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Thoracic outlet syndrome (ToS) has confounded clinicians for decades. Often seen in athletes, ToS is more commonly found in people using their arms in a repetitive motion, including computer programmers, secretaries and construction workers. These activities can lead to compression of nerves or blood vessels, or both, in the thoracic outlet.

Diagnosing the condition is difficult since many of its symptoms overlap with other more common musculoskeletal issues of the upper extremities. "There's no one blood test or radiographic test or physical exam finding that definitively makes the diagnosis," says Stanford vascular surgeon Jason Lee, MD. "It's a combination of positive and negative tests."

Treatment can be just as challenging, particularly when the nerve is compressed. Surgery consists of first rib and scalene muscle removal, but outcomes in the past were unpredictable. In the past five years, Dr. Lee and his colleagues developed a highly-selective algorithm to determine which patients best respond to surgery, based on a specific set of steps for work-up and surgical intervention. Their protocol, which was published in 2010 in the Journal of Vascular Surgery, has increased successful surgical outcomes for ToS operations from 50 to nearly 90 percent.

This algorithm, now commonly followed in many other centers across the country, focuses on a ToS-specific physical therapy technique known as the Edgelow protocol. This series of stretches and breathing and posture adjustments is designed to alter the compressed space of muscles and bones in the thoracic outlet that contributes to ToS,and therefore mimics what surgery is intended to do.

What the research has shown is patients who improved completely with therapy alone would obviously not need the surgery, but that those who didn't respond at all to therapy probably wouldn't be helped by further anatomical reconfiguration. Those patients who were helped partially by the Edgelow protocol are considered the best candidates for surgery.

For a patient's perspective of ToS treatment atStanford, see med.stanford.edu/tos