Approach Considerations

In thoracic outlet syndrome with vascular compromise or nerve compression, with resultant atrophy of the intrinsic hand muscles, the diagnosis is not controversial and specific tests can confirm the diagnosis. However, no infallible clinical tests, laboratory tests, radiographic tests, or electrical studies establish the diagnosis of thoracic outlet syndrome syndrome in patients with disputed or nonspecific-type thoracic outlet syndrome.^[29]Many tests are available to refine the differential diagnosis and confirm or exclude other potential conditions (see Differentials and Other Problems to Be Considered).

Laboratory Studies

To exclude systemic disease and inflammation, a few simple blood tests may refine the differential diagnosis for thoracic outlet syndrome, including a blood glucose level, complete blood cell (CBC) count, erythrocyte sedimentation rate (ESR), basic metabolic panel, thyrotropin level, and rheumatologic workup, if indicated.

Radiography

Cervical spine and upper thoracic spine radiographs may demonstrate bony abnormalities. Chest, shoulder, and clavicle radiographs may also identify bony abnormalities.

Computed tomography (CT) scanning and magnetic resonance imaging (MRI)

CT scanning and MRI are more useful for identifying other conditions that might cause similar symptoms, rather than for establishing the diagnosis of thoracic outlet syndrome.^[30]

Magnetic resonance angiography (MRA)

MRA can be useful for the diagnosis of arterial vascular thoracic outlet syndrome.^{[31, 32]}

Venography and duplex scanning

Venography and duplex scanning (ie, ultrasonography combined with Doppler velocity waveforms) are used to assist in the diagnosis of subclavian vein compression (thrombosis). These tests can be performed dynamically with positions that recreate the tension placed on the thoracic outlet during certain motions such as abduction and external rotation.

Other Tests

Electrodiagnostic studies can be helpful for classic cases of neurogenic thoracic outlet syndrome and therefore can be useful when the results are positive. However, many symptoms are intermittent in neurogenic thoracic outlet syndrome; therefore, negative test results do not rule out this diagnosis. Electrodiagnostic testing can also be helpful in diagnosing other neuromuscular disorders.

Nerve conduction velocity has been used for the diagnosis of thoracic outlet syndrome as defined by a reduction to less than 85 m/s of either the ulnar or median nerves across the thoracic outlet and was found to corroborate the clinical diagnosis. A nerve conduction velocity of less than 60 m/s was considered an indication for surgery.^[18]However, as with many aspects of thoracic outlet syndrome, this remains controversial and has not been universally accepted.

Somatosensory evoked potentials are equally controversial, with some studies favoring their use^[33]and others not.^[34]

Electromyography may be helpful in confirming the presence or absence of a specific alternative diagnosis.

A study reported that intravascular ultrasound detected greater levels of stenosis than venography in the treatment of 14 venous thoracic outlet syndrome patients.^[35]

Treatment & Management

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Media Gallery

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

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Author

Daryl A Rosenbaum, MD Associate Professor, Director of Sports Medicine Fellowship, Department of Family and Community Medicine, Wake Forest University School of Medicine

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

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, American Medical Society for Sports Medicine

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, American Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

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

Disclosure: Received salary from Medscape for employment. for: Medscape.

Russell D White, MD Clinical Professor of Medicine, Clinical Professor of Orthopedic Surgery, 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, American Medical Society for Sports Medicine

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, Arthroscopy Association of North America, Herodicus Society, American Orthopaedic Society for Sports Medicine

Disclosure: Received consulting fee from Biomet, Inc. for speaking and teaching; Received grant/research funds from Smith and Nephew for fellowship funding; Received grant/research funds from DJ Ortho for course funding; Received grant/research funds from Athletico Physical Therapy for course, research funding; Received royalty from Biomet, Inc. for consulting.

Additional Contributors

Craig C Young, MD Professor, Departments of Orthopedic Surgery and Community and Family Medicine, Medical Director of Sports Medicine, 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, Phi Beta Kappa

Disclosure: Nothing to disclose.

Acknowledgements

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.

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.