When Gabby Harrison, 22, tagged a runner out during a softball game, the last thing she anticipated was an injury to her elbow that would result in a four-year medical journey.
Thoracic Outlet Syndrome: Symptoms and Treatment
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About the Program
The Thoracic Outlet Syndrome Program at Massachusetts General Hospital specializes in expert evaluation and treatments for a wide range of thoracic outlet syndrome (TOS) cases, both common and complex.
Our pioneering work in thoracic outlet syndrome has established Mass General as a major referral center for this complex condition, helping patients across the United States and around the world. With a rich history of success, our care team excels in offering solutions for patients with symptoms of TOS, including those whose prior treatments were unsuccessful. We care for people of all ages, including children, young adults, adults, and older patients.
What is thoracic outlet syndrome?
The thoracic outlet is a narrow space in the body located behind the collarbone and in front of the first rib. Thoracic outlet syndrome is a group of disorders that occur when the brachial plexus nerves, subclavian vein, and/or subclavian artery are irritated or damaged due to compression (squeezing) in this area.
What are the symptoms of thoracic outlet syndrome?
Symptoms can include, but are not limited to, shoulder, neck, arm, hand and finger pain, numbness, discoloration, and swelling.
What are the types of thoracic outlet syndrome?
The three types of TOS that affect the thoracic outlet are:
- Neurogenic thoracic outlet syndrome (nerve-related) is the most common form of TOS. It can occur when the nerves of the brachial plexus, located in the lower neck and upper chest, are irritated.
- Venous thoracic outlet syndrome (vein-related) occurs when the subclavian vein becomes narrowed, irritated, and damaged. This can lead to the development of a blood clot. Symptoms of venous thoracic outlet syndrome include swelling, a feeling of tightness in the upper arm, and discoloration, often resulting in a bluish appearance of the affected limb.
- Arterial thoracic outlet syndrome (artery-related) is a very rare form of TOS that occurs when the subclavian artery is narrowed and damaged. This leads to the formation of blood clots or an aneurysm. The blood clots may break off and travel to the arm, hand, and fingers. Symptoms of arterial thoracic outlet syndrome include pain, discoloration, and a noticeable coolness in the arm, hand, and fingers.
Our team effectively treats people of all ages by giving them personalized and age-appropriate diagnoses and treatment plans. Many of our patients are high school and college athletes, as well as professional athletes. We work closely with our patients to achieve their goals of returning to sports and work and improving their quality of life.
Our minimally invasive diagnostic tests and treatments often provide alternatives care options to surgery. When surgery is recommended, we provide the necessary information for patients to make informed decisions about their health care. Our expert team is available to answer any questions.
How is TOS diagnosed?
Correctly diagnosing thoracic outlet syndrome is the key to successfully treating it. We customize a diagnostic and treatment plan for each patient.
Our thorough clinical assessment begins at the initial office visit with a detailed physical examination and discussion about their medical history. Examinations and treatments are tailored to each patient’s needs and may include:
- Ultrasound-guided botulinum toxin A injections.
- A unique CT angiogram (CTA) scan designed by Mass General TOS specialists.
- A high-resolution MRI scan of the thoracic outlet to get a more complete picture of the condition.
- Vascular studies:
- Arteriogram, an X-ray that uses contrast dye to visualize the arteries.
- Venogram, an X-ray that uses contrast dye to visualize the veins.
- Magnetic resonance angiography (MRA), a noninvasive exam of the blood vessels.
- MRI of the cervical spine or shoulder.
- Studies to evaluate the function of the motor and sensory nerves.
- Noninvasive, ultrasound-guided vascular exams.
Our CT angiogram and ultrasound-guided muscle injections using botulinum toxin A are scheduled once your physician has ordered them. They may require prior authorization from your insurance. During this process, we may need to communicate with you.
About the CT Scan
This is a specially configured CT scan created by radiology experts at Mass General. It provides a detailed view of the thoracic outlet area from the top of the neck to the middle of the chest. It can take up to five days to develop and recreate these images in 3-D. Once the radiologist has interpreted the scan results, you will be contacted by our office to discuss them.
About the Ultrasound-guided Muscle Injections
Sometimes, the neck and shoulder muscles compress and irritate the nerves and blood vessels in the thoracic outlet. One way our team checks for and treats thoracic outlet syndrome is by injecting botulinum toxin A into these muscles. These injections are done by radiologists using ultrasound imaging to precisely target specific muscles. The injections may help relieve some of the compression in the thoracic outlet and improve symptoms. We use a symptom tracker to determine improvements.
Your care team will work with you to decide the best next steps in your care plan.
How is thoracic outlet syndrome treated?
Treatment for Neurogenic TOS
Ultrasound-guided injections with botulinum toxin A may help relieve nerve compression for patients with neurogenic thoracic outlet syndrome. Many patients whose symptoms have improved following muscle injections may be able to participate more actively in physical therapy, which can improve the overall results. If symptoms do not improve, surgery will be discussed.
Treatment for Venous TOS
Doctors can find venous TOS in two ways: a duplex ultrasound of the upper body, like the arm or shoulder, or with a test called an arteriogram or venogram. Both of these tests help doctors see if there is a clot in the blood vessels.
When a clot is found, medication is used to dissolve it. However, for most patients, just treating the clot is not always enough. The main problem is often the veins that were narrowed by the compression in the thoracic outlet region. If there is pressure on the vein from the outside, surgery from a highly trained TOS specialist may be recommended to fix it. Patients may need to continue to use blood-thinning medication to prevent blood clotting for up to three months following surgery.
Treatment for Arterial TOS
Arterial thoracic outlet syndrome, which is the rarest type of TOS, occurs when pressure harms the blood vessel. Just because there's pressure doesn't mean the blood vessel is damaged, so doctors use special imaging with contrast to carefully check for damage, such as a duplex ultrasound of the upper body.
Patients with arterial TOS often require surgery. They will meet with a highly trained TOS specialist to discuss their options.
Surgery to Treat TOS
When non-surgical treatment does not correct the compression (pressure) or clotting in the thoracic outlet area of the body, surgery can relieve the pressure by creating additional space and repairing damaged arteries and veins. Patients who require surgery can be confident that they will receive specialized care from an experienced team. A successful surgical outcome depends on an accurate diagnosis and expert-level surgical care. Your care team will work with you to decide if surgery is a good option for you.
Surgery for thoracic outlet syndrome may include:
- Resection of the first rib and the anterior and middle scalene. This surgery is commonly performed to treat neurogenic and venous TOS. Any unhealthy tissue or scarring in the area will be removed. The brachial plexus, subclavian vein, subclavian artery will be protected. To do this, the surgeon will make a small incision, or cut, just behind and parallel to the collarbone. Typically, patients will need to stay at the hospital for two nights after surgery so that our team can monitor their pain levels and vital signs.
- Resection of the pectoralis minor muscles (pec minor muscles). This surgery is specifically used to treat neurogenic TOS in the pec minor muscles, which are the smaller, deeper muscles of the chest. To do this, the surgeon will make a small cut in the armpit, release the muscle and move it away from nerves in this space causing these symptoms. This is an outpatient procedure, which means that patients can return home on the same day as the surgery. The patient will need a ride home.
Information for Pediatric/Young Adult Patients
Thoracic outlet syndrome—neurogenic, venous, and arterial—can affect children. Our team has significant experience in caring for patients of all ages, including those whose prior TOS treatments were unsuccessful. For pediatric patients with TOS, we most commonly see adolescents between the ages of 10-18, typically with neurogenic TOS or venous TOS. Though not technically considered pediatric, our team is also experienced in treating young adults with TOS between the ages of 19-25.
The symptoms of TOS in children are often the same as adults, such as:
- Pain in the arm, shoulder, neck and/or chest.
- Numbness or tingling in the arm and/or hand.
- Weakness or fatigue in the arm and/or hand.
Parents and caregivers are an important part of the child’s care team and will be involved every step of the way.
In the initial appointment, your child will undergo an age-appropriate evaluation, which will include a physical exam and a conversation about their medical history. Every effort is made to diagnose and treat this syndrome minimally invasively. Tests and treatments will be thoroughly explained, and questions are encouraged. Our care team will follow your child’s progress throughout this process. Younger patients occasionally require anesthesia when receiving tests to diagnose their condition.
Children diagnosed with TOS may need to take a break from activities that may aggravate their symptoms, such as sports. It is always our goal to provide your child with everything they need to recover and get back to what they love to do. Your care team will support you and your child through the treatment journey.
A combination of physical therapy and minimally invasive ultrasound-guided injections may be recommended. Your child will be provided with ongoing support from the entire care team. If surgery is recommended, your child may have to stay at the hospital to recover after surgery. Specialized care is provided within the hospital.Enroll your child in Patient Gateway
For Adult Patients
We are dedicated to making sure that patients with TOS understand their options and have all the information they need to feel confident in their health care decisions.
How to Request an Appointment
- Register as a new patient: Call Mass General Registration at 866-211-6588. Please have your insurance information ready for this call. During this call, you will receive a medical record number. If you are already a patient at Mass General, please update your registration information by calling Mass General Registration.
- Complete our questionnaire: Once you have registered, please complete our online New Patient Questionnaire. Once the form has been submitted, our team will contact you to schedule an appointment.
- For international patients who reside outside of the U.S.: Please contact the Mass General International Patient Center team to start your thoracic outlet syndrome care journey at Mass General.
Worker's Compensation Case
If you have worker's compensation insurance, please inform our staff immediately.
- Contact your adjuster and request a prior authorization for a new patient consultation. Dr. Donahue’s National Provider Identifier (NPI) is 1548236052.
- After you have obtained an authorization, you must provide our staff with the following information:
- Your claim number.
- The name of your company’s worker’s compensation insurance.
- Your employer’s name and telephone number.
- Your adjuster’s name and telephone number.
The Mass General billing department will then contact your adjuster to agree on payment for this visit. Please inform our staff if the adjuster requires a request from our office. Once this information is processed, you will be scheduled for a new patient appointment.
Billing and Insurance
Mass General accepts most health insurance plans, including Medicare and Medicaid.
Before scheduling your first visit, check with your health insurance provider to learn about your coverage. Mass General cannot guarantee that your insurance provider will pay for your care. It is your responsibility to understand what types of coverage your health insurance provides and to be sure that you meet all requirements set by your specific plan.
Your health insurance provider will be able to inform you of your level of coverage and what, if any, copayments, coinsurances and deductibles will be your responsibility. If you do not contact your provider, you can ultimately be responsible for all or a large portion of your bill.
Thoracic Outlet Syndrome Research Focused on Diagnostic Techniques and Surgical Outcomes
The key to treating thoracic outlet syndrome is correctly diagnosing it. Our research focuses on improving diagnostic techniques. In collaboration with the Mass General Department of Radiology, our researchers developed unique ways for using MRI and CT scans to diagnose TOS, including two new evaluation strategies. We adjusted each technology to develop images that are more detailed than what was previously available, providing a more accurate diagnosis of thoracic outlet syndrome.
View Select Publications
- Panda N, Hurd J, Madsen J, Anderson JN, Yang ME, Sulit J, Kuhan S, Potter AL, Colson YL, Yang CJ, Donahue DM. Efficacy and Safety of Supraclavicular Thoracic Outlet Decompression. Ann Surg. 2023 Sep 1;278(3):417-425. doi: 10.1097/SLA.0000000000005957
- Donahue D, Auchincloss H. Thoracic Outlet Syndrome. Thoracic Surgery Clinics. 2021 Feb 1. doi: 10.1016/S1547-4127(20)30097-9
- Illig K, Thompson R, Freischlag J, Donahue D, Jordan S, Lum Y, Gelabert H. Thoracic Outlet Syndrome. Springer International Publishing. 2021. doi: 10.1007/978-3-030-55073-8
- Donahue D, Godoy I, Gupta R, Donahue J, Torriani. Sonographically Guided Botulinum Toxin Injections in Patients with Neurogenic Thoracic Outlet Syndrome: Correlation with Surgical Outcomes. Skeletal Radiol. 2019 Dec 5. doi: 10.1007/s00256-019-03331-9. PMID: 31807876
Our doctors are highly skilled in properly diagnosing and treating thoracic outlet syndrome.
- Director of Thoracic Outlet Syndrome Program, Division of Thoracic Surgery
- Assistant Team Physician for the New England Patriots
- Consultant for the Boston Bruins, and Boston Red Sox
Canadian Sydney Gill’s Journey with Thoracic Outlet Syndrome
Before her experience with thoracic outlet syndrome, Sydney Gill was active with an exceptional passion for horseback riding. Sydney’s life took a turn when she started experiencing pain in her right arm. As she got older, the pain continued to grow and disrupt her life, leading Sydney and her parents to seek medical care.
It Takes a Family: The Smart Family’s Experience with Thoracic Outlet Syndrome
Kerri Smart and three of her children were gradually diagnosed with thoracic outlet syndrome over a decade and treated at Massachusetts General Hospital. Kerri describes the family’s journey with this elusive disorder and the steps they took to pursue the best possible treatment for TOS.
Related News and Articles
- Patient Story
- Oct | 21 | 2019
Kerri Smart describes her family's journey with Thoracic Outlet Syndrome (TOS) and their treatment experience with Dr. Dean Donahue, director of the TOS Program in the Division of Thoracic Surgery at Massachusetts General Hospital.
- Patient Story
- Apr | 22 | 2019
In 2017, Karen English began experiencing pain related to Thoracic Outlet Syndrome (TOS). After nearly a year of medical consultations, she was referred to the Division of Thoracic Surgery to meet with Dean Donahue, MD, the director of the TOS Program.
- Patient Story
- Jun | 1 | 2018
In 2015, Julia came to Massachusetts General Hospital to see Dr. Dean Donahue and receive treatment for thoracic outlet syndrome (TOS).
If you would like to request an appointment with or refer a patient to the Thoracic Outlet Syndrome Program, please use the following contact information.