Diagnosis

Diagnosing thoracic outlet syndrome can be difficult because the symptoms and their severity can vary greatly among people with the disorder. To diagnose thoracic outlet syndrome, your doctor may review your symptoms and medical history and conduct a physical examination.

  • Physical examination. Your doctor will perform a physical examination to look for external signs of thoracic outlet syndrome, such as a depression in your shoulder, swelling or pale discoloration in your arm, abnormal pulses, or limited range of motion.
  • Medical history. Your doctor will likely ask about your medical history and symptoms, as well as your occupation and physical activities.

Provocation tests

Provocation tests are designed to try to reproduce your symptoms. The tests may help your doctor determine the cause of your condition and help rule out other causes that may have similar symptoms.

In these tests, your doctor may ask you to move your arms, neck or shoulders in various positions. Your doctor will check your symptoms and examine you in different positions.

Imaging and nerve study tests

To confirm the diagnosis of thoracic outlet syndrome, your doctor may order one or more of the following tests:

  • X-ray. Your doctor may order an X-ray of the affected area, which may reveal an extra rib (cervical rib). X-rays also may rule out other conditions that may be causing your symptoms.
  • Ultrasound. An ultrasound uses sound waves to create images of your body. Doctors may use this test to see if you have vascular thoracic outlet syndrome or other vascular problems.
  • Computerized tomography (CT) scan. A CT scan uses X-rays to obtain cross-sectional images of your body. A dye may be injected into a vein to view the blood vessels in greater detail (CT angiography). A CT scan may identify the location and cause of blood vessel (vascular) compression.
  • Magnetic resonance imaging (MRI). An MRI uses powerful radio waves and magnets to create a detailed view of your body. Your doctor may use an MRI to determine the location and cause of blood vessel (vascular) compression. An MRI may reveal congenital anomalies, such as a fibrous band connecting your spine to your rib or a cervical rib, which may be the cause of your symptoms.
  • Angiography. In some cases, you may be given an intravenous dye before a CT or MRI scan. The dye helps to make blood vessels more visible on the images.
  • Arteriography and venography. In these tests, your doctor inserts a thin, flexible tube (catheter) through a small incision, usually in your groin. The catheter is moved through your major arteries in arteriography, or through your veins in venography, to the affected blood vessels. Then your doctor injects a dye through the catheter to show X-ray images of your arteries or veins.

    Doctors can check to see if you have a compressed vein or artery. If a vein or artery has a clot, doctors can deliver medications through the catheter to dissolve the clot.

  • Electromyography (EMG). During an EMG, your doctor inserts a needle electrode through your skin into various muscles. The test evaluates the electrical activity of your muscles when they contract and when they're at rest.
  • Nerve conduction study. These tests use a low amount of electrical current to test and measure your nerves' ability to send impulses to muscles in different areas of your body. This test can determine if you have nerve damage.

Treatment

In most cases, a conservative approach to treatment is effective, especially if your condition is diagnosed early. Treatment may include:

  • Physical therapy. If you have neurogenic thoracic outlet syndrome, physical therapy is the first line of treatment. You'll learn how to do exercises that strengthen and stretch your shoulder muscles to open the thoracic outlet, improve your range of motion and improve your posture. These exercises, done over time, may take the pressure off your blood vessels and nerves in the thoracic outlet.
  • Medications. Your doctor may prescribe anti-inflammatory medications, pain medications or muscle relaxants to decrease inflammation, reduce pain and encourage muscle relaxation.
  • Clot-dissolving medications. If you have venous or arterial thoracic outlet syndrome and have blood clots, your doctor may administer clot-dissolving medications (thrombolytics) into your veins or arteries to dissolve blood clots. After you're given thrombolytics, your doctor may prescribe medications to prevent blood clots (anticoagulants).

Surgical options

Your doctor may recommend surgery if other treatment hasn't been effective, if you're experiencing ongoing symptoms or if you have progressive neurological problems.

A surgeon trained in chest (thoracic) surgery or blood vessel (vascular) surgery will perform the procedure.

Thoracic outlet syndrome surgery has risks of complications, such as injury to the brachial plexus. Also, surgery may not relieve your symptoms, and symptoms may recur.

Surgery to treat thoracic outlet syndrome, called thoracic outlet decompression, may be performed using several different approaches, including:

  • Transaxillary approach. In this surgery, your surgeon makes an incision in your chest to access the first rib, divide the muscles in front of the rib and remove a portion of the first rib to relieve compression. This approach gives your surgeon easy access to the first rib without disturbing the nerves or blood vessels. But, that only gives your surgeon limited access and makes it harder to see muscles and cervical ribs that may be contributing to compression behind the nerves and blood vessels.
  • Supraclavicular approach. This approach repairs compressed blood vessels. Your surgeon makes an incision just under your neck to expose your brachial plexus region.

    Your surgeon then looks for signs of trauma or muscles contributing to compression near your first (uppermost) rib. Your surgeon may remove the muscles causing the compression and repair compressed blood vessels. Your first rib may be removed if necessary to relieve compression.

  • Infraclavicular approach. In this approach, your surgeon makes an incision under your collarbone and across your chest. This procedure may be used to treat compressed veins that require extensive repair.

In venous or arterial thoracic outlet syndrome, your surgeon may deliver medications to dissolve blood clots prior to thoracic outlet compression. Also, in some cases, your surgeon may conduct a procedure to remove a clot from the vein or artery or repair the vein or artery prior to thoracic outlet decompression.

If you have arterial thoracic outlet syndrome, your surgeon may need to replace the damaged artery with a section of an artery from another part of your body (graft) or an artificial graft. This procedure may be done at the same time as your procedure to have the first rib removed.

Lifestyle and home remedies

If you're diagnosed with thoracic outlet syndrome, your doctor or physical therapist will instruct you to do exercises at home to strengthen and support the muscles surrounding your thoracic outlet.

In general, to avoid unnecessary stress on your shoulders and muscles surrounding the thoracic outlet:

  • Maintain good posture
  • Take frequent breaks at work to move and stretch
  • Maintain a healthy weight
  • Avoid carrying heavy bags over your shoulder
  • Avoid activities that worsen symptoms, or find ways to adapt activities so that they don't cause symptoms
  • Create a work area that allows you to keep good posture and doesn't make symptoms worse

Coping and support

Symptoms associated with thoracic outlet syndrome can be caused by a number of other conditions, which makes it difficult for doctors to diagnose the condition. Many people experience thoracic outlet syndrome symptoms for years before they are diagnosed with the condition, which can cause stress and frustration. Be sure to discuss your concerns with your doctor if your symptoms persist and a diagnosis hasn't been made.

Preparing for your appointment

You're likely to start by seeing your primary care doctor. In some cases, your doctor may refer you to a doctor trained in blood vessel (vascular) conditions or blood vessel surgery.

Here's some information to help you prepare for your appointment.

What you can do

  • Be aware of any pre-appointment restrictions. When you make the appointment, ask if there's anything you need to do before you arrive at the office.
  • Write down any symptoms you're experiencing, including any that seem unrelated to the reason for which you scheduled the appointment. Be as specific and detailed as possible in describing your symptoms, including what part of your body is affected and how the discomfort makes you feel.
  • Write down key personal information, including any physical traumas you've experienced, such as a car accident or work-related injury. Even if they occurred years ago, your doctor will want to know about them. Also note any repetitive physical activities that you've performed now or in the past at work, in sports, and for hobbies and other recreational activities.
  • List your key medical information, including other conditions you're being treated for and the names of any prescription and over-the-counter medications or supplements that you're taking.
  • Take a family member or friend along, if possible. Someone who accompanies you may remember something that you missed or forgot.
  • Write down questions to ask your doctor.

Preparing a list of questions will help you make the most of your time with your doctor. For thoracic outlet syndrome, some basic questions to ask your doctor include:

  • What's the most likely cause of my symptoms?
  • What kinds of tests do I need?
  • What treatments are available, and which treatment do you recommend for me?
  • How likely are nonsurgical treatments to improve my symptoms?
  • If conservative treatments aren't effective, is surgery an option?
  • Is there anything I can do to prevent a recurrence of this problem?
  • Will I need to change my job?
  • Do I need to limit or give up other activities that may be causing my symptoms?
  • If you're recommending weight loss, how much weight do I need to lose to notice an improvement in my symptoms?
  • I have other health conditions. How can I best manage them with this condition?
  • Are there any brochures or other printed material that I can take home with me? What websites do you recommend visiting?

Don't hesitate to ask any other questions you have.

What to expect from your doctor

Your doctor is likely to ask you a number of questions, such as:

  • When did you first notice your symptoms?
  • How would you describe your symptoms?
  • Have your symptoms changed over time?
  • Where does your pain seem to start and where does it go from there?
  • Does the pain or numbness worsen when you lift your arms overhead?
  • Does anything else seem to worsen or improve your symptoms?
  • What activities do you perform on your job?
  • Do you or did you play sports?
  • What are your hobbies or most frequent recreational activities?
  • Have you been diagnosed or treated for any other medical conditions? When?
  • Have you noticed a lack of color or a blue color in one or more of your fingers or your entire hand or other changes to the area?

What you can do in the meantime

While you're waiting for your appointment, try taking a nonsteroidal anti-inflammatory drug (NSAID), such as ibuprofen (Advil, Motrin IB, others). Your discomfort also may be improved if you maintain good posture and avoid using repetitive movements and lifting heavy objects.

Thoracic outlet syndrome care at Mayo Clinic

Aug. 27, 2016
References
  1. Ferri FF. Thoracic outlet syndrome. In: Ferri's Clinical Advisor 2016. Philadelphia, Pa.: Mosby Elsevier; 2016. https://www.clinicalkey.com. Accessed May 31, 2016.
  2. Kuhn JE, et al. Thoracic outlet syndrome. Journal of the American Academy of Orthopaedic Surgeons. 2015;23:222.
  3. NINDS thoracic outlet syndrome information page. National Institute of Neurological Disorders and Stroke. http://www.ninds.nih.gov/disorders/thoracic/thoracic.htm. Accessed May 31, 2016.
  4. Goshima K. Overview of thoracic outlet syndromes. http://www.uptodate.com/home. Accessed May 24, 2016.
  5. Buller LT, et al. Thoracic outlet syndrome: Current concepts, imaging features, and therapeutic strategies. The American Journal of Orthopedics. 2015;44:376.
  6. Thoracic outlet syndrome. American Academy of Orthopaedic Surgeons. http://orthoinfo.aaos.org/topic.cfm?topic=a00336. Accessed May 31, 2016.
  7. Grunebach H, et al. Thoracic outlet syndrome. Vascular Medicine. 2015;20:493.
  8. Riggs EA. AllScripts EPSi. Mayo Clinic, Rochester, Minn. May 10, 2016.