ChiroACCESS Clinical Review

Thoracic Outlet Syndrome: Therapy

This information is provided to you for use in conjunction with your clinical judgment and the specific needs of the patient.

Lead Author(s): 

Dwain M. Daniel, D.C.


How this evidence was rated:

Strength of Recommendation Taxonomy (SORT)

Published on

August 25, 2010

Text Size:     
As discussed in the thoracic outlet syndrome (TOS) prevention and diagnosis monographs, TOS is a very controversial topic in the medical literature.  Disagreements over methods to arrive at a diagnosis, whether it is under-diagnosed or over-diagnosed or even exists at all have resulted in a gross lack of evidence related to treatment.  A recent Cochrane Review (1) could only locate 1 randomized clinical trial (RCT) on treatment.  That study was small, highly suspect of bias and compared 2 surgical protocols (2).  For the practitioner who desires to practice in a non-evidence based environment, TOS is the perfect diagnosis.  Outside of a handful of case series and case reports, virtually all the evidence on treatment is based on expert opinion or is anecdotal.

Most studies combine a variety of approaches in treatment.  Most include strengthening, stretching, postural training, manipulation/mobilization and breathing exercises.  The reader should note although the different treatment protocols have been broken down into separate groups, almost all protocols include a mixture of interventions.  Success rates vary with the study but generally 62% to 88% of patients experience improvements or are satisfied with treatment (3;4).  Several authors have stated early intervention is important to success in the treatment of TOS as delayed treatment may lead to intraneural scarring and chronicity (5;6).

Most studies recommend 10 to 12 treatment sessions over a month’s time with most protocols recommending long term home exercise programs (7).  Improvement should become apparent within the first 6 to 8 treatments or it is unlikely improvement will occur according to Ingesson et al. (8).   

A very interesting study was published in 2001 in the Journal of Vascular Surgery by Landry et al.  They found there were no statistical differences in outcomes between 79 disputed TOS patients who were treated with either conservative care or surgical care at an average follow-up of 4.2 years.  The authors of this study concluded that “it is essential that proponents of surgical treatment of disputed TOS prove that surgical therapy is superior to conservative management” and until then “we will continue to favor conservative therapy” (9).

Up to 95% of TOS cases fall into the neurological TOS category (true and disputed) (10).  Although it is uncommon, venous TOS can result in a potentially life threatening upper extremity venous thrombosis.  The physician must have the knowledge and skill to recognize the different forms of TOS in order to minimize risk to his/her patient.  Most cases of TOS can be initially treated with conservative means.  Patients that do not respond or worsen may, due to the severity of symptoms, have no other option other than surgical intervention.

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Povlsen B, Belzberg A, Hansson T, Dorsi M. Treatment for thoracic outlet syndrome. Cochrane Database Syst Rev 2010;(1):CD007218.

 [ Medline ID 20091624 ]


Sheth RN, Campbell JN. Surgical treatment of thoracic outlet syndrome: a randomized trial comparing two operations. J Neurosurg Spine 2005 Nov;3(5):355-63.

 [ Medline ID 11525208 ]


Hanif S, Tassadaq N, Rathore MF, Rashid P, Ahmed N, Niazi F. Role of therapeutic exercises in neurogenic thoracic outlet syndrome. J Ayub Med Coll Abbottabad 2007 Oct;19(4):85-8.

 [ Medline ID 18693607 ]


Lindgren KA. Conservative treatment of thoracic outlet syndrome: a 2-year follow-up. Arch Phys Med Rehabil 1997 Apr;78(4):373-8.

 [ Medline ID 9111456 ]


Bayford T. Thoracic Outlet syndrome: An overview of diagnosis and treatment. SportEX medicine 2009;44:13-7.


Aligne C, Barral X. Rehabilitation of patients with thoracic outlet syndrome. Ann Vasc Surg 1992 Jul;6(4):381-9.

 [ Medline ID 1390029 ]


Vanti C, Natalini L, Romeo A, Tosarelli D, Pillastrini P. Conservative treatment of thoracic outlet syndrome. A review of the literature. Eura Medicophys 2007 Mar;43(1):55-70.

 [ Medline ID 16955064 ]


Ingesson EEU, Ribbe EB, Norgren LEH. Thoracic outlet syndrome - evaluation of a physiotherapeutical method. Manual Medicine 1986;2:86-8.

 [ MANTIS ID 15743 ]


Landry GJ, Moneta GL, Taylor LM, Jr., Edwards JM, Porter JM. Long-term functional outcome of neurogenic thoracic outlet syndrome in surgically and conservatively treated patients. J Vasc Surg 2001 Feb;33(2):312-7.

 [ Medline ID 11174783 ]


Nichols AW. Diagnosis and management of thoracic outlet syndrome. Curr Sports Med Rep 2009 Sep;8(5):240-9.

 [ Medline ID 19741351 ]


Novak CB, Collins ED, Mackinnon SE. Outcome following conservative management of thoracic outlet syndrome. J Hand Surg Am 1995 Jul;20(4):542-8.

 [ Medline ID 7594276 ]


Liebenson CS. Thoracic outlet syndrome: diagnosis and conservative management. J Manipulative Physiol Ther 1988 Dec;11(6):493-9.

 [ Medline ID 3075651 ]


Rayan GM. Thoracic outlet syndrome. J Shoulder Elbow Surg 1998 Jul;7(4):440-51.

 [ Medline ID 9752662 ]


Ghoussoub K, Tabet G, Faraj C, Sleilaty G, Roukoz S, Jebara V. [Predictive factors of long-term functional rehabilitation in thoracic outlet syndromes: 85 patients]. Ann Readapt Med Phys 2007 Apr;50(3):134-9.

 [ Medline ID 17320996 ]


Goudreau J, Pepin J, Dubois S, Boyer L, Larue C, Legault A. A second generation of the competency-based approach to nursing education. Int J Nurs Educ Scholarsh 2009;6(1):Article15.


Sions JM, Manal TJ. Thoracic manipulations may show promise in the conservative management of thoracic outlet syndrome. J Orthop Sports Phys Ther 2009;39(1):A63-A64.


Grice A. Scalenus anticus syndrome: diagnosis and chiropractic adjustive procedure. J of the Canadian Chiropractic Association 1977;March 1977:15-9.

 [ MANTIS ID 6622 ]


Dobrusin R. An osteopathic approach to conservative management of thoracic outlet syndromes. J Am Osteopath Assoc 1989 Aug;89(8):1046-7.

 [ Medline ID 2670857 ]


Beckett RH, Lundy KC. Consider chiropractic management of thoracic outlet syndrome. Nurse Pract 1992 Jul;17(7):9, 13.

 [ Medline ID 1495600 ]


Knutson GA. Thermal asymmetry of the upper extremity in scalenus anticus syndrome, leg-length inequality and response to chiropractic adjustment. J Manipulative Physiol Ther 1997 Sep;20(7):476-81.

 [ Medline ID 9310903 ]


Wood VE, Biondi J. Double-crush nerve compression in thoracic-outlet syndrome. J Bone Joint Surg Am 1990 Jan;72(1):85-7.

 [ Medline ID 2295677 ]


Narakas AO. The role of thoracic outlet syndrome in the double crush syndrome. Ann Chir Main Memb Super 1990;9(5):331-40.

 [ Medline ID 1705129 ]


Walsh MT. Therapist management of thoracic outlet syndrome. J Hand Ther 1994 Apr;7(2):131-44.

 [ Medline ID 8038876 ]


Ault J, Suutala K. Thoracic Outlet Syndrome. J Manual Manipulative Therapy 1998;6(3):118-29.

 [ MANTIS ID 40383 ]


Nakatsuchi Y, Saitoh S, Hosaka M, Matsuda S. Conservative treatment of thoracic outlet syndrome using an orthosis. J Hand Surg Br 1995 Feb;20(1):34-9.

 [ Medline ID 7759931 ]


Wehbe MA, Schlegel JM. Nerve gliding exercises for thoracic outlet syndrome. Hand Clin 2004 Feb;20(1):51-5, vi.

 [ Medline ID 15005384 ]


Crosby CA, Wehbe MA. Conservative treatment for thoracic outlet syndrome. Hand Clin 2004 Feb;20(1):43-9, vi.

 [ Medline ID 15005383 ]


Ko GD, Nowacki NB, Arseneau L, Eitel M, Hum A. Omega-3 fatty acids for neuropathic pain: case series. Clin J Pain 2010 Feb;26(2):168-72.

 [ Medline ID 20090445 ]


Degeorges R, Reynaud C, Becquemin JP. Thoracic outlet syndrome surgery: long-term functional results. Ann Vasc Surg 2004 Sep;18(5):558-65.

 [ Medline ID 15534735 ]


Franklin GM, Fulton-Kehoe D, Bradley C, Smith-Weller T. Outcome of surgery for thoracic outlet syndrome in Washington state workers' compensation. Neurology 2000 Mar 28;54(6):1252-7.

 [ Medline ID 10746594 ]


Jamieson WG, Chinnick B. Thoracic outlet syndrome: fact or fancy? A review of 409 consecutive patients who underwent operation. Can J Surg 1996 Aug;39(4):321-6.

 [ Medline ID 8697324 ]


Woods WW. Thoracic outlet syndrome. West J Med 1978 Jan;128(1):9-12.

 [ Medline ID 625979 ]


Atasoy E. Thoracic outlet compression syndrome. Orthop Clin North Am 1996 Apr;27(2):265-303.

 [ Medline ID 8614579 ]