Thoracic Outlet Syndrome

Thoracic outlet syndrome (TOS) affects nerves and blood vessels in your thoracic outlet — a passageway located just below your collarbone. TOS occurs when a bone or muscle narrows nerves and blood vessels in this passageway, preventing them from working properly.

There are three types of TOS, depending on the particular nerves or blood vessels affected:

• Neurogenic TOS affects the nerves that regulate movement and feeling in your arm and hand.
• Venous TOS affects the major veins in the lower neck and upper chest. This type may come on suddenly, often after unusual or exhaustive arm activity.
• Arterial TOS affects one of the arteries under your collarbone by causing an aneurysm (a bulging of the artery).

Vascular surgeons at RUSH provide expert care for all types of TOS. They can diagnose and relieve symptoms unique to your TOS condition.

Causes of Thoracic Outlet Syndrome

The following circumstances may increase your risk of developing TOS:

• Anatomical (irregular) development: This includes a cervical rib (an extra first rib), or an extra or an irregular muscle in your neck. These may be congenital (present at birth), or you may develop them over time.
• Repetitive motions of the arm and shoulder: Certain jobs or sports requiring heavy lifting or raised arms may irritate the nerves or vessels in your thoracic artery. Some jobs that may put you at a higher risk include package couriers, hairstylists or auto mechanics. And sports that could cause TOS include weightlifting, swimming or baseball.
• Injury: This includes old fractures of your collarbone and whiplash.

Thoracic Outlet Syndrome Symptoms

You may experience various symptoms, depending on which of type of TOS you have.

Neurogenic TOS Symptoms

Signs of neurogenic TOS are as follows:

• Pain or aches in your neck, back of the head or shoulder
• Tingling or numbness in your fingers, hand or arm
• Increased discomfort or weakness when you raise your arm for extended periods of time. For example, they may worsen when you’re combing your hair or putting away dishes in upper kitchen cabinets.

Venous TOS Symptoms

Signs of venous TOS are as follows:

• Edema (swelling) of the arm, hand or fingers
• Noticeably swollen veins in the chest, neck or shoulder
• Bluish discoloration in the upper body

Arterial TOS Symptoms

Signs of arterial TOS are as follows:

• Cold or discolored (white) hand
• Pain in the hand and arm
• Open sores on the fingers

A Diagnosis You Can Count On

At RUSH, we take the following steps to diagnose your symptoms:

• A thorough review of your health history, including your current symptoms and past test results
• A physical exam that focuses on your hand and arm movement
• Additional testing, if needed

Additional Testing

TOS symptoms can be similar to those of other conditions, like carpal tunnel syndrome. This is why we sometimes order additional tests to confirm or rule out TOS as the cause of your symptoms.

Common tests may include the following:

• X-ray of the chest to check for irregular bone growth, like a cervical rib (an extra first rib)
• CT scan or MRI to rule out cervical spine impingement (a pinched nerve in your neck)
• Ultrasound of the upper arm blood vessels to check for narrowing or blockages
• Angiogram to check for how well blood is flowing through your blood vessels
• Nerve conduction study to check for nerve damage

Treatment for Thoracic Outlet Syndrome at RUSH

Our goal with treatment is to ease your pain and symptoms. Without treatment, your TOS may cause these other health problems:

• Permanent arm swelling, pain or weakness
• Permanent nerve damage
• Gangrene (when blood stops flowing to a specific area of your body, resulting in dead body tissue)
• Blood clots

Your first step in getting proper treatment is to discuss options with your RUSH provider. They may recommend a nonsurgical treatment, surgery or a combination to best manage your TOS symptoms.

Physical Therapy

If you have neurogenic TOS, you may be able to get relief from your symptoms through physical therapy. Typically, physical therapy is the first part of your treatment plan.

RUSH offers a three-month physical therapy treatment to help you manage your TOS symptoms. This treatment focuses on the following:

• Improving movement of your neck and shoulder.
• Strengthening your neck and shoulder muscles.
• Practicing better posture and body alignment so your muscles can work together most effectively.
• Breathing techniques, like diaphragmatic breathing, to help provide relief to muscles associated with breathing.

At the end of your physical therapy, you will follow up with your doctor. If your symptoms have not lessened, your doctor may recommend additional treatments.

Scalene Injection

Your scalene muscles are three muscles located along each side of your neck. Your doctor may recommend a scalene injection in these muscles for one or more of the following reasons:

• To further confirm your TOS diagnosis. If the treatment helps relieve your symptoms, that indicates that you do, in fact, have TOS.
• To relieve your TOS symptoms.

If the scalene injection helps relieve your symptoms, this indicates you may be a good candidate for a scalenectomy. Your RUSH provider will help you decide if a scalenectomy is a good treatment for you.

Surgery

If you have venous or arterial TOS, your symptoms may be more advanced. In this case, your doctor will likely recommend surgery as the most effective treatment.

If you have neurogenic TOS, your doctor may recommend surgery if physical therapy does not relieve your symptoms. You may also be a candidate for surgery if your symptoms are more advanced.

Vascular surgeons are skilled in several surgical approaches to treat thoracic outlet syndrome. These procedures can help the nerves and blood vessels in your thoracic outlet work properly.

RUSH offers the following surgical treatments:

Surgeries for neurogenic TOS:

• First rib resection: Your surgeon removes a rib to make more room for compressed blood vessels and nerves.
• Scalenectomy: Your surgeon removes part of your scalene muscles (the three muscles on each side of your neck). This surgery also relieves compressed blood vessels and nerves and can prevent blood clots. Scalenectomy may be performed at the same time as a first rib resection.

Surgery for venous TOS:

• Thrombolysis: Your surgeon removes a blood clot to reopen your vein. This surgery can reduce arm swelling and blueish discoloration.

Surgery for arterial TOS

• Subclavian aneurysm repair: Your surgeon repairs an enlarged portion of your subclavian artery. This can prevent serious complications, like a stroke.

After any of these surgeries, your surgeon may recommend another round of physical therapy to help improve your strength and activity level.

You can expect to return to everyday activities within three weeks after surgery. If you’re an athlete or an active adult, you can expect to return to full competition after three months.

RUSH Excellence in Thoracic Outlet Syndrome Care

• Get care quickly: If you’re looking for thoracic outlet syndrome care, RUSH vascular surgeons can see you quickly. You can typically schedule a next-day virtual visit to connect with a specialist right away. Or, you can see a provider in person within a week of calling for an appointment.
• Targeted physical therapy: Your vascular surgeon collaborates with physical therapists at RUSH to design a specific TOS physical therapy plan. Your plan will focus on strengthening the muscles that are weakened the most by TOS — your neck, arm and shoulder.
• Expertise in pain management: We understand how pain can affect all aspects of your day-to-day life. Your vascular surgeon can collaborate with RUSH’s pain management team to help safely manage your pain.