Costoclavicular syndrome G54.0

The first description of brachial plexus compression syndrome was by Sir Astley Cooper in 1817, cervical rib syndrome in 1861 by Coote et al., compression of the first rib by Murphy et al. in 1910, scalenus anticus syndrome was described by Ochsner et al. in 1935 and costoclavicular compression syndrome by Falconer et al. in 1943.

It was not until 1956 that Peet recognized the similarity of the symptoms and summarized them under the generic term "thoracic outlet syndrome" (König 2008).

The first surgical resection of a cervical rib for neurovascular complaints was performed by Coote in 1861. The transaxillary resection was published by Roos in 1966 and this procedure became particularly important until the mid-1970s due to its good results. A supraclavicular resection procedure was described by Murphy et al. in 1980. In the meantime, endoscopic procedures have also been described (Bürger 2014).

A costoclavicular syndrome is a palpatory constriction between the first rib and the clavicle (Herold 2025), which can lead to a bottleneck syndrome of the brachial plexus, the axillary artery and the axillary vein (Heisel 2007).

The costoclavicular syndrome is divided according to the compressed structures into:

- neurogenic form, which occurs most frequently (95%)

- arterial form, which is the rarest form at approx. 1%

- venous form, which is found in approx. 2-3% (Panther 2022 / Masocatto 2019)

The costoclavicular syndrome is part of the thoracic outlet syndrome (TOS)

The following syndromes are also subsumed under "TOS":

- Scalenus- cervical rib syndrome: This involves a narrowing of the posterior scalenus gap, triggering various symptoms such as pain in the shoulder and neck area, paraesthesia of the ulnar forearm, the edge of the hand and the 4th or 5th finger, atrophy of the small hand muscles or paresis of the small hand muscles in certain postures (Hettenkofer 2003).

- M. scalenus anterior syndrome

- Hyperabduction syndrome

- M. pectoralis minor syndrome (Bürger 2014)

- Compression of the subclavian artery: This leads to a change in the color and temperature of the affected arm. The pulse is weakened on this side (Fliegel 2023).

- Compression of the subclavian vein: The affected limb is bluish in color and swollen because the blood cannot flow back (Fliegel 2023).

- Secondary Raynaud's syndrome (Hettenkofer 2003)

In older publications, TOS and TIS (thoracic inlet syndrome) tend to be attributed to the female sex. Figures from the Federal Statistical Office from 2011, however, speak of 888 men and 808 women suffering from TOS. The peak age range was between 40 and 60 years (Eckstein 2013).

- Steep position of the 1st rib

- Thoracolumbar scoliosis caused by a thoracic deformity

- Hypertrophic callus formation after clavicle fracture

- mechanical stress in soldiers, for example, due to carrying a rucksack, also known as "rucksack paralysis" or "stone carrier paralysis" (Heisel 2007)

- Tumors of the clavicle (Bullermann-Benend 2025)

When carrying loads, costoclavicular syndrome typically causes the clavicle to move closer to the first rib, resulting in compression of the brachial plexus (Hettenkofer 2001). When working overhead, compression of the subclavian artery can lead to a loss of pulse with a feeling of heaviness, loss of strength and cyanosis (Hepp 2004).

The neurogenic form is predominantly characterized by:

- numbness

- weakness

- Pain in the affected extremity

- paraesthesia (Masocatto 2019)

In the venous form:

- severe pain

- Edema (Masocatto 2019)

In the arterial form:

- Feeling of coldness of the affected extremity

- pallor

- Non-radicular pain (Masocatto 2019)

The following tests can be used for further diagnostics:

- Adson test

Compression of the subclavian artery causes paleness of the hand, a feeling of coldness, rapid fatigability of the muscles, muscle cramps and a stenosis noise of the artery with a pulse deficit. Compression of the artery can be triggered, for example, by carrying a heavy rucksack (Hepp 2004).

- Hyperabduction

This leads to pain when working overhead or when an arm is raised during sleep (Hepp 2004).

- Abduction test

In the abduction test, corresponding complaints occur when the arm is held in 90° abduction and external rotation with a tight fist closure for 3 minutes (Hepp 2004).

The following instrumental examinations are possible:

- Standard X-ray

- Doppler sonography

- MRI or spiral CT

- EMG

- NLG

- Arteriography and phlebography in both neutral and provocation position (Hepp 2004)

- Diseases of the musculoskeletal system, cervical spine, shoulder girdle or arm such as arthritis, carpal tunnel syndrome, Raynaud's syndrome, rotator cuff syndrome, tenosynovitis, fibromyalgia, cervical radiculopathy, idiopathic inflammation of the brachial plexus, Pancoast tumor and many more. (Masocatto 2019).

Compression can lead to deep vein thrombosis of the upper extremity (Herold 2025)

Neurogenic form:

The neurogenic form is initially treated with postural changes, physiotherapy (such as the Eden maneuver [Streeck 2006]) and medication with anti-inflammatory drugs. If these measures do not lead to an improvement in symptoms, surgical decompression may be an option (Masocatto 2019).

Venous form:

In the venous form, treatment has always been based on anticoagulants. However, studies have shown that there are increased complications in the form of recurrent thrombosis, persistent pain and restricted arm mobility. The current treatment is now a continuous infusion of plasminogen activator. If treatment is given within 2 weeks of the onset of symptoms, the success rate for restoring the subclavian vein is 100% (Masocatto 2019).

Arterial form:

In the arterial form, the therapy depends very much on the affected structure. The most effective treatment is surgery, but this can be associated with complications. Therefore, in patients with mild acute ischaemia, embolization of a catheter-guided thrombolysis may be useful before the actual surgical therapy. In severe ischemia, embolectomy in conjunction with thoracic outlet decompression is usually necessary (Masocatto 2019).

1. Bürger T (2014) Thoracic outlet syndrome. 1 - 2 From: Gefäßmedizin Scan 1 DOI: http://dx.doi.org/10.1055/s-0034-1377914
2. Bullermann-Benend M, Groeneveld M, Rolker S (2025) Practical Handbook of Nutrition in Palliative Medicine Elsevier Urban und Fischer Verlag 221
3. Eckstein H (2013) Compression syndrome of the upper thoracic aperture. Vascular Surgery 18 175-176
4. Fliegel B E, Menezes R G (2023) Anatomy, Thorax, Cervical Rib. In: StatPearls, Treasure Island (FL) Bookshelf ID: NBK541001
5. Heisel J (2007) Neurologische Differentialdiagnostik. Georg Thieme Publishers Stuttgart / New York 115-116
6. Hepp W R, Debrunner H U (2004) Orthopaedic diagnostics. Georg Thieme Publishers Stuttgart / New York 114-115
7. Herold G et al (2025) Internal Medicine. Herold Publishers 830-831
8. Hettenkofer H J, Droste U, Frenssen E, Hammer M, Kellner H, Miehle W, Miehlke R K, Neudorf U, Perniok A, Sattler H, Schmidt K, Schneider M, Späth M (2003) Rheumatology: Diagnostics - Clinic - Therapy. Georg Thieme Verlag Stuttgart / New York 216
9. Hettenkofer H J (2001) Rheumatology: Diagnostics - Clinic - Therapy. Georg Thieme Publishers Stuttgart / New York 217
10. Kasper D L, Fauci A S, Hauser S L, Longo D L, Jameson J L, Loscalzo J et al. (2015) Harrison's Principles of Internal Medicine. Mc Graw Hill Education
11. König W, Antoniadis G (2008) Compression syndromes of the shoulder girdle. In: Assmus H, Antoniadis G (2008) Nerve compression syndromes. Steinkopff Verlag Germany 123
12. Masocatto N O, Da-Matta T, Prozzo T G, Couto W J, Porfirio G (2019) Thoracic outlet syndrome: a narrative review. Rev Col Bras Cir. 46 (5) e20192243
13. Panther E J, Reintgen C D, Cueto R J, Hao K A, Chim H, King J J (2022) Thoracic outlet syndrome: a review. J Shoulder Elbow Surg. 31 (11) e545-e561
14. Streeck U, Focke J, Klimpel L, Noack D WManual therapy and complex rehabilitation. Volume 1: Basics, upper body regions. (2006) Springer Verlag Heidelberg/ New York 341