Thoracic Outlet Syndrome (TOS)

Thoracic Outlet Syndrome (TOS) occurs when blood vessels or nerves in the space between the collarbone and first rib (the thoracic outlet) become compressed. This compression can lead to pain, numbness, or swelling in the arm and hand. TOS is classified into three main types — neurogenic, venous, and arterial — each with unique symptoms and treatment approaches.

At The Medical Group of New Jersey, our vascular surgeons work collaboratively with physical therapists and neurologists to provide accurate diagnosis and personalized treatment plans, from conservative therapy to surgical decompression when needed.

Symptom Onset & Initial Evaluation

Thoracic outlet syndrome (TOS) occurs when nerves or blood vessels are compressed between the collarbone and first rib. Symptoms often develop gradually—especially in people with repetitive arm movements, poor posture, or a history of trauma to the neck or shoulder area.

Common symptoms include:

• Neck, shoulder, or arm pain that worsens with activity
• Numbness or tingling in the fingers, especially when the arm is raised
• Swelling or bluish discoloration of the arm (seen in venous TOS)
• Coldness or paleness in the hand (seen in arterial TOS)
• Weak grip strength or fatigue with overhead or repetitive motions

During your evaluation, your vascular surgeon will review your symptoms, occupational activities, and medical history, followed by a focused physical exam. Specific maneuvers, such as Adson’s or Roos test, may be performed to reproduce symptoms and help identify which nerves or blood vessels are being compressed.

Diagnosis

Because TOS can involve nerves, veins, or arteries, accurate diagnosis requires careful testing to determine the exact type and location of compression.

• Duplex Ultrasound or Venography: Detects vein compression or the presence of a blood clot.
• CT or MR Angiography: Provides detailed images of arteries to evaluate narrowing or aneurysm formation.
• Electromyography (EMG): Measures nerve activity to confirm neurogenic involvement.
• Provocative Imaging Tests: Assesses changes in blood flow during specific arm positions to pinpoint the site of compression.

At The Medical Group of New Jersey, each case is reviewed by vascular and radiology specialists to ensure a comprehensive, multidisciplinary evaluation and the most precise diagnosis possible.

Treatment

Treatment for thoracic outlet syndrome is personalized based on the type (neurogenic, venous, or arterial) and the severity of symptoms.

Conservative & Medical Management

Many patients benefit from non-surgical therapies focused on relieving compression and improving posture:

• Physical therapy: Emphasizes posture correction, shoulder stability, and gentle nerve-gliding exercises.
• Pain management: Use of anti-inflammatory medications (NSAIDs) or muscle relaxants for comfort.
• Activity modification: Avoiding repetitive overhead movements or heavy lifting that aggravate symptoms.

Procedural & Surgical Options

When conservative measures are not enough, or when significant vascular compression or clotting occurs, surgical intervention may be recommended to restore normal blood flow and relieve pressure on surrounding nerves.

• First Rib Resection and Scalenectomy: Removes a portion of the first rib and nearby scalene muscles to eliminate the structures compressing the nerves or blood vessels.
• Venous Thrombolysis or Stenting: Used in venous TOS to dissolve existing clots or open narrowed veins that restrict circulation.
• Arterial Reconstruction: In cases of arterial TOS, damaged or narrowed arteries may be repaired or reconstructed to restore healthy blood flow.

At The Medical Group of New Jersey, our vascular surgeons use minimally invasive or hybrid surgical techniques whenever possible to ensure a safe recovery, reduced pain, and long-term symptom relief.

Ongoing Management & Long-Term Prevention

Successful recovery from TOS requires continued attention to posture, mobility, and vascular health. Long-term management helps maintain results and prevent recurrence.

• Continued Physical Therapy: Ongoing exercises improve shoulder and neck flexibility, strengthen supportive muscles, and maintain proper alignment.
• Postural Correction: Ergonomic adjustments at work and during daily activities help reduce strain on the thoracic outlet.
• Avoid Repetitive Strain: Limit overhead work, heavy lifting, or carrying heavy bags on one shoulder.
• Follow-Up Imaging: Regular ultrasound or angiographic studies ensure proper blood flow and monitor for nerve recovery after surgery.

Our vascular surgery team provides comprehensive follow-up care and rehabilitation coordination, helping patients safely return to work, exercise, and daily life with improved comfort and function.