs robotically. The same symptoms are occasionally caused by a lung cancer at the top of the lung, a Pancoast tumour, which is excluded with a CT scan of the chest. Private appointments within 2–3 days. Self-referrals welcome.
Last reviewed: October 2026 · Dr Lawrence Okiror FRCS(CTh) FRCSEd(CTh) · GMC 6150382
Thoracic outlet syndrome is commonly mistaken for cervical spine disease, rotator cuff injury, or carpal tunnel syndrome. Many patients have had treatment for these conditions without improvement before TOS is considered. If that applies to you, the thoracic outlet should be assessed.
Surgery is not the first step. Physiotherapy, posture work, and activity modification are always tried first. Surgery is considered only where conservative treatment has not achieved adequate improvement and the anatomy of compression is clearly surgical.
Where conservative treatment has not helped and surgery is the right step, Dr Okiror performs thoracic outlet decompression via a robotic keyhole approach, removal of the first rib, with less disruption and a faster recovery than open surgery.
Arm and hand symptoms are almost always investigated at the neck, the shoulder or the wrist first, because those problems are far more common. When none of that treatment helps, the pattern of the symptoms is the clue: whole arm rather than one nerve, worse with the arms up, and unchanged by the neck and shoulder care already tried.
That pattern points to the thoracic outlet, the space between the collarbone and the first rib. A specialist assessment answers three questions: is this thoracic outlet syndrome, is there a tumour at the top of the lung pressing on the same nerves, and if it is TOS, does it need surgery? Most people are managed without an operation. Request a specialist assessment at London Bridge Hospital within 2–3 working days →
The thoracic outlet is the narrow space between the collarbone and the first rib, through which the nerves and blood vessels that supply the arm pass from the neck. When this space is too tight, those structures become compressed, causing the symptoms in the arm and hand.
The most common form. Nerves compressed, causing pain, numbness, tingling, and weakness in the arm and hand. Worse with overhead activity or carrying. The hand may feel clumsy or weak.
Most common form
Vein compressed, causing arm swelling, heaviness, and sometimes blue discolouration. This is a vascular problem treated by vascular surgery, and a suddenly swollen, blue arm can mean a clot, which needs urgent attention.
Vascular, seek urgent care
Artery compressed, causing coldness, pallor and pain in the arm and hand. Least common but most serious. Coldness, pallor or loss of pulse is a vascular emergency, it needs urgent vascular and emergency assessment, not an elective appointment.
Vascular emergency
The symptoms of thoracic outlet syndrome overlap with cervical spine disease, a rotator cuff injury, or carpal tunnel syndrome. These are more common conditions, so they are investigated and treated first.
The difference is that TOS symptoms are typically worse with overhead activity, involve the whole arm and hand rather than a single nerve area, and do not improve with cervical spine or shoulder treatment. If your neck has been treated, your shoulder investigated, and carpal tunnel injected, and you still have the same symptoms, thoracic outlet syndrome is the diagnosis to consider.
One cause has to be excluded before TOS is treated. A lung cancer at the very top of the lung, a Pancoast tumour, grows into the same nerves over the first rib and produces the same pain down the inside of the arm, the same tingling in the little and ring fingers and the same weak grip. It is treated as a shoulder or neck problem for months in the same way. The features that point to it are pain that is constant and unrelated to arm position, often bad enough to prevent sleep, weight loss, a drooping eyelid or smaller pupil on the same side, and a history of smoking. A chest X-ray often does not show it, because the top of the lung sits behind the collarbone. A CT scan of the chest does, and it is requested at the first consultation where any of those features is present.
A CT scan of the chest tells the two apart. Pancoast tumour →
Where TOS is confirmed and decompression is the right step, the operation is effective at relieving the compression in well-selected patients. The emphasis is on careful selection, operating only where it is needed, and on a plain account of the likely benefit before any decision.
Questions most commonly asked by patients with persistent arm and hand symptoms not resolved by neck or shoulder treatment.
Book an Assessment →Or call Jo Mitchelson:
020 7952 2882
Self-referrals welcome. Private appointments at London Bridge Hospital or The Lister Hospital Chelsea within 2–3 days; the whole pathway can stay in Chelsea for those who prefer. Dr Okiror will assess whether thoracic outlet syndrome is the cause, exclude a tumour at the top of the lung where that is needed, and give you a clear answer and a clear plan.
Jo Mitchelson, PA · 020 7952 2882 · pa@lungsurgeon.co.uk
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