Go Ahead & Brush Your Shoulder Off: Thoracic Outlet Syndrome in the ED

Thoracic outlet syndrome is a compression disorder of the brachial plexus, subclavian vein, or subclavian artery that is often missed early in the ED. Neurogenic disease causes pain and paresthesias, while vascular disease can present with arm swelling, limb ischemia, stroke, or pulmonary embolism.

Thoracic Outlet Syndrome Recognition

• Three-compartment compression anatomy: TOS arises where the neurovascular bundle is crowded at the scalene triangle, costoclavicular space, or beneath the pectoralis minor, a useful frame for otherwise scattered shoulder, arm, and vascular complaints.
• Neurogenic versus vascular patterns: Neurogenic TOS is most common and points to C8-T1 symptoms, neck or shoulder pain, and hand weakness, while venous or arterial disease shifts the picture toward edema, cyanosis, claudication, or ischemia.
• Swollen arm red flag: Venous TOS is the form that produces true unilateral arm swelling and heaviness from subclavian vein compression, a pattern worth separating from cellulitis, DVT, or musculoskeletal shoulder pain.
• Ischemic complication spectrum: Arterial TOS can present with pallor, cold intolerance, distal embolic symptoms, and even stroke, underscoring why missed vascular disease is more than a chronic pain diagnosis. We get into the bedside consequences in the episode.
• Gilliatt-Sumner hand finding: Thenar or hypothenar wasting, the classic Gilliatt-Sumner hand, is a high-credibility clue to chronic neurogenic TOS rather than a routine overuse complaint.

Exam, Imaging, and Disposition

• Provocative bedside maneuvers: Roos, Adson, and Wright testing can support the diagnosis when they reproduce pain, paresthesias, pallor, cyanosis, or pulse change, but none should be treated as a stand-alone rule-in test.
• Roos test signal: The elevated arm stress test is commonly abnormal in TOS; inability to complete the maneuver because of worsening symptoms is more concerning than simple forearm fatigue.
• Vascular imaging pathway: Suspected venous TOS starts with venous ultrasound, while arterial disease pushes toward Doppler studies, angiography, or CT angiography in a position that can reveal dynamic compression.
• Conservative first-line care: Most neurogenic cases begin with physical therapy and symptom control using agents such as ibuprofen or muscle relaxants, while vascular thrombosis changes the urgency and trajectory of care.
• Admission and consultation triggers: Ischemia, venous or arterial thrombosis, aneurysm, stenosis, or intractable pain should prompt admission and vascular surgery involvement, with thrombolysis and decompression reserved for selected cases. We walk through where the ED handoff matters in the chapter.

References:

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