Information for health professionals

“NTOS (neurogenic thoracic outlet syndrome) is a real diagnosis, but one that is often made late – delayed by years in some cases. Outcomes, in turn, depend on the time from symptom onset to therapy (surgical and nonsurgical). If the primary care physician has a reasonable level of suspicion and can make the diagnosis early, he or she has significantly impacted the life of a patient. Do this and you are a hero.” (Illig et al., 2013)

The Thoracic Outlet Syndrome Centre of Excellence (TOSCOE®) held at The Cherington Practice provides diagnosis and co-ordinated care for over 100 patients a year with TOS. Rob Patterson and his team have had an interest in the management of all forms of TOS for many years. Encompassing a multidisciplinary approach to this challenging condition we have developed close relationships with diagnostic and interventional radiologists, pain management clinicians, surgeons and other specialists.

We provide care for all ages including for example the young teenage athlete through to the more elderly patient who experiences symptoms of TOS amongst many other health issues.

We uniquely offer a diagnostic scalene block service for the diagnosis of TOS as well as Botox injections for its management through our interventional radiology pathway.

Our specialist physiotherapy treatment programme brings together the most effective treatments for NTOS identified through the years and from around the world.

We have and continue to build links to surgeons with an interest in the management of TOS all over the UK and within specialist units in the USA.

Our care for patients with TOS includes the use of questionnaires as used by high volume TOS clinics as well as providing long-term follow-up for those who have been through our recovery programme.

Could your patient have neurogenic thoracic outlet syndrome (NTOS) or neurogenic pectoralis minor syndrome (NPMS)?

NTOS should be defined by the presence of three of the following four criteria.

1. Local findings

a. History: Symptoms consistent with irritation or inflammation at the site of compression – scalene triangle in the case of NTOS and pectoralis insertion site in the case of NPMS – along with symptoms due to referred pain in the areas near the thoracic outlet. Patients may complain of pain in the chest wall, axilla, upper back, shoulder, trapezius region, neck, or head (including headache).

b. Examination: Pain on palpation of the affected area as above.

2. Peripheral findings

a. History: Arm or hand symptoms consistent with central nerve compression. Such symptoms can include numbness, pain, paresthesias, vasomotor changes, and weakness (with muscle wasting in extreme cases).

i. These peripheral symptoms are often exacerbated by manoeuvres that either narrow the thoracic outlet (lifting the arms overhead) or stretch the brachial plexus (dangling; often driving or walking/running).

b. Examination: Palpation of the affected area (scalene triangle or pectoralis minor insertion site) often reproduces the peripheral symptoms.

i. Peripheral symptoms are often produced or worsened by provocative manoeuvres that are believed to narrow the scalene triangle (EAST) or to stretch the brachial plexus (ULTT).

3. Absence of other reasonably likely diagnoses (cervical disc disease, shoulder disease, carpal tunnel syndrome, chronic regional pain syndrome, brachial neuritis) that might explain the majority of symptoms.

4. In those who undergo it, the response to a properly performed test injection is positive.

(Illig et al., 2016)

Referring a patient

If you are a GP, Consultant or other healthcare professional interested in having us evaluate and/or treat a patient that you think might have a form of thoracic outlet syndrome (TOS), please contact us on 0117 9625195 or email