eMedicine Specialties > Physical Medicine and Rehabilitation > Plexopathy
Thoracic Outlet Syndrome: Treatment & Medication
Updated: Jul 1, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Rehabilitation Program
Physical Therapy
Modalities with deep heat (eg, therapeutic ultrasound), electric stimulation, superficial heat (eg, Hydrocollator packs), stretching exercises, postural correction exercises, and strength and endurance exercises are all useful or necessary components of thoracic outlet syndrome treatment. Ultrasound is the preferred modality as it is capable of heating deep muscular and soft-tissue structures, which is essential to increase elasticity and facilitate effective stretching and/or manipulation, especially for the scalenes (see first image below and Image 4) and pectoralis minor muscles (see second image below and Image 5). Ideally, ultrasound should be performed immediately before the stretching or manual treatment, since the deep tissues cool (from 41-42°C back to 37°C) within 20-30 minutes.
Stretching technique for the pectoralis minor muscle. Left: The patient has taken the slack out of the muscle. Center: He then rotates the body away from the side being stretched, increasing traction. Right: Maximum rotation and stretch effect are achieved slowly. Image courtesy of The Journal of the American Osteopathic Association
Sagittal plane posture of patient with thoracic outlet syndrome before (left) and after (right) treatment. Notice the release of the pelvis that occurred with the reduction in hyperlordosis, which allowed the shoulder girdle to drop back and open the thoracic outlet. Image courtesy of The Journal of the American Osteopathic Association
Mobilization and manipulation procedures (often performed by an osteopathic physician) usually are indicated and necessary to release tight contracted/restricted vertebral segments and soft tissue (myofascial) regions, especially the anterior/middle scalenes (see first image below and Image 6) and pectoralis minor muscle (see second image below and Image 7) entrapment sites.
Spray and stretch with a vapo-coolant spray is an effective adjunct to the other modalities mentioned here. Note that the research-based scientific evidence for these modalities is limited.
Myofascial release technique for the scalene muscles. Left: Side-lying approach. Right/top: Supine approach with pillow under thorax. Right/bottom: Supine approach with head extended off the table and supported by the operator's knees. Image courtesy of The Journal of the American Osteopathic Association
Stretching technique for the scalene (anterior and middle) muscles. Left: The arm on the side to be stretched is secured down (hooked under the seat) to allow more control and effective stretch. Center: The opposite hand wraps partially around the head for good control to assist with the stretch. Right: After proceeding as far as tolerated, the patient leans the whole trunk away from the side being stretched, creating additional traction (downward) on the muscle by the arm that is secured. Image courtesy of The Journal of the American Osteopathic Association
Occupational Therapy
Work simplification and back protection techniques often are helpful. These educational tools are available from the occupational therapist, as well as from the physical therapist.
Medical Issues/Complications
Essentially, there are no randomized, controlled trials demonstrating that specific treatment modalities are more effective than placebo. In general, research into thoracic outlet syndrome (TOS) and its treatment can be difficult for the following several reasons:
- If the etiology of the problem cannot be agreed upon, then focusing treatment becomes difficult.
- The proposed areas of pathophysiology and diffuse nature of symptoms are not easily amenable to surgery or other treatment modalities.
- Many patients with TOS have coexistent chronic pain syndrome with disability and depression.
Treatment of the chronic pain and disability can be a much more complex problem and involves employment of multiple disciplines with consideration for a biopsychosocial model of treatment. Patients with nonspecific TOS and suggestion of chronic pain syndrome with disability may do best with chronic pain treatment and treatment of psychological issues.
Additional issues of concern include the following:
- More advanced/severe TOS can result in functional loss of the upper extremity.
- Concomitant cervical degenerative joint/disc disease limits the neck range of motion (ROM) that is necessary to stretch associated soft tissue restriction and limit conservative treatment options (eg, physical therapy).
- Shoulder arthritis/bursitis/tendonitis can interfere with stretching of the pectoral muscles and limit the effectiveness of conservative therapy approaches.
- Manual treatment to the pectoral/chest wall muscles must be sensitive to overlying breast tissue and implants (prostheses) in female patients.
- Manual treatment must consider the proximity of the involved muscles to the brachial plexus. Vigorous stretching or manipulation of these structures may not be tolerated well and can aggravate symptoms. The phrenic nerve and accessory phrenic nerve overlie the anterior scalene muscle and also must be considered.
- Scalene nerve block has been used as a treatment and as a diagnostic test; however, this procedure is dangerous due to the close proximity of the brachial plexus to the scalenes (see Procedures for more details).
Surgical Intervention
- First rib resection has been advocated by many surgeons to treat thoracic outlet syndrome. Many also use scalenectomy, in combination with rib removal or as a second procedure, if the initial surgery is ineffective.11 Resection of accessory ribs and fibrous bands should be performed, especially if observed to be tethering the plexus.
- In cases where clavicular fracture is responsible for plexus compression, removal of hyperabundant callus may be necessary. Occasionally, resection of associated musculature is required, including the subclavius and infraclavicular soft tissue. Reduction of clavicular nonunion fragments and internal fixation (with pins) may be indicated.
- Complications from surgical treatment have been devastating, especially brachial plexopathy (eg, injury to the long thoracic nerve with scapular winging). Generally, surgery is used as a last resort after a prolonged trial (ie, months) of conservative treatment.
- Some authors have advocated breast reduction in extreme cases, where very large breasts obviously are adding uncontrollable weight loads to the anterior chest wall.
Consultations
- Physical medicine and rehabilitation specialists (physiatrists) are generally familiar with thoracic outlet syndrome (TOS) and conservative treatment options. They usually are best positioned to implement and direct the therapy program, and they also have been trained extensively in electrodiagnosis, which may provide the best objective evidence for the disorder in its true neurogenic form. Neurologists are also capable diagnosticians for TOS. (See image below and Image 8.)
Algorithm for the treatment of nonprogressive thoracic outlet syndrome (TOS). Anti-inflammatory medication, muscle relaxants, and activity modifications all are used as indicated and tolerated in all cases. Values for very severe TOS are greater than those for severe TOS, and the patient probably should be referred for surgical evaluation.
- Some internists or cardiologists who specialize in peripheral cardiovascular disorders may be able to help with the diagnostic workup, especially when vascular or autonomic symptoms predominate. They also may be familiar with the use of medications to help control symptoms (eg, vasodilators, calcium-channel blockers). Rheumatologists can assist in ruling out connective tissue disorders or autoimmune diseases that might be associated with TOS or might be complicating the clinical picture.
- Thoracic and cardiovascular surgeons are the most likely surgical specialists to treat TOS; however, not all of these surgeons have an active interest or willingness to deal with the disorder. Occasionally, neurosurgeons can offer operative treatment for TOS patients.
- Plastic surgeons (or some general surgeons) may be used for reduction mammoplasty, when indicated.
- Anesthesiologists may be needed to perform diagnostic and therapeutic blocks.
- Orthopedists may be required to diagnose and treat concomitant shoulder joint pathology and other related disorders, such as complications from clavicular fractures.
Other Treatment
- Osteopathic manipulation has been shown to be highly effective in treating thoracic outlet syndrome, especially in combination with vigorous stretching exercise. The most useful procedures involve a vigorous myofascial release to the scalenes and pectoral muscles (especially pectoralis minor). These techniques are applied most easily immediately following modality treatment with ultrasound, which heats the deep muscular structures and renders them more elastic and responsive to manipulation and stretching.
- All other areas of restriction or dysfunction also should be addressed and treated with manipulation, since even pelvic/sacral abnormality can influence the thoracic outlet. This abnormality is most obvious with unleveling, or a sacral tilt that shifts the thorax and places skeletal and muscular strain on the shoulder girdle region. Some orthoses, such as a heel lift, may be a useful adjunct in such cases.
- Injection of trigger points in associated muscular structures may be indicated and necessary. An injection of deep muscular structures, such as a scalene block, however, is dangerous (close proximity to brachial plexus) and should be avoided or performed by an anesthesiologist. Even so, a study by Torriani et al of diagnostic injections indicated that anesthetic can be safely injected into the anterior scalene muscle with ultrasonographic guidance (see Procedures).10
Medication
Muscle relaxants (eg, Flexeril, Soma, Robaxin, Parafon forte) are options to help decrease muscle tightness and restriction, thereby facilitating conservative treatment with exercise and manipulation. Tizanidine (Zanaflex) is being used for muscle tension cephalgia and may hold promise for thoracic outlet syndrome (TOS).
Anti-inflammatory medication can decrease irritability and pain and enhance conservative treatment results. Long-acting preparations often are most effective and are tolerated better (eg, Relafen, Daypro, Celebrex). Voltaren or Arthrotec and Celebrex are relatively long-acting alternatives that are less irritating to the GI tract than Naproxen or Clinoril.
Some internists or rheumatologists may recommend vasodilators and calcium-channel blockers, if significant vascular and vasoconstrictive involvement exists. These agents are not primary drugs of choice for TOS but should be considered ancillary or secondary options to be considered and integrated into treatment as clinically indicated.
Muscle relaxants
Used to relax and loosen the tight musculature involved in TOS, facilitate stretching and manipulation treatments, relieve pain, and assist with sleep.
Cyclobenzaprine (Flexeril)
Muscle relaxer of moderate duration, centrally acting, related to TCAs chemically. This drug often produces a "hangover" effect, which can be minimized by taking the nighttime dose 2-3 h before going to sleep.
Adult
10 mg tid PO; 20-30 mg before hs may be necessary, and taking only 5 mg (half a tab) bid/tid (in addition to hs dose) may be less sedating and better tolerated during daytime; not to exceed 60 mg/d
Pediatric
Not established
Coadministration with MAO inhibitors and TCAs may increase toxicity; cyclobenzaprine may have additive effect when used concurrently with anticholinergics; effects of alcohol, CNS depressants, and barbiturates may be enhanced with cyclobenzaprine; may block antihypertensive action of some medications, like guanethidine; may enhance seizure risk in patients taking tramadol (Ultram); atropinelike actions
Documented hypersensitivity; have taken MAO inhibitors within the last 14 d; cardiac conditions; hyperthyroidism
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in patients with angle-closure glaucoma and urinary hesitance; use of anticholinergic medications; avoid operating machinery
Carisoprodol (Soma)
Short-acting medication that works at spinal cord level.
Adult
350 mg PO tid/qid
Pediatric
Not established
Increases toxicity of alcohol, CNS depressants, MAO inhibitors, clindamycin, phenothiazines
Documented hypersensitivity; acute intermittent porphyria
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in renal and hepatic impairment; psychologic dependence, abuse, and possible withdrawal symptoms may occur
Methocarbamol (Robaxin)
Short-acting muscle relaxer that probably works through CNS mechanisms.
Adult
750-1500 mg PO tid/qid; not to exceed 8 g/d
Pediatric
Not established
May cause color interference with screening tests for 5-HIAA and VMA
Documented hypersensitivity; renal impairment
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in patients with history of seizures
Chlorzoxazone (Flexaphen, Paraflex, Parafon Forte)
Short-acting muscle relaxer, working via central pathways (spinal cord and subcortical).
Adult
250-500 mg PO tid/qid up to 750 mg PO tid/qid
Pediatric
20 mg/kg/d or 600 mg/m2/d PO tid/qid
Increases toxicity of CNS depressants
Documented hypersensitivity; hepatic impairment
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Rare idiosyncratic and unpredictable hepatocellular damage, possibly fatal; may cause tachycardia and tightness in chest
Nonsteroidal anti-inflammatory drugs
Have analgesic, anti-inflammatory, and antipyretic activities. Their mechanism of action is not known, but may inhibit cyclo-oxygenase activity and prostaglandin synthesis. Other mechanisms may exist as well, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell-membrane functions.
Nabumetone (Relafen)
Nonacidic NSAID rapidly metabolized after absorption to a major active metabolite that inhibits cyclo-oxygenase enzyme, which in turn inhibits pain and inflammation.
Adult
1-2 g PO qd
Pediatric
Not established
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; active peptic ulceration, hepatic impairment
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Category D in third trimester of pregnancy; elderly patients may require lower doses; caution in hepatic and renal impairment
Oxaprozin (Daypro)
For relief of mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing activity of cyclo-oxygenase, which is responsible for prostaglandin synthesis.
Adult
600-1200 mg PO qd; not to exceed 1800 mg/d
Pediatric
Not established
Increases toxicity of anticoagulants, aspirin, and diuretics
Documented hypersensitivity, history of GI disease, cardiac failure, renal or hepatic dysfunction, bleeding disorders
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
May cause dizziness, indigestion, nausea, and abdominal cramps
Celecoxib (Celebrex)
Inhibits primarily COX-2. COX-2 is considered an inducible isoenzyme, induced during pain and inflammatory stimuli. Inhibition of COX-1 may contribute to NSAID GI toxicity. At therapeutic concentrations, COX-1 isoenzyme is not inhibited thus GI toxicity may be decreased. Seek lowest dose of celecoxib for each patient.
Adult
200 mg/d PO qd; alternatively, 100 mg PO bid
Pediatric
Not established
Coadministration with fluconazole may cause increase in celecoxib plasma concentrations because of inhibition of celecoxib metabolism; coadministration of celecoxib with rifampin may decrease celecoxib plasma concentrations
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Category D in third trimester of pregnancy; may cause fluid retention and peripheral edema; caution in compromised cardiac function, hypertension, conditions predisposing to fluid retention; severe heart failure and hyponatremia, because may deteriorate circulatory hemodynamics; NSAIDs may mask usual signs of infection; caution in the presence of existing controlled infections; evaluate symptoms and signs suggesting liver dysfunction, or in abnormal liver lab results
Naproxen (Anaprox, Naprelan, Naprosyn)
For relief of mild to moderate pain; inhibits inflammatory reactions and pain by decreasing activity of cyclo-oxygenase, which results in a decrease of prostaglandin synthesis.
Adult
500 mg PO followed by 250 mg q6-8h; not to exceed 1.25 g/d
Pediatric
<2 years: Not established
>2 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Category D in third trimester of pregnancy; acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug
Sulindac (Clinoril)
Decreases activity of cyclo-oxygenase and in turn inhibits prostaglandin synthesis. Results in a decreased formation of inflammatory mediators.
Adult
150-200 mg PO bid or 300-400 qd; not to exceed 400 mg/d
Pediatric
Not established
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; patients whom aspirin, iodides or other NSAIDs induce hypersensitivity; gastrointestinal (GI) bleed, and renal insufficiency
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Category D in third trimester of pregnancy; acute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal papillary necrosis may occur; increases risk of acute renal failure in preexisting renal disease or compromised renal perfusion; low white blood cell counts occur rarely, and usually return to normal in ongoing therapy; discontinuation of therapy may be necessary if there is persistent leukopenia, granulocytopenia, or thrombocytopenia; caution in anticoagulation defects or are receiving anticoagulant therapy
Diclofenac (Voltaren, Cataflam)
Inhibits prostaglandin synthesis by decreasing activity of enzyme cyclo-oxygenase which in turn decreases formation of prostaglandin precursors.
Adult
25 mg PO bid/tid
If well tolerated, increase by 25 or 50 mg at weekly intervals until satisfactory response is obtained or total daily dose of 150-200 mg is reached
Higher doses generally do not increase effectiveness
Pediatric
<12 years: Not established
>12 years: Administer as in adults
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding) may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; do not administer into CNS or give to patients with peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, and those at high risk of bleeding
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Category D in third trimester of pregnancy; acute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal papillary necrosis may occur; increases risk of acute renal failure in patients with preexisting renal disease or compromised renal perfusion; low white blood cell counts occur rarely, and usually return to normal in ongoing therapy; discontinuation of therapy may be necessary if there is persistent leukopenia, granulocytopenia, or thrombocytopenia
Diclofenac and misoprostol (Arthrotec)
Inhibits prostaglandin synthesis by decreasing activity of enzyme cyclo-oxygenase which in turn decreases formation of prostaglandin precursors.
Misoprostol is prostaglandin analog that protects lining of GI tract by replacing depleted prostaglandin E1 in prostaglandin-inhibiting therapies.
Adult
1 tab PO bid/tid
Pediatric
Not established
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding) may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
Acute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal papillary necrosis may occur; increases risk of acute renal failure in patients with preexisting renal disease or compromised renal perfusion; low white blood cell counts occur rarely, and usually return to normal in ongoing therapy; discontinuation of therapy may be necessary if there is persistent leukopenia, granulocytopenia, or thrombocytopenia
More on Thoracic Outlet Syndrome |
| Overview: Thoracic Outlet Syndrome |
| Differential Diagnoses & Workup: Thoracic Outlet Syndrome |
 Treatment & Medication: Thoracic Outlet Syndrome |
| Follow-up: Thoracic Outlet Syndrome |
| Multimedia: Thoracic Outlet Syndrome |
| References |
| Further Reading |
| « Previous Page | Next Page » |
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Further Reading
Related eMedicine topics: Brachial Plexus Injuries, Traumatic
Brachial Plexus Injury
Brachial Plexus, MRI
Subclavian Artery Thrombosis
Thoracic Outlet Obstruction
Thoracic Outlet Syndrome [Emergency Medicine]
Thoracic Outlet Syndrome [Neurology]
Thoracic Outlet Syndrome [Radiology]
Thoracic Outlet Syndrome [Sports Medicine]
Traumatic Brachial Plexopathy
Clinical guidelines:
ACR Appropriateness Criteria® plexopathy. American College of Radiology - Medical Specialty Society. 2006. 13 pages. NGC:005539
Clinical trials:
Treatment of Thoracic Outlet Syndrome (TOS) With Botox
Ultrasound Guidance for Interscalene Brachial Plexus Block
Keywords
thoracic outlet syndrome, thoracic outlet, thoracic syndrome, outlet syndrome, brachial plexus, brachial plexopathy, brachial plexus injury, cervical rib syndrome, cervicobrachial myofascial pain syndrome, cervicobrachial pain syndrome, costoclavicular mass syndrome, costoclavicular syndrome, scalenus anticus syndrome, scalenus syndrome, thoracic outlet compression syndrome
