Thoracic outlet syndrome (TOS)
What is thoracic outlet syndrome (TOS)?
TOS refers to a group of three distinct disorders caused by compression of the nerves or blood vessels in the lower neck and upper chest area, known as the thoracic outlet. This space is bordered by:
- The clavicle (collarbone): Stabilizes the shoulder and protects chest organs.
- The first rib: Assists in respiration and protects the lungs.
- The sternum (breastbone): Protects the heart and aids in breathing.
- The pectoralis minor muscle: Supports shoulder function.
Compression within this space can affect:
- Nerves: Most commonly the brachial plexus, which controls movement and sensation in the shoulder, arm and hand.
- Blood vessels: The subclavian artery and vein, which transport blood to and from the arm, respectively.
Types of TOS
TOS presents in three forms, each with distinct causes, and symptoms:
Neurogenic TOS (NTOS)
- Cause: Compression of the brachial plexus
- Symptoms:
- Pain in the neck, shoulders, arms or hands
- Numbness or tingling in the forearms or fingers
- Weakness in the hands or arms
- Diagnosis: Often challenging due to nonspecific symptoms. Evaluation includes a detailed medical history, physical exam and specific diagnostic tests or procedures
Venous TOS (VTOS)
- Cause: Compression of the subclavian vein
- Symptoms:
- Swelling, discoloration or pain in the arm
- Heaviness or easy fatigue in the affected arm
- Acute blood clots (Paget-Schroetter syndrome), a medical emergency
- Diagnosis: Typically confirmed with imaging, such as venograms
Arterial TOS (ATOS)
- Cause: Compression of the subclavian artery
- Symptoms:
- Coldness or discoloration in the hands
- Severe pain or blue discoloration (indicating a medical emergency)
- Diagnosis: Clinical evaluation and imaging tests to assess arterial blood flow and anatomy
Symptoms and risk factors
Common symptoms of TOS vary depending on the structures affected, but may include:
- Pain, numbness or tingling in the upper body
- Arm heaviness or poor circulation
- Swelling or discoloration in the arms or hands
Risk factors include:
- Anatomical variations like a cervical rib
- Traumatic injuries
- Poor posture or repetitive arm motions
- Obesity, pregnancy or depression
How is TOS diagnosed?
TOS diagnosis requires a combination of:
- Physical exams: Special maneuvers to provoke symptoms and assess blood flow
- Imaging tests: X-rays, MRIs and CT scans to visualize compression
- Electromyography (EMG): Evaluates nerve function
- Endovascular techniques: Detailed imaging using catheters for venous or arterial TOS
Treatment options
Treatment for TOS depends on the type and severity of the condition and includes:
Nonsurgical approaches:
- Physical therapy: Stretching and strengthening exercises to reduce compression
- Medications: Anti-inflammatories or blood thinners to manage pain or clotting
- Injections: Botox or steroids to relax muscles and alleviate compression
Surgical options:
- Rib resection: Removal of the first rib or cervical rib to decompress the area
- Approaches:
- Supraclavicular: Ideal for arterial cases requiring vascular reconstruction
- Infraclavicular: Can be removed for venous cases
- Transaxillary: A cosmetically favorable option for rib resection
- Transthoracic (robot-assisted): Minimally invasive with faster recovery
What sets Northwell apart
TOS can significantly impact your quality of life, even affecting your ability to work. Because its symptoms often mimic other conditions, it can be misdiagnosed.
At Northwell, we understand this challenge. Our multidisciplinary team of vascular surgeons, thoracic surgeons, orthopedic surgeons, neurologists, physiatrists and physical therapists collaborates to provide accurate diagnoses and personalized, evidence-based treatment plans—getting you back to the activities you love.
Using leading-edge diagnostics and minimally invasive surgical techniques, we're committed to providing the highest quality TOS care for the best possible outcomes.
Managing and preventing TOS
While not all cases of TOS are preventable, you can reduce your risk with:
- Good posture and ergonomic adjustments
- Regular stretching and strengthening exercises
- Avoiding repetitive overhead motions
- Maintaining a healthy weight