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Patient Information: What to Expect

Personalized Treatment

Treatment for thoracic outlet syndrome (TOS) is highly specific to each patient. Expert diagnosis is essential to determine whether nerves or blood vessels are being compressed and which bones or muscles are involved in the compression. If possible, a conservative treatment is often recommended at first — particularly for neurogenic TOS — progressing to injections or surgery only if you don’t find permanent relief with conservative measures.

Q&A | What is thoracic outlet syndrome; how is it diagnosed and treated

Assistant Professor of Surgery Dr. Ying Wei Lum discusses causes, symptoms and risk factors of thoracic outlet syndrome.

What to Expect from Your First Visit

Your care team will begin by conducting the following:

  • Complete medical history
  • Physical examination
  • Discussion of symptoms

Thoracic outlet syndrome can sometimes be caused by weight gain, increased muscle mass, injury or repetitive overhead motion. To better understand what might be causing your symptoms, your care team may also ask about:

  • Work and lifestyle activities
  • Recent injuries or changes

Appropriate diagnostic scans may then be performed.

What to Expect from Your Treatment

 A customized treatment plan will be developed by your care team based on your type of TOS, the severity of your condition, and previous treatments you have received. TOS treatments include:

  • Physical therapy
  • Anterior/middle scalene, pec minor injections (local anesthetic and botulinum toxin injections)
  • Decompression surgery

Physical Therapy

The first-line treatment for neurogenic TOS, the most common type, is physical therapy. Often it’s the only treatment many patients will need. We provide a set of written instructions you can bring to a physical therapist, or you can visit the Johns Hopkins Medicine Department of Physical Medicine and Rehabilitation.

Length of treatment: The normal course of treatment is six to 10 weeks, with two to three sessions per week. If physical therapy does not provide relief, you can return to the clinic for further treatment.

Resuming activity: You will be taught how to do “maintenance” home physical therapy exercises on your own to manage your shoulder if your symptoms are controlled during the formal physical therapy sessions. Most patients are able to resume their normal activities if physical therapy is successful.

Anterior Scalene Muscle Injections

If physical therapy doesn’t relieve your symptoms, further diagnostic tests, such as an initial injection of local anesthetic into the scalene muscles, may be recommended. If you respond to this diagnostic injection, then botulinum toxin may be helpful.

In this treatment, a small amount of botulinum toxin is injected into the scalene muscles near the site where they are thought to be compressing the nerves.

Length of treatment: In rare cases, a single-dose injection may give permanent relief. However, most treatments usually last two to three months.

Decompression Surgery

There are several different approaches to decompression surgery. Your vascular surgeon will opt for the one that best treats your condition.

Length of stay: Depending on the type of TOS and kind of surgery that is performed, most patients stay in the hospital for one day and are ready for discharge from the hospital the day after surgery. If you’re coming from out of town, you should expect to stay in Baltimore for two to three days before returning home.

Recovery: Most patients will feel some level of discomfort/pain as they recover from surgery for at least 1-2 weeks.

Return to activity: Patients often to return to light activity in seven to 10 days. Returning to work, therefore, will depend on the physical demands of the job. We strongly recommended you not overexert yourself by doing any repetitive overhead movements or lifting more than 10 to 15 pounds for three months.

Physical therapy: The course of physical therapy begins two weeks after surgery. We recommend you attend two to three sessions per week, for eight to 12 weeks. You can visit a physical therapy practice that is convenient for you. You will be given specific written physical therapy instructions to provide to your therapist.

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