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 in the Division of Thoracic Surgery at Massachusetts General Hospital provides expert diagnosis, treatment and support to patients with thoracic outlet syndrome (TOS).
Multidisciplinary Approach to Care
Our doctors and nurses are highly skilled in properly diagnosing and treating thoracic outlet syndrome. Because of the pioneering work that our providers have done in all areas of TOS and their experience in treating both common and complex cases, the Thoracic Outlet Syndrome Program at Mass General is a major referral center for this disorder, helping patients from all over the U.S. and globally. Our physicians and care team have a long-standing history of offering solutions for patients whose prior treatments were unsuccessful.
We work collaboratively with specialists across various disciplines at Mass General to provide expert care to our patients with the goal of achieving the best possible outcomes.
These areas include:
- Pain Management Center
- Department of Neurology
- Department of Orthopaedic Surgery
- Department of Physical and Occupational Therapy
- Fireman Vascular Center
- Interventional Radiology - Musculoskeletal (MSK)
- Physical Medicine and Rehabilitation Service
- Vascular Interventional Radiology
What Is Thoracic Outlet Syndrome (TOS)?
Thoracic outlet syndrome is a group of disorders that occur when the nerves in the brachial plexus and the blood vessels of the subclavian artery and subclavian vein are compressed, in the area between the collarbone and the first rib (the thoracic outlet).
Symptoms of Thoracic Outlet Syndrome
Thoracic outlet syndrome symptoms can include, but are not limited to, shoulder, neck, arm, hand and finger:
Types of Thoracic Outlet Syndrome
There are three types of TOS impacting different areas in the thoracic outlet:
- Arterial thoracic outlet syndrome (artery-related), a rare form of TOS that occurs when compression damages the blood vessel under the collarbone
- Neurogenic thoracic outlet syndrome (nerve-related), the most common form of TOS that results from abnormalities in the lower neck and cervical rib region compressing the brachial plexus, which is the network of nerves that govern the function of movement (motor) and feeling (sensory) in the arms and hands
- Venous thoracic outlet syndrome (vein-related), results when the major veins in the lower neck and upper chest are damaged
Though it tends not to become prevalent until teenage years or young adulthood, thoracic outlet syndrome can occur across all ages and genders. Our team treats adults, young adults and pediatric patients whose TOS developed for a variety of reasons, including athletics.
Our doctors work with specialists across Mass General Brigham to treat patients who have developed TOS due to sports-related injuries. These patients can range from the youth level to professional athletes.
Thoracic Outlet Syndrome Treatment
For many patients, our initial treatment includes a combination of physical therapy and medications, as many of our patients do not require surgery to improve their symptoms. Each treatment decision, including the decision to perform surgery, is specific to each patient.
Treatment for arterial TOS
Arterial thoracic outlet syndrome, the rarest and least common form of TOS, occurs when compression damages the blood vessel. Compression of this vessel does not equate to blood vessel damage, and detailed analysis using imaging with contrast is used to assess for damage.
Patients with arterial TOS often require surgical treatment and will meet with their surgeon to discuss their options.
Treatment for neurogenic TOS
Neurogenic thoracic outlet syndrome, a common form of TOS, results from compression of the brachial plexus nerves.
Physical therapy is the first line of treatment for many patients with neurogenic thoracic outlet syndrome. In some cases, several months of dedicated physical therapy may be required before a patient begins to notice improvement in their symptoms. Physical therapy may address:
- Poor diaphragmatic breathing
- Shortening and tightness of the scalene muscles, which are the group of muscles in the neck, located in the front on either side of the throat
- Weakness of the cervical flexor muscles (attached to the front of the spine), upper thoracic extensor muscles (attached to the back of the spine) and the muscles that provide support across joints
Ultrasound-guided injections into specific neck and chest muscles with Botox® may be used to relieve compression of nerves in some patients. Many patients whose symptoms have improved following Botox injections may be able to participate more actively in a physical therapy, which can improve the overall results.
For neurogenic TOS, a successful surgical outcome depends on a combination of an accurate diagnosis and technical precision during surgery. Determination of whether surgery is a good option to treat neurogenic TOS can be difficult will be made by the care team and the patient.
Treatment for venous TOS
Venous thoracic outlet syndrome results when the major veins in the lower neck and upper chest are damaged.
The treatment of venous TOS begins following the initial imaging. When a clot formation is identified, medication to dissolve this clot can be administered immediately. For most patients, the underlying problem is narrowing of the vein from thoracic outlet compression, so treating the clot alone is not always sufficient. If there is external vein compression, surgery may be recommended to relieve it, depending upon the severity. Patients may need to remain on medications (blood thinners) to prevent clotting for up to three months following surgery. After this timeframe, patients can return to normal activity.
When is surgery needed for thoracic outlet syndrome?
When other therapies are not successful in relieving the compression or clotting in the thoracic outlet, surgery can create additional space in the area or repair blocked or damaged arteries and veins. Patients who require surgery can be confident that they will receive specialized care from an experienced team.
Surgery for TOS may involve:
- If present, removal of an additional rib in the neck or an abnormality in the spine at the base of the neck
- Partial removal of the scalene muscles in the neck
- Removal and reconstruction of the subclavian artery (an artery leading to each arm that delivers blood to the heart)
- Removal of other tissues or scarring, which may be causing compression of the thoracic outlet area
- Removal of the first thoracic rib
The preferred surgical approach for thoracic outlet syndrome is a two-to-three-inch incision, or cut, above the collarbone at the base of the neck. Patients with venous or arterial TOS may require repair of veins and arteries, involving a second smaller incision below the collarbone.
The average stay at Mass General following surgery is one to two days.
The thoracic outlet may also become compressed in an area below the pectoralis minor muscle and shoulder. This is known as pectoralis minor syndrome. In our experience, this occurs in less than half of our patients. When this is present, it may require an additional surgical procedure performed through a two-inch incision in the armpit. This is a less extensive procedure than rib removal, and it is typically done on an outpatient basis.
How to Diagnose Thoracic Outlet Syndrome (TOS)
Making the correct diagnosis of thoracic outlet syndrome is the key to successfully treating it. The Mass General Thoracic Outlet Syndrome care team customizes a diagnostic and treatment program for each patient.
Testing for Thoracic Outlet Syndrome
Our thorough clinical assessment begins with a detailed history and physical examination during the initial office visit. Additional examinations are tailored to each patient’s needs and may include:
- A high-resolution MRI scan of the thoracic outlet to get a more complete picture of the condition
- Invasive 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
- Nerve-conduction studies to evaluate the function of the motor and sensory nerves
- Noninvasive, ultrasound-guided vascular exams
- Some patients may need additional testing and procedures, such as a specialized cardiothoracic (CT) scan and/or Ultrasound-Guided Botox® injections
How is a CT scan used to diagnose TOS?
This is a unique scan developed at Mass General that shows a detailed view of the thoracic outlet region from the top of the neck to the mid-chest area. The three-dimensional images in this scan take approximately 10 days for the radiologists to reconstruct and read, so your results will not be immediately available. The results are an important piece of information that our team will use to determine how to treat your symptoms. To receive your results, please call the office approximately 10 days after the study.
How are ultrasound-guided Botox injections used to diagnose TOS?
Botox® changed my quality of life. I am able to be in less pain and have more of my regular life functionality brought back. I felt less pain at work, could sleep better at home and feel better overall. It is a miracle treatment and I’m grateful to live in a place that offers it. It has really been so life changing for me.
Thoracic Outlet Syndrome Patient
In some cases, the muscles in the neck and shoulder area contribute to compression or irritation of the nerves and blood vessels in the thoracic outlet. One way our team evaluates patients for thoracic outlet syndrome is by injecting Botox into certain muscles in the thoracic outlet. These injections are performed by physicians in the Department of Radiology using ultrasound to precisely target specific muscles. The injections may help relieve some of the compression in the thoracic outlet.
After your appointment is scheduled, the TOS administrator will send you Botox forms via email to help keep record of your symptoms before and after the injections. Depending on your body’s reaction to Botox, it can take up to one month for you to feel any effects.
Your care team will work with you to determine the best treatment options going forward. This is always a collaboration between you and the team.
Insurance for CT scan and Botox injections
The specialized CT scan and Botox injections require prior authorizations from your insurance company, which may take up to three weeks to process. We ask that you please be patient during this time.
Once the authorizations are approved by your insurance company, the TOS administrator will call you to schedule the CT scan and Botox injections. If you have not heard from our office within one month of your initial consult, please call us to check in.
Information for New Patients
The Mass General Thoracic Outlet Syndrome team is dedicated to ensuring that patients with TOS understand their health care choices and have the necessary information to make decisions affecting their health and well-being.
Below you will find information about the patient process for those who are new to Mass General and the Division of Thoracic Surgery, worker’s compensation and the international patient process.
Request an Appointment
- Register as a new patient. Call Mass General Registration at 866-211-6588 and have your insurance information ready. You will be given a medical record number upon registration. If you are already a patient at Mass General, please update your registration information by calling Mass General Registration
- Complete our questionnaire. Please download and fill out our New Patient Questionnaire. Once the form has been submitted, our team will contact you to schedule an appointment
- Enroll in Patient Gateway: Patient Gateway provides secure online access to your health information whenever you need it. Enroll to request appointments and communicate with your care team
- Submit imaging discs and reports. Prior to your appointment, please send us any imaging discs and reports that are pertinent to your thoracic outlet syndrome and an up-to-date list of medications. Some examples of images and reports that are helpful for our team to see include:
- MRIs of the neck, chest or shoulders
- CAT or CT scans of the neck or chest
- Plain x-rays of the neck or chest
- Electromyogram (EMG) and nerve conduction studies
- Vascular studies, such as Doppler ultrasounds
- Venogram reports
- Operative notes from prior TOS surgeries
- Operative notes from prior neck or shoulder surgeries
Our mailing address is:
Dr. Dean Donahue
Massachusetts General Hospital
Thoracic Outlet Syndrome Program, Austen 7
55 Fruit Street
Boston, MA 02114
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.
International Patients with Thoracic Outlet Syndrome
The International Patient Center at Mass General is a dedicated, full-service and multilingual office that assists foreign patients seeking a consultation, a second opinion or medical treatment at Mass General. From appointment scheduling to travel arrangements, our International Patient Center staff’s sole purpose is to help make your Mass General journey as healing and stress-free as possible. International patients are encouraged to contact our International Patient Center team to learn more about starting your care journey at Mass General.
Pediatric Patients with Thoracic Outlet Syndrome
Thoracic outlet syndrome — neurogenic, venous and, in rare cases, arterial — can affect both adults and children. Our team has deep 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 considered pediatric, our team is also experienced in treating young adults with TOS between the ages of 19-25.
The symptoms of TOS in pediatric patients are frequently the same as adults. These symptoms can include:
- 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
In the initial appointment, pediatric patients will undergo a thorough evaluation process including a history and exam. Younger patients occasionally require anesthesia for imaging studies. Parents and caregivers are an important part of the child’s care team and will be involved every step of the way.
If surgery is required, pediatric patients will remain at the hospital to recover following surgery. If a combination of physical and drug therapy is the recommended treatment, pediatric patients are provided with ongoing support from the TOS surgery team at Mass General, when needed.
Children diagnosed with TOS will need to rest and refrain from any activities, including sports, that may aggravate the symptoms until they are treated and improved. It is always our goal to provide everything your child needs to recover and get back to what they love to do. Your care team will support you and your child through the treatment journey.
Billing and Insurance for Thoracic Outlet Syndrome Care
Mass General accepts most health insurance plans, including Medicare and Medicaid.
Before scheduling your hospital visit, check with your health insurance provider to see if you are covered and learn the specifics of your coverage. Insurance plans are agreements made between you and your insurer. Mass General cannot ensure that an 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 stipulated 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
As the key to treating thoracic outlet syndrome is correctly diagnosing it, our research efforts focus on improving diagnostic techniques. In collaboration with the Mass General Department of Radiology, our thoracic outlet syndrome researchers have developed unique protocols for using MRI and CT scans to diagnose TOS and have developed two new evaluation strategies that build upon the standard MRI and CT technologies. We recalibrated each technology to develop images that are more detailed than previously available, providing a more accurate diagnosis of thoracic outlet syndrome.
- 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.
- Thoracic Surgery
- Department of Surgery
- 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
- Director of Robotic Thoracic Surgery MGH Network
- Program Director of Robotic Surgical Education
Grateful for the Diagnosis: Karen's Story
Since childhood, Karen English, 50, had experienced a range of symptoms related to TOS. After nearly a year of medical consultations, she was referred to Mass General's Division of Thoracic Surgery to meet with Dean Donahue, MD, director of the TOS Program.
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).
- Patient Story
- Aug | 15 | 2015
Rachael Vaters-Carr shares her experience as a patient in the Thoracic Outlet Syndrome (TOS) Program at Massachusetts General Hospital, including the comprehensive and compassionate care she received from her team of specialists.