Thoracic Outlet Syndrome - Diagnosis and Treatment

Diagnosis

Diagnosing thoracic outlet syndrome (TOS) can be complex because symptoms often look like other problems.

Healthcare providers usually examine a person’s symptoms, review their medical history, and perform specific scans or tests to look for nerve compression, blood clots, or unusual anatomy affecting the nerves or blood vessels.

Key tests and imaging include:

Ultrasound

Healthcare providers often use ultrasound as the first scan. It helps detect problems with blood flow, especially in venous or arterial thoracic outlet syndrome.

This test shows if veins like the subclavian vein or arteries like the subclavian artery are squeezed or blocked. Ultrasound helps check for swelling and clot formation, which can signal venous thoracic outlet syndrome.

X-Ray

An X-ray gives a quick look at the bones in the chest, neck, and shoulders. It helps spot unusual bone shapes, including the presence of a cervical rib. An X-ray may reveal changes that could explain weakness, numbness, or tingling in the arms.

CT Scan (Computerized Tomography)

A CT scan uses detailed X-ray images to find what is pressing on blood vessels or nerves. Sometimes, doctors use a dye (CT angiography) to make the arteries and veins easier to see.

This scan can detect blood clots, blockages, or an abnormal path of vessels and nerves at the top of the chest.

Scan	What It Shows	Purpose in TOS
CT Scan	Cross-sections of body	Finds compressions
CT Angiography	Blood vessels	Studies arteries/veins

MRI (Magnetic Resonance Imaging)

MRI uses magnets and radio waves to create clear pictures of soft tissues. This test shows the brachial plexus and nearby muscles, such as the anterior scalene muscle, which can be involved in neurogenic thoracic outlet syndrome.

Health professionals sometimes use contrast dye in MRI scans (MR angiography/venography) to view vessels more clearly. The arm and neck might be moved into different positions during the scan.

This can help detect changes in blood flow or nerve compression that only appear with certain movements.

Arteriogram and Venogram (Angiography)

During these exams, a specialist places a small tube (catheter) into a blood vessel and injects dye. This allows real-time X-ray images of blood flow through arteries and veins.

Arteriogram: Finds blockages, narrowing, or abnormal patterns in arteries.
Venogram: Checks the veins for clots, blockages, or narrowing.

Nerve and Function Tests

Nerve Conduction Studies & Electromyography (EMG): These tests help find out if the brachial plexus or its branches are being squeezed.
- Nerve conduction studies measure how well and how quickly signals move through the nerves in the arm and hand.
- EMG records electrical activity in muscles.
Provocative Maneuvers and Physical Exam Techniques: Providers use physical tests that ask patients to move their arm, shoulder, or neck in certain ways. These movements can bring out symptoms and help confirm the diagnosis. If arm swelling, discoloration, or pins-and-needles start during these tests, or if the pulse weakens or disappears, TOS becomes more likely.

Some common symptoms that guide the use of these tests include:

Tingling or numbness in the fingers, hands, or arms.
Weak grip or arm fatigue.
Pain in the neck, shoulder, or arm, especially with activity.
Swelling in the arm or hand.
Signs of blood clotting, like color changes or veins appearing larger.

Types of TOS and Their Diagnostic Focus

Type of TOS	Main Problem	Key Tests Used
Neurogenic	Nerve compression	EMG, Nerve Studies, MRI
Venous	Vein compression/clots	Ultrasound, Venogram, CT, MRI
Arterial	Artery compression	CT Angiography, Arteriogram, Ultrasound

Each form of thoracic outlet syndrome often affects certain structures:

Neurogenic TOS: Mostly involves the brachial plexus nerves and nearby muscles, like the anterior scalene.
Venous TOS: Involves the subclavian vein and can cause swelling, pain, and blood clots.
Arterial TOS: Involves the subclavian artery and may cause coolness, paleness, or loss of pulse in the arm.

Providers Consider:

Certain risk factors increase suspicion for TOS, including:

Repetitive arm or shoulder movements
Sports or jobs with overhead activity
Past neck or chest injuries
Unusual anatomy like a cervical rib or thickened muscle

Step-By-Step Example of Diagnosis Process:

History + Symptoms: Providers ask about numbness, tingling, weakness, swelling, arm pain, or pins-and-needles. They check for any job or sports activity that uses the shoulder or arm a lot.
Physical Exam: They look for muscle wasting, color changes, swelling, or a difference in the pulse between arms.
Provocative Maneuvers: Providers move the arm or neck in specific ways to try to bring out symptoms.
Imaging: They use ultrasound or X-ray first, then CT, MRI, or vascular studies if needed.
Nerve Studies: If weakness or numbness is present, they use nerve conduction and EMG tests.

Signs of Each TOS Type:

Sign/Symptom	Neurogenic	Venous	Arterial
Numbness/Tingling	Yes	Sometimes	Sometimes
Weakness	Yes	Rare	Sometimes
Arm Swelling	Rare	Yes (common)	No
Color Change	Rare	Blue or swollen arm	Pale or cool arm
Blood Clots	Rare	Yes	Possible
Pulse Changes	Sometimes	No	Yes

Treatment

Surgical Choices

Doctors consider surgery when non-surgical treatments do not improve symptoms or if symptoms keep getting worse.

Specialists such as thoracic surgeons or vascular surgeons perform these procedures to relieve pressure on nerves and blood vessels in the thoracic outlet.

Types of Procedures

Thoracic Outlet Decompression: Surgeons remove a section of the first rib, and sometimes a nearby muscle, to make more space for nerves and blood vessels.
Blood Vessel Repair: If arteries or veins are damaged, the surgeon repairs or replaces the injured vessel. Sometimes they use a healthy piece of artery from another part of the body or an artificial graft.

Clot Management Before Surgery

If there is a blood clot in an artery or vein, the surgeon treats it before decompression.

Doctors might use medication that breaks up clots or perform a procedure to remove the clot.

Possible Risks and Considerations

All surgeries come with some risks. Thoracic outlet decompression can cause bleeding, infection, and nerve injury (especially to the brachial plexus nerves in the arm).

Symptoms may not fully improve, or symptoms might come back later.

Surgical Approaches: At a Glance

Procedure type	Purpose	Who Performs It	Risks
Rib and muscle removal	Increases space for nerves and vessels.	Thoracic or vascular	Nerve injury, infection
Blood vessel repair/graft	Fixes damaged arteries or veins.	Vascular surgeon	Bleeding, graft problems
Clot removal or dissolving	Eliminates obstructions prior to decompression surgery.	Vascular surgeon	Reaction to medicines, bleeding

Recovery and Follow-up

After surgery, follow-up appointments help check the results and look for possible side effects. Physical therapy is often part of the recovery process to restore movement and strength.

Home Tips and Daily Management

Managing thoracic outlet syndrome at home often involves simple lifestyle changes. Consistent exercise therapy, as part of conservative treatment, helps support the muscles around the thoracic outlet.

Physical therapy routines can improve strength and flexibility. Keeping good posture is important. People should take regular breaks during daily activities to stretch and move.

It is also helpful to maintain a healthy weight. Other self-care steps include setting up workspaces that allow for correct posture, using gentle massages, and applying heat to the shoulder area.

Relaxation approaches, like deep breathing or light stretching, can also reduce tension and help manage symptoms.

Dealing With Daily Challenges and Getting Support

It can take a long time for people to find out they have thoracic outlet syndrome, especially since the symptoms can look like other issues. TOS affects women more commonly.

If symptoms continue without answers, people should share concerns with a healthcare provider.

Helpful tips for daily life:
- Keep a journal of symptoms.
- Stay patient during tests.
- Lean on family or friends for encouragement.

Talking about what you feel and asking questions during appointments can help you get the support needed.

Getting Ready for Your Visit

Steps to Take Before You Go

Getting organized before you see a healthcare provider can help you have a better appointment.

Here are several important things to keep in mind:

Check for Special Instructions: Call ahead and ask if you need to follow any rules before your visit. For example, you may need to avoid eating or stop taking certain medicines.
Keep Track of Symptoms: Write down all your symptoms, even those that seem minor. Be specific about how long you have had them, where you feel discomfort, and what makes it better or worse.
Review Your Medical Background: List any past injuries or accidents, such as those from sports, work, or car crashes. Note any repeated physical activities from hobbies or work, as these can sometimes lead to thoracic outlet syndrome (TOS).
Document Medications and Conditions: Make a list of all medicines and supplements you take. Include any other medical conditions you have.
Consider Bringing Support: Bring a friend or family member if possible. They might notice details or remember questions you forget.
Make a List of Questions: Planning ahead can help you get the most from your visit. Some questions to start with include:

Possible Questions for the Provider
What is likely causing these symptoms?
What tests do I need?
What treatments would you suggest?
Could TOS be caused by injury, trauma, or an anatomical issue?
Would weight loss or lifestyle changes help?
Are there any activities I should avoid?
What is the outlook for TOS?
What options are there besides surgery?

Ask about causes such as prior trauma, cervical rib, tumors, or other changes in the costoclavicular space. These can be linked to thoracic outlet syndrome.

Questions Your Healthcare Provider Might Ask

During your visit, the healthcare professional will ask about many details. These questions help them understand your situation and find possible causes like nerve or blood vessel compression, injury, or anatomical changes:

When did your symptoms begin?
How would you describe your pain or discomfort?
How have your symptoms changed or spread over time?
Where does the discomfort start, and does it travel elsewhere?
Does lifting your arms or certain movements make things worse?
Do any activities or postures relieve your symptoms?
What do you do for work? Does it involve repeating the same movements?
Have you participated in sports or physical hobbies?
Have you ever been treated for other health problems?
Are there any visible changes in color, swelling, or shape in your fingers, hand, or arm?

Mention any history of trauma, surgery, anatomical differences, or tumors. These details can affect the area where nerves and blood vessels pass between the collarbone and first rib.

Thoracic Outlet Syndrome – Diagnosis and Treatment