TOS occurs when nerves or blood vessels are compressed in the thoracic outlet, the narrow space between the collarbone and the first rib. This compression causes symptoms like pain, numbness, tingling, and weakness in the arms and hands. Causes often include anatomical variations, trauma, or repetitive strain. Successful treatment requires identifying the specific compressed structure and applying a targeted strategy to relieve the pressure.
Understanding the Diagnostic Process
Diagnosis begins with a physician reviewing the patient’s medical history and performing a detailed physical examination, assessing posture, muscle weakness, or swelling. The exam often includes provocative maneuvers to reproduce symptoms. For example, the Roos test involves holding the arms up and continuously opening and closing the hands for three minutes. The Adson maneuver checks for vascular compression by observing a diminished radial pulse when the patient turns their head and takes a deep breath.
Specialized tests confirm the diagnosis and determine which structures are compressed: nerves, veins, or arteries. Since neurogenic TOS (compression of the brachial plexus nerves) accounts for about 90% of cases, nerve conduction studies and electromyography (EMG) are often ordered to assess nerve function. Imaging studies, such as X-rays, MRI, or CT scans, help identify anatomical causes like an extra cervical rib or soft tissue abnormalities. The results dictate the specific treatment path, as neurogenic, venous, and arterial TOS require distinct approaches.
Primary Non-Surgical Treatment Strategies
Conservative management is the initial and most common strategy for TOS, especially neurogenic cases. This approach focuses on relieving pressure through muscle re-education, strengthening, and posture improvement, requiring consistent effort over several months. A structured physical therapy (PT) program is designed to increase the space within the thoracic outlet.
PT concentrates on strengthening shoulder girdle muscles, such as the scapular stabilizers, to prevent drooping and improve alignment. Exercises like banded pull-aparts and scapular push-ups activate muscles responsible for maintaining upright posture. Mobility in the upper back is also addressed through movements like the thoracic extension exercise, which reduces regional stiffness.
Stretching routines lengthen tight muscles contributing to compression, such as the scalenes and pectoralis muscles. The scalene stretch involves tilting the head away from the affected side while lowering the shoulder to decompress the neck. Nerve gliding exercises, or nerve flossing, gently mobilize the compressed brachial plexus nerves, helping reduce symptoms like tingling and numbness.
Pharmacological interventions manage pain and inflammation alongside physical therapy. Nonsteroidal anti-inflammatory drugs (NSAIDs) reduce swelling, and muscle relaxants may decrease tension in the neck and shoulder. Injections of botulinum toxin into the scalene or pectoralis minor muscles can provide longer-term relief by temporarily relaxing the compressing muscles.
Lifestyle adjustments support PT and prevent symptom flare-ups. Patients should avoid activities involving repetitive overhead arm movements or carrying heavy items on the shoulder, which increase pressure. Adopting ergonomic supports and maintaining good posture while working or sitting helps keep the neck and shoulders in a decompressed position.
Surgical Paths for Advanced Thoracic Outlet Syndrome
Surgery may be considered if conservative measures fail after four to six months, or in cases of acute vascular involvement. The main procedure is Thoracic Outlet Decompression (TOD), which permanently removes the structures causing compression. TOD typically involves removing the first rib, dividing the anterior and middle scalene muscles, and removing anomalous fibrous bands or scar tissue.
The two most common surgical approaches are the transaxillary and the supraclavicular methods. The transaxillary approach uses an incision in the armpit to access and remove the first rib from below. Although this method offers cosmetic benefits, it can limit the surgeon’s ability to fully access the brachial plexus nerves and scalene muscles.
The supraclavicular approach uses an incision above the collarbone, providing direct access to the scalene triangle and the brachial plexus. This allows for more complete nerve decompression and better visualization of the scalene muscles for resection. Surgeons often prefer this approach for neurogenic TOS to ensure thorough release of compressed nerves.
Vascular TOS requires urgent intervention. For venous TOS, involving subclavian vein compression, the procedure includes first rib resection followed by specialized vascular treatments. These treatments may include thrombolysis to dissolve clots or venoplasty to repair the damaged vein. Arterial TOS, the least common type, requires immediate decompression, often followed by arterial reconstruction or repair, to prevent permanent damage.
Long-Term Management and Reducing Symptom Recurrence
Long-term management is necessary after initial treatment to maintain relief and prevent symptom recurrence. Adherence to a maintenance exercise program is the foundation of sustained wellness, focusing on continued strengthening of postural muscles and regular stretching. Consistent performance of these exercises prevents muscle tightening and keeps the shoulder girdle properly aligned.
Patients should integrate ergonomic adjustments into daily life, especially in workspaces or during prolonged arm use. Avoiding triggers, such as carrying heavy bags over the shoulder or sleeping in positions that exacerbate compression, protects the thoracic outlet. Managing body weight and related health issues can further reduce strain on the neck and shoulder structures.
Regular follow-up with a physical therapist or physician monitors progress and allows for adjustment of the maintenance program. Even after successful surgery, symptoms can return due to scar tissue formation or non-compliance with rehabilitation. Sustained relief requires commitment to these preventative measures and viewing treatment as an ongoing process of physical upkeep.