Thoracic Outlet Syndrome has recently received national attention with
several high-profile professional athletes having suffered from its initial
debilitating effects. Whether it’s a basketball player unable to
accurately shoot a jumper to a pitcher not being able to spot a fastball,
Thoracic Outlet Syndrome (TOS) can wreak havoc on both the body and mind.
While TOS may on the surface appear to be a career killer for athletes,
if properly diagnosed and treated, an athlete can return to the court
or field and perform at the highest level.
The thoracic outlet is the area located between the lower neck and upper
chest. The site is surrounded by the collarbone, first rib, and scalene
muscles of the neck. TOS occurs when the blood vessels or nerves in the
thoracic outlet area become compressed, irritated, or injured. The compression
can cause various symptoms, including pain, numbness, weakness in the
neck, shoulder, or down into the hand, and other symptoms. TOS more commonly
affects females and is most common in adults between 20-40. Athletes who
participate in sports hallmarked by repetitive overhead arm motions, including
baseball, football, basketball, tennis, swimming, water polo, and volleyball,
are more likely to develop TOS than other people.
It is highly beneficial for athletes to understand the signs and symptoms
of TOS in order to visit a specialist earlier in their diagnosis, avoid
a misdiagnosis and subsequent ineffective treatments, all while achieving
effective treatment, resolution of symptoms, and eventual return to play
in their chosen sport. The symptoms experienced by athletes with TOS can
vary greatly, depending on the structures involved.
“Classic” TOS symptoms include neck, shoulder, and extremity
pain, especially if these symptoms are neuropathic or associated with
numbness, tingling, weakness, or vascular complications. “New Classic”
symptoms that should be examined and evaluated by physicians who might
suspect TOS in their athlete patients include:
- Unilateral or asymmetrical extremity swelling.
- Asymmetric extremity temperature.
- Tenderness around the clavicle bone.
When such symptoms are present alongside classic symptoms, they should
raise a health care provider’s suspicion of TOS. In addition to
classic and new classic symptoms, there can be symptoms that are common
indicators of TOS in athletes that might be overlooked. Possibly overlooked
symptoms include hand, wrist, or otherwise unexplained elbow complaints,
headaches, muscle spasm and tenderness (possibly in the face), and chronic
tendinitis in the elbow or wrist.
TOS can be difficult to diagnose because the experience of symptoms can
vary significantly between athletes. There is no singular “Gold
Standard” diagnostic test for TOS. Therefore, a doctor will use
each patient’s clinical presentation, description of symptoms, medical
history, physical examination, and possibly imaging such as an MRI of
the brachial plexus as “supporting evidence” to confirm a
diagnosis. For physicians who know what to look for, the diagnosis of
TOS can be a unifying hypothesis – meaning it helps to explain an
array of symptoms perhaps not explainable by another, more narrow diagnosis
– such as cervical arthropathy or frozen shoulder, for example.
Most athletes with TOS will respond effectively to conservative treatments
for the condition. Such treatments may include:
- Physical therapy is designed to help patients work on posture and shoulder
- Medications designed to reduce swelling, pain, and the neuropathic features
that may be accompanying the pain,
- Scapular bracing,
- Biofeedback: designed to relax specific muscles and quiet the autonomic
- Muscle Retraining: with particular emphasis on proprioception and positioning.
For some people, conservative treatment options won’t be sufficient
for alleviating the symptoms associated with TOS. In those individuals,
local ultrasound-guided trigger point, steroid, or Botox injections into
specific muscles can help relax them for an extended time. That extended
period of muscle relaxation for multiple months can help many TOS patients
optimize the above-listed conservative treatment options to their fullest
Most people will not need to undergo surgery to treat TOS effectively.
However, there are rare cases where people with TOS have such a significant
structural abnormality that they will require surgical intervention to
correct the condition. In these cases, procedures such as scalenectomy,
1st Rib Resection, or Pectoralis Minor surgery may be indicated as surgical
I employ a holistic approach to treatment for any neurologic condition,
including TOS, in my clinical practice at the Center for Sports Neurology
and Pain Medicine at the Cedars-Sinai Kerlan-Jobe Institute. Humans are
not isolated sections of anatomy – our bodies and brains work together
to keep us healthy and strong across the lifespan. For example, with TOS
and athletes, depression can be one factor in this illness equation that
might be overlooked because it doesn’t fit into the “anatomical”
equation for treatment. But an athlete’s psychological wellness
is a significant factor in their overall wellness and successful treatment
journey with TOS. It absolutely MUST be considered, evaluated, and addressed
if necessary. This is also where a team approach to treatment becomes
crucial. Neurologists, surgeons, orthopedists, injectionists, and psychologists
all play vital positions on the “effective treatment team”
of TOS athletes. As the saying goes for effective child-rearing, “it
takes a village,” the same can be said for a well-rounded and ultimately
effective approach to TOS treatment in athletes.