Understanding Thoracic Outlet Syndrome

Your arms, hands, and fingers depend on a bundle of nerves and blood vessels that travel from your neck through a narrow passageway at the top of your chest before reaching the upper extremity. This passageway – the thoracic outlet – is formed by the first rib below, the collarbone (clavicle) above, and the scalene muscles of the neck on either side. Under normal conditions, these structures have just enough room to pass through without compression. When that space becomes too narrow, nerves are pinched, veins are squeezed, or arteries are compressed – and the result is thoracic outlet syndrome. TOS is not a single disease but a group of related conditions classified by which structures are being compressed and what symptoms result. Understanding these distinctions is critical both for proper medical treatment and for recognizing when a healthcare provider has failed to diagnose or treat the condition appropriately.

Anatomy of the Thoracic Outlet

The thoracic outlet contains three critical structures that supply the entire upper extremity. The brachial plexus – a network of nerves originating from spinal cord levels C5 through T1 – controls all movement and sensation in the shoulder, arm, forearm, and hand. The subclavian artery carries oxygenated blood from the heart to the arm. The subclavian vein returns deoxygenated blood from the arm back to the heart. These three structures pass through progressively narrower spaces as they travel from the neck to the arm. The first and most important bottleneck is the interscalene triangle – the gap between the anterior scalene muscle, the middle scalene muscle, and the upper surface of the first rib. The second is the costoclavicular space – the gap between the clavicle above and the first rib below. The third is the subcoracoid space beneath the pectoralis minor muscle near the shoulder. Compression can occur at any of these three sites, and identifying the exact location of compression is essential for surgical planning.

Three Types of Thoracic Outlet Syndrome

Why TOS Is So Frequently Misdiagnosed

Thoracic outlet syndrome is one of the most commonly misdiagnosed musculoskeletal conditions in medicine. The symptoms of neurogenic TOS – arm pain, numbness, tingling in the fingers, weakness in the hand – overlap substantially with several other conditions. Patients are frequently diagnosed with and treated for carpal tunnel syndrome, cubital tunnel syndrome, cervical disc disease, rotator cuff injury, fibromyalgia, or complex regional pain syndrome before anyone considers TOS as the underlying cause. This diagnostic confusion exists for several reasons. There is no single definitive test for neurogenic TOS. Standard nerve conduction studies (EMG/NCS) are often normal in nTOS because the compression is positional and dynamic rather than constant. MRI of the cervical spine may show incidental findings that divert attention away from the true source of symptoms. Many primary care physicians, orthopedists, and even neurologists have limited experience with TOS and do not include it in their differential diagnosis when a patient presents with upper extremity pain and numbness. The result is that patients often endure months or years of ineffective treatment – carpal tunnel releases that do not help, cervical epidural injections that provide no relief, shoulder surgeries that fail to resolve symptoms – before being referred to a vascular surgeon or thoracic surgeon who recognizes TOS. Each unnecessary procedure and each year of delayed diagnosis represents preventable suffering.

Symptoms: What Patients Experience

Neurogenic TOS: The Most Common Presentation

Neurogenic TOS affects the brachial plexus and produces symptoms that follow nerve distribution patterns. Patients typically describe pain, numbness, and a “pins and needles” sensation that starts in the neck and shoulder and radiates down the arm to the hand and fingers. The fourth and fifth fingers are most commonly affected when the lower trunk of the brachial plexus (C8–T1) is compressed, while the thumb, index, and middle fingers are affected when the upper trunk (C5–C6) is involved. A critical distinguishing feature is that symptoms are provoked or worsened by specific arm positions – particularly raising the arms overhead, reaching forward, or carrying objects at the side. Patients may notice their hands go numb while driving, blow-drying their hair, typing, or sleeping with arms overhead. Over time, the affected hand may lose grip strength, and the muscles at the base of the thumb (thenar eminence) may visibly shrink – a sign of chronic nerve compression that indicates the diagnosis has already been delayed too long. Many patients also experience headaches (typically occipital, at the back of the skull), neck pain, chest wall pain, and a sensation of heaviness or fatigue in the affected arm. These widespread symptoms contribute to diagnostic confusion and may lead to referrals to headache specialists, cardiologists, or rheumatologists rather than the vascular or thoracic surgeon who can correctly identify TOS.

Venous TOS: Swelling, Discoloration, and Clotting

Venous TOS presents differently from the neurogenic form and often develops suddenly. The hallmark is significant swelling of the entire arm, which may develop a dusky blue discoloration from impaired blood return. Visible veins may become prominent across the shoulder and upper chest as the body attempts to create alternative drainage pathways around the blocked subclavian vein. In its most acute form – Paget-Schroetter syndrome – a blood clot forms in the compressed subclavian vein, typically after vigorous upper-body activity such as swimming, pitching, or weightlifting. This is a medical emergency that requires immediate anticoagulation and often catheter-directed thrombolysis (clot-dissolving medication delivered directly into the vein) followed by first rib resection to prevent recurrence.

Arterial TOS: The Most Dangerous Form

Arterial TOS is rare but carries the highest risk of catastrophic complications. Compression of the subclavian artery can cause the arterial wall to weaken and form an aneurysm (abnormal bulging). Blood clots that form within the aneurysm can break loose and travel downstream, lodging in the small arteries of the hand and fingers. Patients may notice coldness, pallor, or cyanosis (bluish discoloration) in the affected hand, diminished pulse at the wrist, painful ulcers on the fingertips, or sudden severe pain indicating acute digital ischemia. Left untreated, arterial TOS can result in gangrene and amputation of fingers.

What Causes TOS and Who Is at Risk

Anatomical Factors

Some people are born with structural variations that narrow the thoracic outlet and predispose them to TOS. The most well-recognized is a cervical rib – an extra rib that extends from the seventh cervical vertebra, found in less than 1% of the general population but in approximately 10% of TOS patients. Cervical ribs may be fully formed or present as fibrous bands that compress neurovascular structures. Other anatomical variations include abnormally tight or accessory scalene muscles, elongated transverse processes of the C7 vertebra, and anomalous fibrous bands within the thoracic outlet.

Traumatic Causes

Physical trauma is a major trigger for TOS. Motor vehicle accidents – particularly rear-end collisions causing whiplash – can disrupt the delicate balance of the thoracic outlet by causing scalene muscle spasm, inflammation, and scarring that persist long after the initial injury heals. Clavicle fractures or first rib fractures can narrow the thoracic outlet through excessive callus formation (bone overgrowth during healing). Even relatively minor falls or direct blows to the shoulder can initiate the chronic muscle changes that eventually lead to nerve or vessel compression.

Repetitive Motion and Occupational Risk

Jobs and activities that require repetitive overhead arm movements or sustained awkward postures are significant risk factors. The scalene muscles and pectoralis minor muscle can hypertrophy (enlarge) from repetitive use, progressively narrowing the spaces through which the brachial plexus and subclavian vessels must pass. Occupations at particular risk include dental hygienists, surgeons, hairdressers, assembly line workers performing overhead tasks, painters, commercial drivers, and office workers with poor ergonomic setups. Athletes – especially swimmers, baseball pitchers, volleyball players, and weightlifters – face elevated risk from the repetitive overhead motions inherent in their sports.

Postural Contributions

Poor posture is both a risk factor for developing TOS and an aggravating factor for those already symptomatic. Forward head posture, rounded shoulders, and thoracic kyphosis (a “slumped” upper spine) change the relationship between the clavicle and first rib, narrowing the costoclavicular space. Sleep position can also contribute – sleeping on the side with arms overhead or prone with the head turned creates sustained compression of the thoracic outlet structures throughout the night.

Diagnosis: How TOS Should Be Identified

Diagnosing thoracic outlet syndrome requires a systematic approach that combines detailed history-taking, focused physical examination, provocative testing, and targeted imaging. The standard of care requires physicians to consider TOS in any patient presenting with upper extremity pain, numbness, or weakness – particularly when prior treatments for other presumed diagnoses have failed.

Physical Examination and Provocative Tests

Several clinical tests can reproduce TOS symptoms by positioning the arm and neck to further narrow the thoracic outlet. The Adson test monitors the radial pulse while the patient takes a deep breath and turns the head – a diminished or absent pulse suggests arterial compression. The Wright test (hyperabduction test) checks for pulse changes and symptom reproduction with the arm elevated and externally rotated. The elevated arm stress test (EAST or Roos test) requires the patient to open and close the hands repeatedly with arms raised at shoulder height for three minutes – reproduction of symptoms, hand pallor, or inability to complete the test suggests TOS. The costoclavicular maneuver positions the shoulder back and down to compress the costoclavicular space. No single provocative test is perfectly reliable, and false positives can occur in healthy individuals. The standard of care requires the physician to evaluate provocative tests in the context of the patient’s complete clinical picture – history, symptom pattern, risk factors, and response to prior treatments – rather than relying on any one test in isolation.

Diagnostic Imaging and Specialized Tests

Imaging plays a critical role in confirming TOS and identifying the site and cause of compression. Chest X-ray can identify cervical ribs, elongated C7 transverse processes, or abnormalities of the first rib or clavicle. MRI of the brachial plexus (often with specific TOS protocols using arm-abducted positions) can demonstrate nerve compression and help identify the anatomical structures responsible. MR or CT angiography with dynamic positioning can reveal arterial or venous compression that only occurs when the arm is in certain positions. For neurogenic TOS, a scalene muscle block – injection of local anesthetic into the anterior scalene muscle under ultrasound guidance – serves as a diagnostic and prognostic tool. Temporary relief of symptoms following a scalene block supports the diagnosis and suggests the patient is likely to benefit from surgical decompression. Nerve conduction studies (EMG/NCS) are often used to rule out other conditions like carpal tunnel syndrome or cervical radiculopathy, but normal results do not exclude neurogenic TOS.

Duplex Ultrasound for Vascular TOS

For suspected venous or arterial TOS, duplex ultrasound with dynamic positioning is the initial imaging study of choice. The technologist examines blood flow through the subclavian artery and vein while the patient moves the arm through various positions. Compression, stenosis, or thrombosis that appears only with arm abduction or elevation is characteristic of vascular TOS. Venography or arteriography may follow to define the anatomy before surgical intervention.

Treatment: From Conservative Care to Surgery

Conservative Treatment: The Required First Step

For neurogenic TOS, the standard of care requires an initial trial of conservative treatment before surgery is considered. Physical therapy focused on postural correction, scalene muscle stretching, shoulder girdle strengthening, and nerve-gliding exercises is the cornerstone of conservative management. Most treatment protocols recommend a minimum of three to six months of dedicated physical therapy before surgery is discussed. Pain management with nonsteroidal anti-inflammatory drugs, muscle relaxants, or neuropathic pain medications (gabapentin, pregabalin) may supplement physical therapy. Botulinum toxin injections into the anterior and middle scalene muscles can provide temporary relief lasting three to six months by relaxing the muscles and reducing compression of the brachial plexus. This serves both as treatment and as a predictor of surgical success – patients who respond to botulinum toxin typically respond well to surgical decompression. Conservative treatment is not appropriate as a first-line approach for venous TOS with acute thrombosis (which requires urgent anticoagulation and thrombolysis) or arterial TOS with embolization or aneurysm (which requires surgical repair).

Surgical Treatment: First Rib Resection and Scalenectomy

When conservative treatment fails to provide adequate relief – typically after three to six months – surgical decompression of the thoracic outlet is considered. The standard surgical procedure involves resection (removal) of the first rib combined with scalenectomy (removal of the anterior scalene muscle) to widen the thoracic outlet and relieve compression of the neurovascular structures. Several surgical approaches exist, each with distinct advantages and risks: Regardless of approach, the surgery carries inherent risks because the first rib is surrounded by critical structures – the brachial plexus, subclavian artery and vein, phrenic nerve, long thoracic nerve, and thoracic duct. Injury to any of these structures during surgery can cause devastating, permanent complications. This anatomical reality is why TOS surgery generates more malpractice claims than any other cardiothoracic procedure.

When the Medical System Fails TOS Patients

Thoracic outlet syndrome malpractice falls into two broad categories: failure to diagnose and surgical negligence. Both can result in permanent, life-altering disability. A landmark peer-reviewed study published in the Journal of Vascular Surgery examined 50 years of TOS malpractice litigation and found that 97.4% of all claims involved negligent surgical treatment, with intraoperative nerve injury reported in 51.3% of cases. Misdiagnosis and failure to obtain informed consent each appeared in 23.1% of claims. Among plaintiff verdicts, the median payout exceeded $725,000 – significantly above average for medical malpractice cases generally.

Diagnostic Failure Patterns

The most common diagnostic failures in TOS cases follow recognizable patterns that an experienced medical malpractice attorney and medical expert can identify in the records: Misdiagnosis as carpal tunnel syndrome: TOS causes numbness and tingling in the hand, and when a physician sees these complaints, carpal tunnel is often the reflexive diagnosis. The patient may undergo nerve conduction studies that show borderline findings, receive a carpal tunnel release that provides no improvement, and continue to suffer while the true cause – brachial plexus compression at the thoracic outlet – goes unaddressed. In some cases, patients undergo multiple carpal tunnel surgeries before TOS is considered. Misdiagnosis as cervical disc disease: MRI of the cervical spine frequently reveals disc bulges or herniations in adults, many of which are asymptomatic and incidental. When a TOS patient’s MRI shows a cervical disc abnormality, the physician may attribute all symptoms to the disc and pursue cervical epidural injections, physical therapy directed at the cervical spine, or even cervical fusion surgery – none of which will address the true source of compression at the thoracic outlet. Dismissal based on normal nerve conduction studies: As discussed above, standard EMG/NCS testing is designed to detect fixed, constant nerve compression and is often normal in neurogenic TOS. Physicians who rely on normal EMG results to rule out TOS demonstrate a fundamental misunderstanding of the condition’s pathophysiology. Failure to refer to a TOS specialist: TOS is a condition best evaluated and managed by vascular surgeons, thoracic surgeons, or physicians with specific TOS expertise. When primary care physicians, orthopedists, or neurologists fail to refer patients whose symptoms have not responded to treatment for other presumed diagnoses, the delay can be measured in years. Failure to recognize vascular TOS as an emergency: Venous TOS with acute subclavian vein thrombosis (Paget-Schroetter syndrome) requires urgent treatment – anticoagulation, catheter-directed thrombolysis, and subsequent first rib resection. When emergency physicians or hospitalists treat upper extremity deep vein thrombosis with anticoagulation alone without recognizing the underlying anatomical compression, patients face recurrent thrombosis, chronic venous insufficiency, and post-thrombotic syndrome. Arterial TOS with distal embolization requires emergent vascular intervention to prevent finger or limb loss.

Surgical Negligence: The Most Common Source of TOS Malpractice Claims

First rib resection is technically one of the most demanding procedures in thoracic and vascular surgery. The first rib lies deep within the thoracic inlet, surrounded on all sides by structures that cannot be injured without devastating consequences. Historical data from a national survey of surgeons performing transaxillary first rib resection documented complete brachial plexus paralysis in 102 instances and partial neurologic deficit in 171 instances among 259 participating surgeons. First rib resection and scalenectomy have been identified as the greatest source of malpractice claims against cardiothoracic surgeons, with nerve injury as the primary basis for litigation. The specific surgical errors that give rise to malpractice claims include: Brachial plexus injury: The brachial plexus lies immediately adjacent to the operative field during first rib resection. Excessive retraction, inadvertent transection, or thermal injury from electrocautery can cause partial or complete paralysis of the arm. Published rates of brachial plexus injury range from 0.6% in large multi-institutional databases to 9% in smaller series, with variation attributable to surgical approach and surgeon experience. Long thoracic nerve injury: The long thoracic nerve runs through or along the posterior surface of the middle scalene muscle. Damage during scalenectomy causes denervation of the serratus anterior muscle, resulting in scapular winging – a visible protrusion of the shoulder blade that impairs arm elevation and overhead function. This injury is permanent because the long thoracic nerve does not regenerate. Phrenic nerve injury: The phrenic nerve runs along the anterior surface of the anterior scalene muscle and controls the diaphragm. Injury during anterior scalenectomy – from cutting, retraction, or thermal damage – paralyzes the ipsilateral hemidiaphragm, causing persistent shortness of breath, exercise intolerance, and reduced quality of life. Vascular injury: The subclavian artery and vein lie within the operative field. Laceration of either vessel during rib resection can cause life-threatening hemorrhage requiring emergent repair. Even non-catastrophic vascular injuries can result in thrombosis, stenosis, or pseudoaneurysm formation. Incomplete rib resection: When the first rib is not fully resected – particularly the posterior stump near the transverse process – residual bone can continue to compress nerves or vessels, causing persistent or recurrent symptoms. Additionally, failure to remove the periosteum along with the rib can lead to bone regrowth (regeneration from the periosteal sleeve) that recreates the compression. Operating without exhausting conservative treatment: Operating on a TOS patient who has not undergone an adequate trial of physical therapy – typically three to six months – violates the standard of care for neurogenic TOS. Premature surgery exposes the patient to all surgical risks without first attempting the treatment that resolves symptoms in a significant percentage of patients. Inadequate informed consent: Given the documented risk of nerve injury, brachial plexus paralysis, phrenic nerve palsy, and other surgical complications, the standard of care requires thorough informed consent that specifically addresses these risks. Failure to inform patients about the possibility of permanent nerve damage, alternative treatments, and the expected success rate constitutes a separate basis for a malpractice claim.

🔍 The Nerve Injury That Changes Everything: Understanding Brachial Plexus Damage from TOS Surgery

The brachial plexus controls virtually all motor function and sensation in the arm, forearm, wrist, and hand. When this nerve network is damaged during first rib resection, the consequences depend on which nerve roots or trunks are affected and the severity of the injury: Upper trunk injury (C5–C6): Loss of shoulder abduction and elbow flexion – the patient cannot raise the arm or bend the elbow. This pattern resembles Erb’s palsy and can leave the arm hanging limply at the side. Lower trunk injury (C8–T1): Loss of hand intrinsic muscle function – the patient cannot grip objects, make a fist, or perform fine motor tasks such as buttoning a shirt, typing, or writing. Hand muscles atrophy visibly over weeks. Complete plexus injury: Total loss of arm function – a flail, insensate limb. This is the most catastrophic surgical complication and is functionally equivalent to an amputation. Unlike some nerve injuries that can recover spontaneously, brachial plexus injuries from surgical transection or severe thermal damage are often permanent. Reconstruction with nerve grafting or tendon transfers may restore partial function, but outcomes are unpredictable and the recovery process takes years. A patient who entered surgery with hand numbness may leave with a permanently paralyzed arm.

Medical Record Red Flags

In evaluating potential TOS malpractice, medical records often reveal patterns that experienced attorneys and medical experts can identify: Multiple prior diagnoses for the same symptoms (carpal tunnel, cervical disc, rotator cuff, fibromyalgia) with no lasting improvement from treatment directed at those conditions. Normal or borderline nerve conduction studies cited as the reason to “rule out” TOS. Patient complaints of positional arm numbness, hand weakness, or overhead-activity-related symptoms documented but not investigated for TOS. Referrals to multiple specialists (orthopedics, neurology, pain management, rheumatology) without referral to a vascular or thoracic surgeon. Carpal tunnel release or cervical fusion performed without pre-operative consideration of TOS as a differential diagnosis. On the surgical side: operative notes that do not document identification and protection of the phrenic nerve before scalenectomy. Use of electrocautery in proximity to the brachial plexus or long thoracic nerve. No documentation of nerve stimulator use during the procedure. Absence of intraoperative nerve monitoring. Post-operative notes that do not document neurological assessment of the upper extremity. New neurological deficits noted post-operatively but attributed to “expected swelling” rather than investigated as potential nerve injury.

Proven Case Outcomes

The following cases illustrate the real-world consequences of TOS malpractice and the accountability that the legal system provides. Each case has been independently verified through court records, appellate decisions, or published verdict reports.

The Four Legal Elements of a TOS Malpractice Claim

To succeed in a medical malpractice lawsuit involving thoracic outlet syndrome under New York law, the plaintiff must prove four elements by a preponderance of the evidence: 1. Duty of Care: The physician or surgeon had a physician-patient relationship that created a legal duty to provide care meeting the accepted standard of medical practice. This is typically straightforward – the duty exists once the physician agrees to evaluate or treat the patient. 2. Breach of the Standard of Care: The physician’s actions or omissions fell below what a reasonably competent physician in the same specialty would have done under similar circumstances. In TOS cases, breach may involve failing to consider TOS in a patient with classic symptoms; operating without an adequate trial of conservative therapy; failing to identify and protect nerves during surgery; using electrocautery near critical nerve structures without safeguards; performing incomplete rib resection; or failing to provide adequate informed consent regarding surgical risks. 3. Causation: The breach of the standard of care directly caused the patient’s injury. In diagnostic delay cases, this means demonstrating that earlier diagnosis and treatment would have avoided the permanent damage that occurred during the delay. In surgical cases, it means proving that the nerve injury resulted from a departure from accepted surgical technique rather than a recognized, non-negligent complication. 4. Damages: The patient suffered actual harm as a result of the negligence. TOS malpractice damages may include medical expenses for corrective surgery, rehabilitation, and ongoing care; lost wages and diminished earning capacity from inability to work; pain and suffering from permanent nerve damage; loss of enjoyment of life; and loss of consortium for the patient’s spouse or partner.

What You Should Do If You Suspect TOS Malpractice

Medical Records to Request

If you or a family member believes TOS was misdiagnosed or that a surgical procedure caused avoidable injury, the first step is obtaining complete medical records. Request emergency department records and triage notes documenting initial presentations; all imaging reports (X-rays, MRI, CT, ultrasound) with timestamps; nerve conduction study (EMG/NCS) reports and interpretations; referral letters between physicians; physical therapy records documenting duration and response to conservative treatment; operative reports (including detailed description of surgical approach, instruments used, and structures identified); anesthesia records; post-operative nursing assessments documenting neurological status; and any communications between surgeons and radiologists.

Red Flags That Suggest Malpractice

Several patterns in the medical record may indicate that the standard of care was not met: symptoms consistent with TOS documented for months or years before the diagnosis was made; carpal tunnel release, cervical fusion, or other surgery performed without considering TOS as a differential diagnosis; surgery performed without documented evidence of an adequate trial of physical therapy (three to six months); operative report that does not mention identification and protection of the phrenic nerve, long thoracic nerve, and brachial plexus; use of electrocautery near the brachial plexus or long thoracic nerve without documentation of nerve monitoring; new neurological deficit noted immediately post-operatively; and no documented informed consent discussion specifically addressing the risk of nerve injury.

New York Statute of Limitations

Under New York CPLR §214-a, medical malpractice claims must be filed within two years and six months of the date of the alleged malpractice. For surgical cases, this typically runs from the date of the negligent procedure. For diagnostic delay cases, the clock may start from the date of the last treatment by the physician who failed to diagnose TOS. Because these deadlines are strictly enforced and exceptions are limited, it is critical to consult with an attorney as early as possible.

Reducing TOS Malpractice: Standards That Should Be Met

While this page is written for patients and families, it also serves as a reference for the clinical standards that should govern TOS diagnosis and treatment. Adherence to these standards reduces the likelihood of both patient harm and malpractice exposure: Diagnostic standards: TOS should be included in the differential diagnosis of any patient with upper extremity pain, numbness, or weakness, particularly when prior treatment for other presumed diagnoses has failed. Normal EMG/NCS results should not be used as the sole basis for excluding TOS. Patients who have undergone unsuccessful carpal tunnel release or cervical surgery should be evaluated for TOS. Referral to a vascular or thoracic surgeon with TOS expertise should be made when the diagnosis is suspected. Pre-surgical standards: Neurogenic TOS patients should complete a minimum of three to six months of structured physical therapy before surgery is offered. Diagnostic scalene block and/or botulinum toxin injection should be considered to confirm the diagnosis and predict surgical response. Informed consent must specifically address the risk of brachial plexus injury, phrenic nerve injury, long thoracic nerve injury, pneumothorax, vascular injury, and symptom recurrence. Intraoperative standards: The phrenic nerve must be identified and protected before the anterior scalene muscle is divided. Nerve stimulation should be used to identify and confirm nerve function intraoperatively. Electrocautery should be used with extreme caution near the brachial plexus, long thoracic nerve, and phrenic nerve – sharp dissection is preferred in proximity to nerve structures. The first rib should be resected completely, including removal of periosteum to prevent bone regrowth. Neurological function of the upper extremity should be assessed before the patient leaves the operating room.

Frequently Asked Questions

References

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16. New York Civil Practice Law and Rules (CPLR) §214-a (Statute of limitations for medical malpractice).

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Disclaimer: This page is for educational and informational purposes only and does not constitute medical or legal advice. Every case is unique. If you believe you have a medical malpractice claim, consult with a qualified attorney. If you are experiencing symptoms of thoracic outlet syndrome, seek evaluation from a physician experienced in the diagnosis and treatment of TOS.