What are the types of Thoracic Outlet Syndrome?

The three types of TOS include neurogenic, venous, and arterial. The types are defined by the structures that are being compressed.

Neurogenic Thoracic Outlet Syndrome

Neurogenic TOS happens when the brachial plexus nerves are compressed. This is the most common form of TOS. Symptoms include pain in the shoulders and neck, numbness, and tingling in the affected arm(s) particularly with overhead activities. These symptoms may vary throughout the day and change depending on activity level.

Venous Thoracic Outlet Syndrome

Venous TOS occurs when the subclavian vein is compressed. This could result in a blood clot(s) in the vein. When a blood clot is present, the condition is referred to as Paget-Schroetter Syndrome. This occurs in a small percentage of those with TOS. This may be caused by excessive effort during repeated strenuous activity, most often seen in high-performing athletes. Symptoms of venous compression may include pain, temperature changes, discoloration and / or swelling in the affected upper extremity that lasts longer than 60 minutes. When these symptoms are present, go immediately to the Emergency Department for care.

Arterial Thoracic Outlet Syndrome

Arterial TOS takes place when the subclavian artery is compressed and the artery is blocked. This type of TOS is rare. Symptoms may include sudden weakness and pain, numbness and tingling, as well as paleness and coldness of the hand.

What Causes Thoracic Outlet Syndrome?

TOS may be caused by repetitive use injuries and / or anatomical reasons such as having an extra cervical rib. People with TOS are often elite high school and college athletes, particularly females, who are involved in repetitive overhead activities such as swimming, softball, and volleyball.

What are the Signs and Symptoms of Thoracic Outlet Syndrome?

Symptoms of TOS can include pain in the shoulders and neck, numbness and tingling in the affected arm(s). Immediate care should be sought for temperature changes, swelling in the affected arm lasting longer than 60 minutes, sudden weakness and / or paleness and coldness of the hand.

How is Thoracic Outlet Syndrome Diagnosed?

Diagnosis of TOS includes a review of the symptoms, and a physical exam. A magnetic resonance imaging / magnetic resonance angiography (MRI/MRA) will likely be done to view compression of vascular and arterial structures.

What are the Treatment Options for Thoracic Outlet Syndrome?

Non-surgical treatment for those with neurogenic TOS may include activity modification and physical therapy. There is a low success rate for long-term resolution of symptoms without significantly changing activity levels. This may look like stopping a sport or changing a job that included the repetitive overhead motions resulting in TOS. Surgery may be needed when activity modification or physical therapy doesn’t work or is not appropriate for the condition.

If non-surgical treatment options and pain management do not resolve a patient’s symptoms, surgery may be recommended. This three-hour procedure typically includes removal of the first rib (or extra cervical rib, if present) along with a scalenectomy (partial removal of scalene muscle) to provide more space for the nerves and blood vessels. If there is compression and tenderness in the pectoralis minor area and / or cubital tunnel region along the elbow, the nerves may need to be released in these areas as well.

Thoracic Outlet Syndrome Prognosis

After surgery, there is a therapy protocol to help patients in their return to activity. More than 85% of surgical patients return to prior activity level without symptoms.

Pain Management for Thoracic Outlet Syndrome

A referral to the Pain Clinic may be recommended to reduce pain symptoms. The goal is to make the pain manageable for daily activities and physical therapy. Cognitive behavioral therapy may be used as well to target nerve pain or muscle tightness.

In addition to medications, the team may recommend injections such as nerve blocks including local anesthetics and steroids. Muscle injections of Botox may help reduce neuropathic pain symptoms. Comprehensive pain management may also include psychosocial support to promote coping skills.