Thoracic Outlet Syndrome 

  • Author: Daryl A Rosenbaum, MD; Chief Editor: Sherwin SW Ho, MD   more...
 
Updated: Dec 2, 2011
 

Background

Thoracic outlet syndrome is not the name of a single entity, but rather a collective title for a variety of conditions attributed to compression of these neurovascular structures as they traverse the thoracic outlet.[1, 2, 3, 4, 5] The thoracic outlet is bordered by the scalene muscles, first rib, and clavicle. Neurovascular structures pass from the neck and thorax into the axilla through this space. Thoracic outlet syndrome remains one of the most controversial clinical entities in medicine.[6, 7, 8] See the image below.

Thoracic outlet syndrome in a 16-year-old volleybaThoracic outlet syndrome in a 16-year-old volleyball player with a stenotic right subclavian vein (arrow) secondary to fibrosis.

For excellent patient education resources, visit eMedicine's Hand, Wrist, Elbow, and Shoulder Center. Also, see eMedicine's patient education articles Shoulder and Neck Pain and Electromyography (EMG).

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Epidemiology

Frequency

United States

The wide variability of symptoms and signs in patients with thoracic outlet syndrome and the lack of an objective confirmatory test for the diagnosis makes correctly identifying patients with thoracic outlet syndrome difficult.[9] Therefore, determining its exact incidence remains elusive; estimates range from 3-80 cases per 1000 population.[10] Thoracic outlet syndrome is more common in women, particularly those with poor muscular development, poor posture, or both.[11]

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Functional Anatomy

The neurovascular bundle courses through 3 spaces, or triangles, as it exits the neck to reach the axilla and proximal arm. All 3 spaces can be the source of compression of the various components of the neurovascular bundle, including the brachial plexus and the subclavian vessels.[12] These spaces are small at rest and become even smaller with certain arm maneuvers, such as abduction and external rotation.[13, 14] This can aid in the diagnosis of thoracic outlet syndrome and forms the basis for provocative testing, which is discussed later (see Clinical, Physical).

The first space is the interscalene triangle. It is bordered by the anterior scalene muscle, the middle scalene muscle, and the upper border of the first rib. This space contains the trunks of the brachial plexus and subclavian artery. The interscalene triangle is the most common site for neural compression, vascular compression, or both.[10]

The second space is the costoclavicular triangle, which is bordered by the clavicle, first rib, and scapula and contains the subclavian artery and vein and the brachial nerves.

The third and final space is beneath the coracoid process just deep to the pectoralis minor tendon; it is referred to as the subcoracoid space.

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Sport-Specific Biomechanics

Thoracic outlet syndrome is most often seen in patients who engage in repetitive motions that place the shoulder at the extreme of abduction and external rotation. An example of such activity is swimming, especially with the freestyle stroke, butterfly stroke, and backstroke. When a swimmer reports tightness and pain around the shoulder, neck, and clavicle as his or her hand enters the water, thoracic outlet syndrome should be suspected.

In addition to swimmers, other athletes affected by thoracic outlet syndrome include water polo, baseball, and tennis players and athletes in any other activity that places repetitive stress on the shoulder at the extremes of abduction and external rotation. These individuals may present with neurologic and arterial or venous symptoms. Venous thoracic outlet syndrome most commonly develops in young male athletes in whom the upper extremity musculature is overdeveloped as a result of work or physical conditioning. Baseball players, whose sport requires repetitive throwing motions, are at increased risk for arterial thoracic outlet syndrome in their dominant arm.

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Proceed to Clinical Presentation
 
 
Contributor Information and Disclosures
Author

Daryl A Rosenbaum, MD  Assistant Professor, Director of Sports Medicine Fellowship, Department of Family and Community Medicine, Wake Forest University School of Medicine; Team Physician, United States Soccer Federation

Daryl A Rosenbaum, MD is a member of the following medical societies: American Academy of Family Physicians, American Medical Society for Sports Medicine, North Carolina Medical Society, and Society of Teachers of Family Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Matthew L Silvis, MD  Assistant Professor, Departments of Family and Community Medicine and Orthopedics and Rehabilitation, Pennsylvania State University College of Medicine

Matthew L Silvis, MD is a member of the following medical societies: American Academy of Family Physicians and American Medical Society for Sports Medicine

Disclosure: Nothing to disclose.

Ajay Kalra, MD  Consulting Surgeon, Surgical Specialists

Ajay Kalra, MD is a member of the following medical societies: Missouri State Medical Association

Disclosure: Nothing to disclose.

Matt Thornburg, MD  Staff Physician, Department of Family and Community Medicine, University of Missouri Health Care at Columbia

Matt Thornburg, MD is a member of the following medical societies: American Academy of Family Physicians and American Medical Association

Disclosure: Nothing to disclose.

Donald Spadone, MD  Assistant Professor, Department of Surgery, Division of Vascular Surgery, University of Missouri Health Sciences Center

Donald Spadone, MD is a member of the following medical societies: American College of Surgeons, American Institute of Ultrasound in Medicine, Association for Academic Surgery, Association for Surgical Education, and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Craig C Young, MD  Professor, Departments of Orthopedic Surgery and Community and Family Medicine, Medical Director of Sports Medicine, Director of Primary Care Sports Medicine Fellowship, Medical College of Wisconsin

Craig C Young, MD is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, American Medical Society for Sports Medicine, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Russell D White, MD  Professor of Medicine, Professor of Orthopedic Surgery, Director of Sports Medicine Fellowship Program, Medical Director, Sports Medicine Center, Head Team Physician, University of Missouri-Kansas City Intercollegiate Athletic Program, Department of Community and Family Medicine, University of Missouri-Kansas City School of Medicine, Truman Medical Center-Lakewood

Russell D White, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Family Physicians, American Association of Clinical Endocrinologists, American College of Sports Medicine, American Diabetes Association, and American Medical Society for Sports Medicine

Disclosure: Nothing to disclose.

Jon B Whitehurst, MD  Clinical Instructor of Surgery, University of Illinois College of Medicine; Partner, Rockford Orthopedic Associates; Orthopedic Chairman, Rockford Memorial Hospital

Jon B Whitehurst, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America

Disclosure: Nothing to disclose.

Chief Editor

Sherwin SW Ho, MD  Associate Professor, Department of Surgery, Section of Orthopedic Surgery and Rehabilitation Medicine, University of Chicago Division of the Biological Sciences, The Pritzker School of Medicine

Sherwin SW Ho, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, Arthroscopy Association of North America, and Herodicus Society

Disclosure: Breg, Inc. Consulting fee Consulting; Biomet, Inc. Consulting fee Consulting; GMV, Inc. Arthroscopy Simulator Evaluation and teaching; Smith and Nephew Grant/research funds Fellowship funding; DJ Ortho Grant/research funds Course funding; Athletico Physical Therapy Grant/research funds Course, research funding

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Thoracic outlet syndrome in a 16-year-old volleyball player with a stenotic right subclavian vein (arrow) secondary to fibrosis.
 
 
 
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