Thoracic Outlet

About Thoracic Outlet Syndrome

The thoracic outlet provides a space between your first rib and your collarbone for nerves and blood vessels to pass through. When this crowded passageway becomes narrowed — a condition called thoracic outlet syndrome (TOS) — it compresses the neurovascular bundle exiting the thoracic outlet, producing pain and inhibiting blood flow.

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 result from weak muscles and poor posture that alter the position of the clavicle.

If left untreated, TOS can cause blood clots and even pulmonary embolisms. Long term TOS can also lead to permanent nerve damage. TOS shares symptoms with other conditions affecting the neck, arm and shoulder, so accurate diagnosis is vital to successful rehabilitation.

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Dr. Lev Kalika
Dr. Lev Kalika

Clinical director & DC RMSK

About Neck and Shoulder Pain Specialist Dr. Lev Kalika

Dr. Kalika, clinical director of NYDNRehab, has devoted his life’s work to finding innovative and effective ways to treat musculoskeletal pain and dysfunction. Dr. Kalika is both a practitioner and a scholar, with multiple peer reviewed studies to his credit.

Dr. Kalika has revolutionized the treatment of thoracic outlet syndrome by combining advanced regenerative technologies with state-of-the-art physical therapy. His approach to thoracic outlet syndrome has achieved groundbreaking results in relieving pain and restoring optimal arm and shoulder function.

Why NYDNRehab is Your Clinic of
Choice for TOS

Physical therapy is the conventional first line of treatment for thoracic outlet compression, but physical therapy alone may not be sufficient to rehabilitate the thoracic outlet. In some cases, beginning physical therapy prior to addressing other issues may actually make the condition worse.

At NYDNRehab, we use high-resolution diagnostic ultrasonography to get a clear picture of the structures that make up the lower neck and clavicle region, to identify the exact cause of pain and rule out other conditions. When appropriate, we may use shock waves or electromagnetic therapies to reduce pain and inflammation, and to relieve pressure on the neurovascular bundle prior to beginning physical therapy.

Our advanced methodologies are rarely found in ordinary physical therapy clinics. Our treatment protocols are personalized, based on your diagnostic results. We never take a one-size-fits-all approach to patient care — we treat the whole patient, not just the symptoms. For fast and effective treatment that really works, NYDNRehab is your physical therapy clinic of choice in NYC.

Why NYDNRehab is Your Clinic of Choice for TOS

TOCS Symptoms and Causes


  • Persistent pain in the neck and shoulder region

  • Pain that worsens when carrying heavy loads

  • Reduced circulation to the hand and forearm

  • Numbness and tingling in the forearm, and the pinky and ring fingers

  • Weakness in the hand muscles when gripping


  • Physical trauma

  • Repetitive overhead movements

  • Poor posture and weak upper body muscles

  • Use of mobile devices that promote a head-forward posture

  • Anatomical defects or tumors

Accurate Diagnosis is Key to Successful TOS Treatment

Diagnosis of thoracic outlet syndrome can be challenging because the condition shares symptoms with other common disorders, including:

  • Rotator cuff injuries
  • Cervical disc compression
  • Fibromyalgia
  • Multiple sclerosis
  • Complex regional pain syndrome
  • Tumors of the spinal cord

Misdiagnosis can lead to inappropriate treatment that can worsen symptoms and prolong pain and discomfort, while failing to resolve the condition.

At NYDNRehab, we use the highest resolution diagnostic ultrasound to visualize the neck and shoulder region in real time. Our capability for superb microvascular imaging enables us to detect restrictions in blood flow in the neurovascular bundle. When combined with a thorough clinical exam and orthopedic assessment, ultrasound gives us a clear picture of the location and severity of the problem.

Accurate Diagnosis is Key to Successful TOS Treatment
TOS Treatment Options

TOS Treatment Options

Once we confirm the specific source of your pain and dysfunction, we design a personalized treatment plan, based on your diagnostic results.

Your treatment plan may include:

  • Regenerative therapies to reduce pain and inflammation and promote tissue healing
  • Posture retraining exercises
  • Ultrasound-assisted feedback training
  • Physical therapy

Our advanced technologies enable us to measure and track your progress, to ensure that your treatment protocol is achieving its intended results.


Regenerative Therapies Accelerate TOS

Regenerative technologies help to jump-start healing by stimulating tissue repair at the cellular level. Our outpatient regenerative therapies expedite recovery with minimal discomfort for the patient.

Focused Extracorporeal Shock Wave Therapy (ESWT)

Focused ESWT produces high frequency sound waves to stimulate the body’s own reparative mechanisms. It is especially effective for reducing pain and inflammation in the thoracic outlet region.

Extracorporeal Magnetic Transduction Therapy (EMTT)

EMTT is a fairly new technology that transmits high energy magnetic pulses that synchronize with the body’s own magnetic fields, triggering a regenerative response. EMTT waves can penetrate deep tissues to target difficult-to-reach areas.

Extracorporeal Pulse Activation Technology (EPAT)

Extracorporeal Pulse Activation Technology (EPAT)

Extracorporeal Pulse Activation Technology (EPAT)

EPAT, also known as defocused shock wave therapy, uses acoustic pressure waves to enhance blood circulation to targeted tissues.

High Energy Inductive Therapy (HEIT)

HEIT uses electromagnetic fields to penetrate tissues, to reactivate the electrochemical function of cells and cell membranes. HEIT stimulates the healing of compressed nerves and blood vessels.

INDIBA CT9 Radiofrequency Device

NESA Neuromodulation Therapy

NESA generates an intermittent biphasic low-frequency current that travels through autonomic neural pathways to restore neural signaling to the brain.


INDIBA therapy uses electrical current to enhance the exchange of ions in damaged cells, to accelerate healing.

Regenerative Ultrasound Guided Injection Therapies

Ultrasound Guided Injection

Injection therapies use natural/neutral solutions to stimulate cellular repair. Guidance by ultrasound ensures that the injected substances hit their mark, for maximum effectiveness.

Focused Shockwave Therapy

Platelet Rich Plasma (PRP)

PRP therapy injects platelets spun from the patient’s own blood to initiate tissue repair and accelerate healing.

Proliferation Therapy, aka Prolotherapy

Prolotherapy uses a biologically neutral solution to stimulate the body’s own natural healing mechanisms.

Prolozone Therapy

Prolozone therapy injects a combination of procaine, anti-inflammatory medications, vitamins, minerals, and a mixture of ozone/oxygen gas to reduce pain and inflammation while jump-starting the healing process.

Electromagnetic Transduction Therapy (EMTT)
Ultrasound Guided Dry Needling

Ultrasound Guided Dry Needling

Myofascial trigger points often contribute to thoracic outlet compression. Dry needling inserts thin non-medicated needles into trigger points to evoke a twitch response, releasing the trigger point and immediately relieving pain.

Ultrasound Guided Hydrodissection

Hydrodissection is a technique for treating peripheral nerve entrapment. It uses a saline solution to separate an entrapped nerve from surrounding adhesions or adjacent structures.

Ultrasound Guided Hydrodissection

Preventing TOS

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, poor posture and reduced range of motion. A regular resistance training program that targets all your major muscle groups, along with improved postural habits, can dramatically reduce your risk of developing TOS.

For athletes or people whose occupations require overhead motion, allowing ample recovery time between activity bouts is essential. Massage, stretching and exercises geared to balancing muscle tension can help prevent the thoracic outlet from narrowing. Applying ice or cryotherapy can help to reduce inflammation that contributes to TOS.

Preventing TOS

Get Personalized TOS Therapy
that Really Works

The area surrounding the neck and shoulder region is made up of a complex network of muscles, connective tissue, bones and nerves that affect both your brain and your body. Because of the region’s complexity, many musculoskeletal issues can arise that share similar symptoms with related conditions. When diagnosis is based on symptoms alone, inappropriate treatment may be prescribed that does more harm than good, costing you time and money while prolonging your pain.

At NYDNRehab, we use the most advanced diagnostic equipment and gold-standard assessments to accurately diagnose your condition. Our state-of-the-art clinic is equipped with some of the most advanced technologies available in rehabilitative medicine to treat your condition and accelerate your recovery.

Our one-on-one personalized approach to patient care sets us apart from average physical therapy clinics that rely on generic templates and timelines, and old-school approaches to physical therapy. To get the best results in the least amount of time, contact NYDNRehab today, and get back to pain-free movement.

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    TOS FAQs

    Will thoracic outlet compression go away on its own?
    If you discontinue the activities that cause TOS, it may possibly get better over time. However, there is no guarantee, and it is impossible to know the exact source of your TOS without a comprehensive clinical exam.
    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 without a clinical exam that includes imaging of the neck and shoulder region, and misdiagnosis can make things worse. It’s best to consult a professional.
    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 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 patients. Conservative care is often sufficient to successfully treat TOS. 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.
    Is TOS physical therapy painful?
    Any type of physical therapy can cause a certain degree of discomfort. At NYDNRehab, we do everything we can to minimize your pain and discomfort, and we take measures before beginning physical therapy to treat other underlying issues that may contribute to pain.

    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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