Thoracic Outlet Syndrome Program
617-726-5200
Coordinated treatment for thoracic outlet syndrome
We provide expert evaluation and treatment for patients of all ages with neurogenic, venous, and arterial thoracic outlet syndrome. Patients have access to a coordinated multidisciplinary team with expertise in advanced diagnostics, nonsurgical therapies, and complex thoracic outlet decompression procedures.
Our team also has extensive experience caring for high school, collegiate, and professional athletes. We work closely with patients to relieve symptoms, restore function, and support a safe return to sport and activity.
About the program
Patients receive coordinated care from a multidisciplinary team that may include thoracic surgeons, vascular specialists, radiologists, rehabilitation medicine physicians, pain management specialists, physical therapists, and other experts as appropriate. This collaborative approach allows for individualized treatment plans designed around each patient's symptoms, goals, and lifestyle.
Our pioneering work in thoracic outlet syndrome has established Mass General Brigham as a major referral center for this complex condition, helping patients across the United States and around the world. With a rich history of success, our care team excels in offering solutions for patients with symptoms of TOS, including those whose prior treatments were unsuccessful. We care for people of all ages, including children, young adults, adults, and older patients.
Why choose Mass General Brigham
Mass General Brigham is a regional, national, and international referral destination for patients with thoracic outlet syndrome, including those with complex presentations or symptoms that have not improved with prior treatment. Patients benefit from:
- Expertise in neurogenic, venous, and arterial thoracic outlet syndrome
- Specialized diagnostic imaging protocols designed specifically for TOS evaluation
- Advanced nonsurgical therapies, including ultrasound-guided injections
- Dedicated experience treating pediatric, adolescent, adult, and athletic populations
- Collaborative care involving thoracic surgery, vascular specialists, radiology, rehabilitation medicine, pain management, and physical therapy
- Access to research-driven care and innovative treatment approaches
Frequently asked questions
The three types of TOS that affect the thoracic outlet are:
- Neurogenic thoracic outlet syndrome (nerve-related) is the most common form of TOS. It can occur when the nerves of the brachial plexus, located in the lower neck and upper chest, are irritated.
- Venous thoracic outlet syndrome (vein-related) occurs when the subclavian vein becomes narrowed, irritated, and damaged. This can lead to the development of a blood clot. Symptoms of venous thoracic outlet syndrome include swelling, a feeling of tightness in the upper arm, and discoloration, often resulting in a bluish appearance of the affected limb.
- Arterial thoracic outlet syndrome (artery-related) is a very rare form of TOS that occurs when the subclavian artery is narrowed and damaged. This leads to the formation of blood clots or an aneurysm. The blood clots may break off and travel to the arm, hand, and fingers. Symptoms of arterial thoracic outlet syndrome include pain, discoloration, and a noticeable coolness in the arm, hand, and fingers.
Our team effectively treats people of all ages by giving them personalized and age-appropriate diagnoses and treatment plans. Many of our patients are high school and college athletes, as well as professional athletes. We work closely with our patients to achieve their goals of returning to sports and work and improving their quality of life.
Our minimally invasive diagnostic tests and treatments often provide alternatives care options to surgery. When surgery is recommended, we provide the necessary information for patients to make informed decisions about their health care. Our expert team is available to answer any questions.
Correctly diagnosing thoracic outlet syndrome is the key to successfully treating it. We customize a diagnostic and treatment plan for each patient.
Our thorough clinical assessment begins at the initial office visit with a detailed physical examination and discussion about their medical history. Examinations and treatments are tailored to each patient’s needs and may include:
- Ultrasound-guided botulinum toxin A injections.
- A specialized CT angiogram (CTA) designed specifically for evaluation of thoracic outlet syndrome.
- A high-resolution MRI scan of the thoracic outlet to get a more complete picture of the condition.
- Vascular studies:
- Arteriogram, an X-ray that uses contrast dye to visualize the arteries.
- Venogram, an X-ray that uses contrast dye to visualize the veins.
- Magnetic resonance angiography (MRA), a noninvasive exam of the blood vessels.
- MRI of the cervical spine or shoulder.
- Studies to evaluate the function of the motor and sensory nerves.
- Noninvasive, ultrasound-guided vascular exams.
Our CT angiogram and ultrasound-guided muscle injections using botulinum toxin A are scheduled once your physician has ordered them. They may require prior authorization from your insurance. During this process, we may need to communicate with you.
About the CT Scan
This specialized CT scan provides a detailed three-dimensional evaluation of the thoracic outlet region, helping clinicians assess anatomic causes of nerve and blood vessel compression. It provides a detailed view of the thoracic outlet area from the top of the neck to the middle of the chest. It can take up to five days to develop and recreate these images in 3-D. Once the radiologist has interpreted the scan results, you will be contacted by our office to discuss them.
About the Ultrasound-guided Muscle Injections
Sometimes, the neck and shoulder muscles compress and irritate the nerves and blood vessels in the thoracic outlet. One way our team checks for and treats thoracic outlet syndrome is by injecting botulinum toxin A into these muscles. These injections are done by radiologists using ultrasound imaging to precisely target specific muscles. The injections may help relieve some of the compression in the thoracic outlet and improve symptoms. We use a symptom tracker to determine improvements.
Your care team will work with you to decide the best next steps in your care plan.
Treatment for neurogenic TOS
Ultrasound-guided injections with botulinum toxin A may help relieve nerve compression for patients with neurogenic thoracic outlet syndrome. Many patients whose symptoms have improved following muscle injections may be able to participate more actively in physical therapy, which can improve the overall results. If symptoms do not improve, surgery will be discussed.
Treatment for venous TOS
Doctors can find venous TOS in two ways: a duplex ultrasound of the upper body, like the arm or shoulder, or with a test called an arteriogram or venogram. Both of these tests help doctors see if there is a clot in the blood vessels.
When a clot is found, medication is used to dissolve it. However, for most patients, just treating the clot is not always enough. The main problem is often the veins that were narrowed by the compression in the thoracic outlet region. If there is pressure on the vein from the outside, surgery from a highly trained TOS specialist may be recommended to fix it. Patients may need to continue to use blood-thinning medication to prevent blood clotting for up to three months following surgery.
Treatment for arterial TOS
Arterial thoracic outlet syndrome, which is the rarest type of TOS, occurs when pressure harms the blood vessel. Just because there's pressure doesn't mean the blood vessel is damaged, so doctors use special imaging with contrast to carefully check for damage, such as a duplex ultrasound of the upper body.
Patients with arterial TOS often require surgery. They will meet with a highly trained TOS specialist to discuss their options.
Surgery to treat TOS
When non-surgical treatment does not correct the compression (pressure) or clotting in the thoracic outlet area of the body, surgery can relieve the pressure by creating additional space and repairing damaged arteries and veins. Patients who require surgery can be confident that they will receive specialized care from an experienced team. A successful surgical outcome depends on an accurate diagnosis and expert-level surgical care. Your care team will work with you to decide if surgery is a good option for you.
Surgery for thoracic outlet syndrome may include:
- Resection of the first rib and the anterior and middle scalene. This surgery is commonly performed to treat neurogenic and venous TOS. Any unhealthy tissue or scarring in the area will be removed. The brachial plexus, subclavian vein, subclavian artery will be protected. To do this, the surgeon will make a small incision, or cut, just behind and parallel to the collarbone. Typically, patients will need to stay at the hospital for two nights after surgery so that our team can monitor their pain levels and vital signs.
- Resection of the pectoralis minor muscles (pec minor muscles). This surgery is specifically used to treat neurogenic TOS in the pec minor muscles, which are the smaller, deeper muscles of the chest. To do this, the surgeon will make a small cut in the armpit, release the muscle and move it away from nerves in this space causing these symptoms. This is an outpatient procedure, which means that patients can return home on the same day as the surgery. The patient will need a ride home.
If you have worker's compensation insurance, please inform our staff immediately.
Contact your adjuster and request a prior authorization for a new patient consultation. Dr. Donahue’s National Provider Identifier (NPI) is 1548236052.
After you have obtained an authorization, you must provide our staff with the following information:
- Your claim number
- The name of your company’s worker’s compensation insurance
- Your employer’s name and telephone number
- Your adjuster’s name and telephone number
Our billing team will work with your adjuster to coordinate authorization and payment requirements. Please inform our staff if the adjuster requires a request from our office. Once this information is processed, you will be scheduled for a new patient appointment.
Information for pediatric/young adult patients
Thoracic outlet syndrome—neurogenic, venous, and arterial—can affect children. Our team has significant experience in caring for patients of all ages, including those whose prior TOS treatments were unsuccessful. For pediatric patients with TOS, we most commonly see adolescents between the ages of 10-18, typically with neurogenic TOS or venous TOS. Though not technically considered pediatric, our team is also experienced in treating young adults with TOS between the ages of 19-25.
The symptoms of TOS in children are often the same as adults, such as:
- Pain in the arm, shoulder, neck and/or chest.
- Numbness or tingling in the arm and/or hand.
- Weakness or fatigue in the arm and/or hand.
Parents and caregivers are an important part of the child’s care team and will be involved every step of the way.
In the initial appointment, your child will undergo an age-appropriate evaluation, which will include a physical exam and a conversation about their medical history. Every effort is made to diagnose and treat this syndrome minimally invasively. Tests and treatments will be thoroughly explained, and questions are encouraged. Our care team will follow your child’s progress throughout this process. Younger patients occasionally require anesthesia when receiving tests to diagnose their condition.
Children diagnosed with TOS may need to take a break from activities that may aggravate their symptoms, such as sports. It is always our goal to provide your child with everything they need to recover and get back to what they love to do. Your care team will support you and your child through the treatment journey.
A combination of physical therapy and minimally invasive ultrasound-guided injections may be recommended. Your child will be provided with ongoing support from the entire care team. If surgery is recommended, your child may have to stay at the hospital to recover after surgery. Specialized care is provided within the hospital.
Our specialists
617-726-5200
Contact the Thoracic Outlet Syndrome Program
617-726-5200
International Patient Services
Contact information for international patients