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Thoracic Outlet Syndrome in Athletes


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 swelling.

    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.

    Diagnosing TOS

    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 potential.
    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.

    A 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.