From the Guidelines
Treatment for thoracic outlet syndrome typically begins with conservative approaches, including physical therapy and pain management, before considering surgery, as recommended by the American College of Radiology Appropriateness Criteria 1. The goal of treatment is to relieve compression of the nerves and blood vessels in the thoracic outlet, and the approach varies based on the specific type of thoracic outlet syndrome (neurogenic, venous, or arterial) and the severity of symptoms.
- Physical therapy is the cornerstone of treatment, focusing on exercises that strengthen chest and shoulder muscles, improve posture, and enhance range of motion.
- Pain management often includes nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen (400-800mg three times daily) or naproxen (250-500mg twice daily) to reduce inflammation and discomfort, as well as muscle relaxants such as cyclobenzaprine (5-10mg three times daily) for muscle spasms 1.
- Lifestyle modifications are essential, including avoiding activities that worsen symptoms, taking frequent breaks from repetitive tasks, maintaining good posture, and losing weight if necessary.
- If conservative treatments fail after 3-6 months, surgical options may be considered, such as first rib resection or scalenectomy to decompress the thoracic outlet, with surgery being more commonly needed for vascular forms of thoracic outlet syndrome than neurogenic forms 2, 3, 4, 5. The use of imaging studies, such as MRI and CT, can help diagnose and plan treatment for thoracic outlet syndrome, and may be used to evaluate the effectiveness of treatment and guide further management 1, 2, 3, 4, 5.
From the Research
Treatment Options for Thoracic Outlet Syndrome (TOS)
The treatment for Thoracic Outlet Syndrome (TOS) typically involves a combination of conservative management and, in some cases, surgical intervention.
- Conservative management is generally recommended as the first stage treatment in favor of surgical intervention 6, 7, 8, 9.
- The main components of conservative management include: + Pain control and medicinal measures 7 + Physical therapy, including exercises to improve posture, strengthen neck and shoulder muscles, and increase range of motion 7, 8, 9 + Lifestyle modifications, such as proper ergonomics at home and in the work setting 7, 9 + Injection therapy with botulinum toxin A or steroids 8
- Surgical decompression is considered for patients who have failed conservative therapy 8, 10.
- Patient education, compliance to an exercise program, and behavioral modification at home and work are critical to successful conservative management 9.
Rehabilitation Approach
The rehabilitation approach for TOS typically involves:
- Graded restoration of scapula control, movement, and positioning at rest and through movement 6
- Restoration of humeral head control, isolated strengthening of weak shoulder muscles, taping, and other manual therapy techniques 6
- Range of motion and nerve gliding exercises 7
- Stretching exercises for the upper trapezius, levator scapulae, suboccipitals, scalenes, sternocleidomastoid, and pectoral muscles 9
Diagnosis and Treatment
Diagnosis of TOS involves a thorough patient history, physical exam, and appropriate imaging studies 8, 10. Treatment of TOS may involve a multidisciplinary approach, including neurologists, physiatrists, family physicians, orthopedic surgeons, vascular surgeons, thoracic surgeons, neurosurgeons, and sometimes psychiatrists 10.