What is the initial management for thoracic outlet syndrome?

Initial Management for Thoracic Outlet Syndrome

Conservative management is the recommended first-line treatment for thoracic outlet syndrome (TOS), with physical therapy focused on scapular control and positioning being the cornerstone of initial management. 1, 2

Types of Thoracic Outlet Syndrome

• TOS can be classified into three main types based on the compressed structures 1:
  • Neurogenic TOS (compression of the brachial plexus)
  • Venous TOS (vTOS - compression of the subclavian vein)
  • Arterial TOS (aTOS - compression of the subclavian artery)

Initial Diagnostic Approach

• Chest radiography is recommended as the initial imaging to identify osseous abnormalities such as cervical ribs or first rib anomalies 1
• For venous TOS, diagnostic studies include catheter-based venography, CT venography, MR venography, or ultrasound duplex Doppler 3
• For neurogenic TOS, MRI without and with IV contrast of the chest may be used 1
• For arterial TOS, CTA with IV contrast, MRA, or US duplex Doppler is recommended 1
• Imaging findings must be correlated with clinical symptoms, as venous compression during arm abduction is common in both symptomatic and asymptomatic individuals 1, 3

Conservative Management Protocol

Physical Therapy (Core Component)

• Graded restoration of scapular control, movement, and positioning at rest and through movement 2
• Postural correction instruction for sitting, standing, and sleeping positions 4
• Stretching exercises targeting:
  • Upper trapezius
  • Levator scapulae
  • Suboccipital muscles
  • Scalene muscles
  • Sternocleidomastoid
  • Pectoral muscles 4
• Strengthening exercises of the lower scapular stabilizers, beginning in gravity-assisted positions 4
• Restoration of humeral head control and isolated strengthening of weak shoulder muscles 2

Additional Conservative Measures

• NSAIDs for pain management 5
• Activity modification to avoid symptom-provoking positions 5
• Taping techniques to support proper posture 2
• Manual therapy techniques as adjunctive treatment 2
• Injection therapy with botulinum toxin A or steroids in selected cases 5

Duration of Conservative Management

• A minimum of 6 weeks of physical therapy is recommended before considering surgical intervention 6
• The American College of Radiology recommends an adequate trial of conservative management for 3-6 months before considering surgery 1

Indications for Surgical Intervention

• Failure of conservative management after an adequate trial (3-6 months) 1
• Progressive symptoms despite conservative treatment 1
• Significant functional compromise 1
• Vascular complications 1
• High-risk occupations where recurrence prevention is critical 1

Surgical Approach When Indicated

• Transaxillary first rib removal is a common surgical approach with reported success rates of complete (85%) or partial (7%) relief in 92% of operated patients 7
• For patients with venous TOS on anticoagulation requiring surgery:
  • Anticoagulation should be discontinued 12-24 hours before surgery 8
  • Postoperatively, anticoagulation can be restarted once adequate hemostasis is achieved, typically 12-24 hours after surgery 8

Keys to Successful Management

• Patient education and compliance with the exercise program are critical to successful conservative management 4
• A coordinated team approach involving thoracic surgeons, neurologists, and physical therapists is important for optimal management 6
• Behavioral modification at home and work is essential for long-term success 4