From the Guidelines
Thoracic outlet syndrome (TOS) should be diagnosed and treated with a multidisciplinary approach, starting with physical therapy and anti-inflammatory medications, and considering surgical decompression if conservative treatments fail after 3-6 months, as recommended by the most recent guidelines 1. The diagnosis of TOS involves identifying compression of the brachial plexus, subclavian artery, and/or subclavian vein at the superior thoracic outlet, which can be caused by anatomical abnormalities, poor posture, or repetitive activities. Some key points to consider in the diagnosis and treatment of TOS include:
- The costoclavicular triangle, interscalene triangle, and pectoralis minor space are the three distinct spaces that can be implicated in TOS, each with different presentations and symptoms 1.
- Imaging studies such as CT, MRI, and MRA can be used to evaluate the thoracic outlet and diagnose TOS, with MRI being particularly useful for evaluating the brachial plexus and cervical spine 1.
- Treatment typically begins with physical therapy to strengthen chest muscles, improve posture, and create more space in the thoracic outlet, as well as anti-inflammatory medications like ibuprofen (400-800mg three times daily) or naproxen (500mg twice daily) to manage pain.
- For severe cases, muscle relaxants such as cyclobenzaprine (5-10mg three times daily) may be prescribed for short-term use, and surgical decompression may be necessary if conservative treatments fail after 3-6 months, which could involve removing the first rib or releasing tight muscles 1.
- Patients should avoid activities that worsen symptoms, maintain good posture, take frequent breaks from repetitive activities, and perform prescribed stretching exercises daily to manage their condition. It is essential to prioritize the most recent and highest-quality study, which in this case is the 2020 guidelines from the Journal of the American College of Radiology 1, to ensure the best possible outcomes in terms of morbidity, mortality, and quality of life for patients with TOS.
From the Research
Diagnosis of Thoracic Outlet Syndrome (TOS)
- TOS can be diagnosed through history, physical examination maneuvers, and imaging in patients with an identifiable narrowing of the thoracic outlet and/or symptoms with a high probability of thoracic outlet neurovascular compression 2
- Diagnosis can be made by evaluating clinical presentation as neurogenic TOS, vascular TOS, or nonspecific-type TOS 3
- Diagnostic tests include history, physical examination, provocative tests, ultrasound, radiological evaluation, and electrodiagnostic evaluation 3
- A thorough patient history, physical exam, and appropriate imaging studies are helpful in diagnosis 4
Classification of TOS
- TOS can be classified as neurogenic, arterial, or venous based on the compressed structure(s) 2
- Neurogenic TOS involves compression of the brachial plexus, while vascular TOS involves compression of the subclavian vessels 3
Treatment of TOS
- Nonsurgical treatment includes anti-inflammatory medication, weight loss, physical therapy/strengthening exercises, and botulinum toxin injections 2
- Conservative management is generally recommended as the first stage treatment in favor of surgical intervention 5
- The main component of the rehabilitation program is the graded restoration of scapula control, movement, and positioning at rest and through movement 5
- Surgical treatment options include brachial plexus decompression, neurolysis, and scalenotomy with or without first rib resection 2
- Patients undergoing surgical treatment for TOS should be seen postoperatively to begin passive/assisted mobilization of the shoulder, and can begin resistance strength training by 8 weeks postoperatively 2