Thoracic outlet syndrome is a condition that was brought into the national
spotlight by high-profile professional athletes who suffered from its
initial debilitating effects. Whether it’s a basketball player unable
to accurately shoot a jumper or a pitcher unable to spot a fastball, thoracic
outlet syndrome, or TOS, can wreak havoc on both the body and mind.
While TOS may initially 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.
Signs and Symptoms of TOS
It's highly beneficial for athletes to understand the signs and symptoms
of TOS so they know to visit a specialist earlier in their diagnosis.
This will help avoid a misdiagnosis and help achieve 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 suspect TOS in their athlete patients include:
- Asymmetric extremity temperature.
- Tenderness around the clavicle bone.
Unilateral or asymmetrical extremity
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, 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 like frozen
shoulder, for example.
TOS Treatment Options
Most athletes with TOS will respond effectively to conservative treatments
for the condition. Such treatments may include:
Physical therapy designed to help patients work on posture and shoulder mechanics.
- Medications to reduce swelling, pain and neuropathic features accompanying the pain.
- Scapular bracing.
- Biofeedback to relax specific muscles and quiet the autonomic nervous system.
- 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, in rare cases, 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, first rib
resection or pectoralis minor surgery may be indicated as
surgical treatment options.
Holistic TOS Treatment
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 our 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
must be considered, evaluated and addressed if necessary.
team approach to treatment is 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 applies for
a well-rounded and ultimately effective approach to TOS treatment in athletes.