Thoracic outlet syndrome

Last reviewed: 30 Aug 2023
Last updated: 27 Oct 2020



History and exam

Key diagnostic factors

  • history of repetitive jobs or overhead hobbies/activities
  • pain in upper extremity and adjacent areas
  • paresthesias in arms, hands, and/or fingers
  • circulatory changes in upper extremity
  • upper extremity fatigue
More key diagnostic factors

Other diagnostic factors

  • history of clavicular fracture
  • history of cardiovascular or thoracic surgery
  • palpation of cervical rib
  • subcutaneous venous collateral around shoulders (Urschel sign)
  • motor weakness
  • hyperhidrosis
  • thenar eminence muscle atrophy
  • exertional pain/claudication
  • supraclavicular systolic bruit
  • blood pressure difference between extremities
  • positive Adson (scalene) test
  • positive costoclavicular test
  • positive hyperabduction test
  • positive Roos test
  • positive stretch test
  • positive upper limb tension tests
  • positive Wright maneuver
  • edema/swelling of upper extremity
Other diagnostic factors

Risk factors

  • cervical rib or bony abnormalities
  • trauma
  • poor posture
  • repetitive overhead activity
  • motor vehicle collisions
  • large breasts or implants
  • obesity
  • age (late teens to 60 years)
  • female sex
  • history of poliomyelitis
  • pregnancy
  • median sternotomy
More risk factors

Diagnostic investigations

1st investigations to order

  • cervical spine x-ray
  • CXR
  • Electromyography/nerve conduction velocity
  • CT angiography
  • Doppler ultrasonography
More 1st investigations to order

Investigations to consider

  • MRI neck/clavicle/shoulder
  • muscle block
  • conventional arteriography
  • magnetic resonance angiography (MRA)
  • contrast venography
  • magnetic resonance venography (MRV)
  • CBC and coagulation studies
More investigations to consider

Treatment algorithm


neurologic TOS (NTOS)

arterial TOS (ATOS)

venous TOS (vTOS)

neurovascular (combined)



Chaney Stewman, MD

Sports Medicine Fellow

Christiana Care Health Services

Department of Family and Community Medicine




CS is the author of a reference cited in this topic.

Marc I. Harwood, MD

Associate Professor

Department of Family and Community Medicine

Jefferson Medical College

Thomas Jefferson University




MIH is the author of a reference cited in this topic.


Dr Chaney Stewman and Dr Marc I. Harwood would like to gratefully acknowledge Dr Pedro K. Beredjiklian, Dr Peter C. Vitanzo, Dr Harold C. Urschel Jr, Rachel Montano, and Brenda Knee, previous contributors to this topic. PKB has stock ownership in Wright Medical Inc. PCV is the author of a reference cited in this topic. HCU is an author of several references cited in this topic. RM and BK declare that they have no competing interests.

Peer reviewers

Ian Loftus, BSc, MB, ChB, FRCS, MD

Professor of Vascular Surgery

St. George's NHS Healthcare Trust




IL declares that he has no competing interests.

Scott R. Laker, MD

Assistant Professor

University of Colorado School of Medicine




SRL is the author of a reference cited in this topic.

John A. Kern, MD


Cardiothoracic Surgery

University of Virginia School of Medicine




JAK declares that he has no competing interests.

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