Strong Heart and Vascular Center

Division of Vascular Surgery

Thoracic Outlet Syndrome

Diagnosis

The thoracic outlet is a triangle in the shoulder formed by the clavicle (collarbone), first rib, and a group of muscles. It is small, and through it pass the artery, vein, and nerves to the arm. While any of those structures can be compressed, the nerves are most commonly affected (neurogenic thoracic outlet syndrome). Such problems can follow injury or occur spontaneously. There are two general types of symptoms. Patients commonly experience pain in the region of the shoulders, either in the muscles or directly over the nerves. Headache is common. Patients can also experience pain or symptoms of nerve irritation in the arm or hand.

Today's Visit

We may perform simple laboratory testing, but this diagnosis depends primarily on your history and physical examination. X-rays and nerve studies may have been performed–they can help eliminate other causes, but are not very helpful for TOS itself. We will also discuss this syndrome in better detail.

What You Can Do

Give us as accurate a story of your symptoms and problems as you can. Especially important are any previous treatments you may have had, including chiropractic and physical therapy, and other diagnoses that may have been discussed with you.

Other Treatment

Neurogenic TOS is often a difficult diagnosis to make, and therefore we are fairly conservative in our recommendations. Physical therapy is critically important and we typically will recommend at least 3-6 months' of treatment before surgery is contemplated. We also will try to ensure that problems such as a pinched nerve or carpal tunnel syndrome are not mimicking TOS. Referral to other physicians may be recommended.

Surgery

The goal of surgery is to decompress the narrow space, and is usually not contemplated unless other measures do not work. If surgery is recommended, it is typically removal of the first rib, which can be done through the axilla ("underarm") or from above the collarbone.

After the Procedure

We will give you strong pain medicine, but you will be very sore. You will be in the hospital for 1-2 days during which the physical therapists will see you to recommend arm exercises, which typically consist of maneuvers to stretch and move your shoulder and should be continued after discharge. You should remove your dressing after 36 hours, after which you can shower normally. If staples are present you should not soak the area until they are removed, which will typically be 7-14 days following the procedure. You can drive when you can use your arm with enough comfort for safe operation of your car. You will see your physician 2-4 weeks after surgery. Depending on your job, absence of anywhere from 4-8 weeks may be necessary. Postoperative physical therapy is often helpful.