The thoracic outlet is a narrow passage located just above the first rib and behind the clavicle, near the base of your neck. It provides a space for nerves (brachial plexus) and blood vessels (subclavian vein and artery) to travel from your chest to your arm. Due to multiple factors, this already-crowded passageway can narrow, compressing the neurovascular bundle, producing pain, and inhibiting blood flow — a condition called thoracic outlet syndrome (TOS).
While technically not a shoulder condition, thoracic outlet syndrome is affected by shoulder mechanics. TOS is common in athletes who participate in overhead sports like swimming, tennis and baseball, and in certain occupations that require overhead movement, like house painting or plaster work. TOS can also arise from weak muscles and poor posture that alter the position of the clavicle.
If left untreated, TOS can cause blood clots and pulmonary embolisms, and long-term TOS can lead to permanent nerve damage. At NYDNRehab, advanced technologies, orthobiologics and holistic methodologies are redefining how thoracic outlet syndrome is diagnosed and treated.
Doctors Kalika and Brosgol are Transforming Thoracic Outlet Treatment in NYC
Dr. Lev Kalika
Clinical director & DC RMSK
Dr. Lev Kalika, DC clinical director of NYDNRehab, is an internationally recognized expert in diagnostic and musculoskeletal ultrasonography, with multiple research papers to his credit. Dr. Kalika has studied with some of the world’s most prestigious experts in diagnostic, fascia, and nerve ultrasonography, including Dr. Ben Kibler, world-renowned orthopedic surgeon and pioneer of scapular dyskinesis. Dr. Kalika has published multiple peer-reviewed studies on ultrasound-guided procedures, and has presented his research at multiple international conferences.
Dr. Yuri Brosgol
Orthobiologic specialist
Dr. Yuri Brosgol, MD is a neurologist with 20+ years of experience in treating pediatric and adult myofascial pain. Dr. Brosgol learned fascial hydro release methodology directly from Dr. Carla Stecco, the world’s leading specialist in fascial science. Dr. Brosgol has become a pioneer in the use of orthobiologic solutions, blazing the trail for transformative advancements in the treatment of musculoskeletal injuries.
Together, Dr. Kalika and Dr. Brosgol are combining their expertise to revolutionize the way myofascial injuries and pain syndromes are treated. Dr. Kalika’s successful track record of diagnosing and rehabilitating athletic injuries, combined with Dr. Brosgol’s expertise in treating myofascial pain, makes NYDNRehab the clinic of choice for thoracic outlet rehab in NYC.
Thoracic Outlet Anatomy, Types, Symptoms and Causes
The thoracic outlet is a space formed at the junction of your neck and shoulder that houses vital structures like the brachial plexus (nerves to the arm and hand), the subclavian artery that feeds your arm, and the subclavian vein that returns deoxygenated blood from your arm to your heart. The esophagus and trachea also pass through the thoracic outlet.
TOS arises when the neurovascular bundle is compressed in one of the three spaces:
The scalene triangle, located above the clavicle, where the anterior and middle scalene muscles and the first rib form a triangle.
The costoclavicular space between the clavicle and the first rib.
The subcoracoid space, located below the clavicle, near the insertion of the pectoralis minor muscle.
The nerves that form the brachial plexus emerge from the spinal cord in the neck and pass between the anterior and middle scalene muscles, responsible for forward and lateral neck flexion, head and neck rotation, and rib elevation when breathing. Tight scalene muscles, along with tight pectoral and deltoid muscles, can all contribute to compression of the brachial plexus within the thoracic outlet.
There are three subtypes of TOS:
Neurogenic TOS is the most common type, accounting for up to 95% of cases. It arises from compression of the brachial plexus, producing pain, weakness, numbness, and tingling in the arm, hand, and fingers, as well as neck pain and headaches. Neurogenic TOS is often exacerbated by overhead activities. It can be caused by hypertrophy of or trauma to the scalene muscles that assist in breathing, and head and neck movement.
Arterial TOS is rare, accounting for less than l% of cases. It arises from compression of the subclavian artery by a cervical rib – an extra rib that grows from the seventh cervical vertebra at the base of the neck, found in less than one percent of the population. Most people with a cervical rib never experience arterial TOS. Symptoms include ischemia in the arm, with symptoms of tingling and coldness. It may also produce distal emboli.
Venous TOS involves the subclavian vein, responsible for returning deoxygenated blood from the upper limb to the heart. When compressed, it can cause arm swelling, cyanosis (lack of blood oxygen), or thrombosis (blood clot formation). Venous TOS accounts for 3-5% of TOS cases.
While TOS in athletes is strongly associated with overhead sports like swimming and tennis, other factors can contribute to TOS in non-athletic populations.
Non-sports causes of TOS include:
Head-forward posture with rounded shoulders
Being overweight and out of shape
Repetitive activities involving the neck, arm and shoulder
Trauma to the clavicle (collar bone)
Having a “cervical rib”
Working at a computer
Staring at a mobile device
Lifting weights and bodybuilding
Playing a musical instrument
Holding or carrying a baby
Carrying a heavy shoulder bag
Most TOS cases can be successfully treated with holistic interventions and lifestyle modifications. Surgical options are extreme, such as scalene muscle release, where the scalene muscles are cut or partially removed to relieve pressure on the brachial plexus, or first rib resection, where part or all of the first rib is removed. TOS surgery can have serious potential complications including bleeding, nerve injury, pneumothorax (from first rib resection), and recurring symptoms post-surgery.
Accurate Diagnosis is Key to Successful TOS Treatment
Dr. Kalika has developed his own holistic methodology for diagnosing and treating conditions of the neck, shoulder and brachial plexus, using cutting edge kinematic motion analysis technology and dynamic ultrasound imaging. In addition to identifying the subtype of TOS, it is important to differentiate TOS from other conditions presenting with similar symptoms.
TOS imposters include:
Suprascapular nerve compression at the shoulder joint, often causing pain and weakness in the rotator cuff muscles
Scapular dyskinesis – abnormal position or movement of the shoulder blade
Parsonage-Turner syndrome (PTS) – a rare neurological condition marked by severe shoulder and arm pain
Quadrilateral space syndrome – compression of the axillary nerve and/or posterior humeral circumflex artery in the shoulder’s quadrilateral space
Cervical radiculopathy – compression or irritation of the nerve roots in the cervical spine
Dr. Kalika’s extensive expertise in diagnostic ultrasonography and knowledge of human anatomy equips him to differentiate between TOS and other shoulder conditions. Our advanced ultrasound technology has capabilities for superb microvascular imaging, helping us to detect blood flow restrictions originating in the neurovascular bundle.
Scapular dyskinesis – abnormal movement of the scapula during shoulder motion – can be a contributing factor in TOS. Scapular dyskinesis often involves forward head posture and rounded shoulders due to weak or dysfunctional shoulder stabilizers, altering scapular positioning, which can narrow the thoracic outlet.
Dynamic scapular stabilization requires well-coordinated muscle activation patterns, especially of the rotator, deltoid, trapezius and rhomboid muscles. ShowMotion is an objective tool for joint movement analysis that uses motion tracking sensors, placed on the patient’s skin to collect data about movement quality. Combining scapular ultrasound with ShowMotion technology provides valuable information for diagnosing and treating thoracic outlet syndrome.
The Role of Fascia in Thoracic Outlet Syndrome
Fascia is a body-wide network of connective tissue that surrounds and connects muscles, nerves, blood vessels and organs. Fascia plays a significant role in thoracic outlet syndrome (TOS). It works together with muscles to provide elastic tension – biotensegrity – that holds tissues, structures and organs in place during movement while allowing for frictionless gliding of nerves and blood vessels.
Fascia can become tight or restricted due to poor posture, repetitive movements, trauma, or scar tissue from injury or surgery. Tight fascia around the scalene and pectoralis muscles can compress the neurovascular bundle, contributing to TOS. At the same time, myofascial trigger points – hard nodules of tightly contracted fibers – can cause pain and interfere with muscle action, and fascial adhesions can restrict mobility. Identifying and treating fascial dysfunction should be a key component of TOC treatment.
Interventions for fascial restrictions that contribute to TOC include:
Ultrasound-guided dry needling, to eliminate myofascial trigger points
Stecco fascial manipulation, to restore the functional properties of damaged fascia
Manual myofascial release to break up adhesions and release entrapped nerves and blood vessels
Fascial hydrodissection, to free up densified fascial layers
Postural correction therapy, to optimize biotensegrity
ShowMotion
ShowMotion is an objective tool for joint movement analysis that uses motion tracking sensors, placed on the patient’s skin to collect data about movement quality. The patient performs a series of joint-specific movements, and the data is analyzed by ShowMotion’s proprietary software and displayed on a computer screen. The collected information provides valuable insights about inefficient movement patterns, compensation patterns, and improvements in movement in response to therapy, enabling us to personalize your TOS rehabilitation.
Neuralign Shoulder Pacemaker
The Neuralign Shoulder Pacemaker is a shoulder rehabilitation device with a kinematic sensor activated by movement. The patient dynamically interacts with the device to stimulate efficient muscle recruitment patterns, enhance movement quality, and restore optimal muscle balance during rehabilitation. The sensor provides objective data that practitioners can use to support decision-making and personalize shoulder rehabilitation.
SM Neuromuscular Electrical Stimulation (SMNMES)
SM neuromuscular electrical stimulation (NMES) dynamically interacts with the patient during therapeutic exercises, providing real-time sensory, auditory and visual biofeedback to the patient. This breakthrough technology helps patients to recalibrate muscle actions, to optimize joint function. SMNMES has helped numerous patients to avoid unnecessary shoulder surgeries, even in complex scenarios.
During PENS treatment, filament-thin needles are inserted through the skin into muscle tissue adjacent to the targeted nerve. A low frequency electrical current is then delivered via the inserted needles to stimulate the dysfunctional nerve. PENS normalizes nerve activity, improves brain plasticity and optimizes muscle recruitment patterns. This therapy is so effective that patients typically need only 4-6 treatment sessions.
Regenerative Therapies Enhance TOS Treatment Outcomes
Regenerative therapies are non-invasive interventions that harness the power of sound, electromagnetic, and radiofrequency waves to stimulate a healing response in damaged tissues. The waves promote healing by attracting stem cells, growth factors and other biological agents to the treatment site. We use regenerative technologies in conjunction with manual therapies, orthobiologics, and physical therapy to enhance treatment effects and accelerate recovery from TOS syndrome.
Many clinics advertise shockwave therapy, but NYDNRehab is one of the few clinics to use radial, linear, focused and defocused shockwaves, guided by ultrasound, to promote tissue healing and restore biotensegrity. In addition to reducing pain and inflammation, ESWT helps to realign collagen fibers, promotes fascial tissue hydration, and helps to restore tissue gliding.
Extracorporeal Magnetic Transduction Therapy (EMTT)
EMTT transmits high energy magnetic pulses to targeted tissues that synchronize with the body’s own magnetic fields, triggering a regenerative response. EMTT waves can penetrate deep tissues to target difficult-to-reach deep fascial planes.
INDIBA Radiofrequency Therapy
INDIBA is a form of TECAR therapy that helps to restore the ionic charge of damaged cells, for faster injury healing and rehabilitation. We use INDIBA in conjunction with other regenerative technologies to optimize treatment outcomes.
We Guide Our Orthobiologic Procedures with High-Resolution Ultrasound Imaging
Orthobiologic injection therapies use natural/neutral solutions, injected with precision thanks to ultrasound guidance. The injected solutions stimulate cellular repair by either nourishing or irritating the targeted cells. Orthobiologics are also effective for separating densified fascial layers and restoring their functional properties. Ultrasound guidance ensures injection accuracy and protects nerves and blood vessels from accidental penetration.
Platelet Rich Plasma (PRP)
PRP therapy uses a sample of the patient’s own whole blood, spun in a centrifuge to extract a high concentration of platelets. When injected into damaged tissues, PRP initiates tissue repair by releasing biologically active agents such as growth factors, cytokines, lysosomes and adhesion proteins. To be effective, it is critical to use the right concentration and quality of platelets, and to and follow proper isolation techniques.
Matrix PRP
Matrix is a highly concentrated PRP, diluted and mixed with fibrinogen. At the injection site, the solution becomes a gel-like collagenous substance that adheres to the walls of tears and ruptures, filling the space between them with a fibrin matrix that helps to stabilize growth factors and attract stem cell migration to the treatment site.
Prolotherapy
Prolotherapy uses a biologically neutral solution to irritate stubborn tissues, triggering the body’s innate healing mechanisms to grow new normal fibers. Prolotherapy is often used for slow-to-heal tissues like fascia, tendons and ligaments, where low vascularity inhibits tissue healing.
Hyaluronic Acid Injections
Hyaluronic acid is a natural component of joint synovial fluid and fascial tissue. Its slippery gel-like properties provide lubrication that reduces friction, enabling joints, muscles and fascia to glide freely without pain. Hyaluronic acid injections can help to restore hydration to fascial layers.
Interfascial Plane and Nerve Hydrodissection
The hydrodissection procedure injects a saline solution into densified fascial layers under ultrasound guidance, separating the layers and releasing entrapped nerves and blood vessels. Hydrodissection is often used in conjunction with manual fascial manipulation, to fully restore fascial integrity.
Preventing Thoracic Outlet Syndrome
For non-athletes, one of the key contributors to TOS is being out of shape. When the muscles that support your upper body are weak, tight or imbalanced, the structures can collapse on themselves, leading to nerve compression, vascular restriction, joint misalignment and reduced range of motion. A resistance training program designed to balance muscle tension and optimize posture can dramatically reduce your risk of developing TOS.
For athletes, ample recovery time between training sessions is essential. Massage, stretching and cross-training exercises can help to balance muscle tension and prevent the thoracic outlet from narrowing. Cold therapy can help reduce inflammation that contributes to TOS.
Get Personalized TOS Therapy that Really Works
The neck and shoulder region is made up of a complex network of bones, muscles, connective tissues, nerves, and blood vessels, and many factors can contribute to thoracic outlet syndrome. At NYDNRehab, we use high-resolution ultrasound imaging to differentiate TOC from imposters. Our holistic and personalized approach ensures that you get the most appropriate TOS treatment, for fast and enduring results, without drugs or surgery.
Our Patient Our patient is a 29 year-old female with Ehlers-Danlos syndrome who was experiencing sharp and burning thoracic pain. She is tender to the touch, which reproduces her pain. The Challenge The patient had had correction surgery for scoliosis as a child, where growing rods were implanted that can be lengthened periodically as the […]
Will thoracic outlet compression go away on its own?
If you discontinue the activities and behaviors that cause TOS, it may possibly get better over time. However, there is no guarantee that your condition will improve, and without a comprehensive clinical exam and advanced diagnostic imaging, it is impossible to differentiate TOS from other conditions with similar symptoms.
How can I tell if I have thoracic outlet compression versus other conditions that affect the neck and shoulders?
There is no way to differentiate TOS from other conditions based on symptoms alone. Accurate diagnosis requires a physical exam that includes imaging of the entire neck and shoulder region. Look for an experienced clinician with specialized training in the nerves and structures of the neck and shoulder region.
How many sessions will it take to rehabilitate my TOS?
TOS can vary greatly from one patient to the next. It may involve nerve compression, vascular constriction, or both, with varying degrees of severity. Rehabilitation in part depends on your physical condition going into treatment, your compliance with your prescribed protocol, and your unique anatomy. By personalizing your treatment protocol, we ensure that you get the exact type and amount of treatment you need to fully recover from TOS.
Can I just get surgery to fix my TOS?
While surgical interventions are available, surgery is not recommended for most TOS patients. In 90 percent or more of patients, conservative care is sufficient to successfully treat TOS, especially if your therapy includes advanced technologies and procedures. If you opt for surgery, there is no guarantee of success, and in cases other than trauma, surgery does not address the underlying causes of TOS.
Who is at risk for thoracic outlet syndrome?
Thoracic outlet syndrome can affect anyone, but certain populations are more at risk than others:
Athletes in sports with repetitive overhead arm motion, like tennis and swimming
People in certain occupations, including painters, window washers, and violinists
Adults aged 20 to 40
Women are more prone to TOS than men
People with neck-forward posture and rounded shoulders
People with prior neck and shoulder injuries
In this instance, an athlete was originally diagnosed with minor quadriceps muscle strain and was treated for four weeks, with unsatisfactory results. When he came to our clinic, the muscle was not healing, and the patients’ muscle tissue had already begun to atrophy.
Upon examination using MSUS, we discovered that he had a full muscle thickness tear that had been overlooked by his previous provider. To mitigate damage and promote healing, surgery should have been performed immediately after the injury occurred. Because of misdiagnosis and inappropriate treatment, the patient now has permanent damage that cannot be corrected.
The most important advantage of Ultrasound over MRI imaging is its ability to zero in on the symptomatic region and obtain imaging, with active participation and feedback from the patient. Using dynamic MSUS, we can see what happens when patients contract their muscles, something that cannot be done with MRI. From a diagnostic perspective, this interaction is invaluable.
Dynamic ultrasonography examination demonstrating the full thickness tear and already occurring muscle atrophy due to misdiagnosis and not referring the patient to proper diagnostic workup
Demonstration of how very small muscle defect is made and revealed to be a complete tear with muscle contraction under diagnostic sonography (not possible with MRI)
Complete tear of rectus femoris with large hematoma (blood)
Separation of muscle ends due to tear elicited on dynamic sonography examination
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Lev Kalika 
Rostyslav Bubnov 
