TOS is a clinical diagnosis.


Clinical assessment is key

This is a relatively uncommon condition and so other more common conditions affecting the shoulder girdle and upper limb often need to be considered as part of the differential diagnoses, and the less experienced practitioner may have difficulty distinguishing many of the associated symptoms & signs.

The clinical features relate to the structure affected, e.g. pressure on the nerves can cause pins & needles, numbness, ache/ pain or even weakness in the upper limb. The distribution of the symptoms will depend on the affected nerve. When the artery is involved, pallor and coolness of the hand can sometimes be evident. Conversely, if the vein is affected, swelling and discolouration of the hand may be observed. Not uncommonly, a combination of symptoms is encountered. There may be subtle physical changes which may be detected by an experienced doctor. A movement assessment (also known as kinesiological assessment) is often required to provide a comprehensive assessment.

The accuracy and reliability of clinical assessment improves with experience and treating a larger number of patients.


Tests may sometimes be required

Tests can be helpful when used appropriately. An ultrasound of the arteries and veins can sometimes show changes which point to this diagnosis. These changes might only be seen when the arm or shoulder is moved to a certain position. Similarly, a CT or MRI scan can sometimes be useful in excluding other conditions or to aid in treatment planning. A simple neck x-ray can demonstrate the rare occurrence of a cervical rib, but not inevitably so. Other tests may sometimes be performed to look at the possibility of other conditions e.g. cervical spondylosis or carpal tunnel syndrome. It is important to realise that a negative test does not exclude thoracic outlet syndrome. Occasionally, invasive tests may be required such as nerve conduction studies, scalene muscle blocks or angiography.


And not forgetting other conditions

Problems around the neck, shoulder, arms & hands are common. They may exist either alone or together with TOS. These include:

  • Cervical spine disease
  • Shoulder pathology of musculoskeletal origin
  • Nerve compression in the elbow, forearm and wrist (e.g. carpal tunnel syndrome)
  • Neuropathies from other medical conditions
  • Autoimmune diseases presenting as Raynaud’s phenomena.
  • Intrinsic spinal cord pathology


What this means:

When you see your specialist, the assessment can sometimes be a lengthy process. Reaching a diagnosis may require more than one visit and involve various tests. Whilst tests may sometimes yield a clear result or be supportive of the condition, diagnosis remains a clinical one in the majority of patients. Eliciting these symptoms and signs is based on knowledge of the surgical anatomy and physiology. A knowledge of the natural history and experience will play a role as well. The absence of other conditions may be supportive of this diagnosis although the presence of other conditions does not preclude it either.

Unfortunately, no single test can reliably identify this condition. Experienced clinicians have a better rate of positive diagnostic correlation but will not be fully accurate all the time.


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Contacting Us


The Small Print

Mr Colin Chan
Consultant Vascular Surgeon
Wirral University Teaching Hospital
Wirral CH49 5PE

Mrs Louise Rule
Wirral University Teaching Hospital
Wirral CH49 5PE

(+44 151 604 7530)


Spire Wirral Hospital
Holmwood Drive
Wirral CH61 1AU

(+44 151 929 5181)

Spire Manchester Hospital
170 Barlow Moor Road
Manchester M20 2AF

(+44 161 447 6600)