Medicine:Thoracic outlet syndrome

From HandWiki
Short description: Compression of nerves or blood vessels between the neck and ribcage
"NTOS" redirects here. For the Windows NT microkernel used in computing, see Windows NT kernel.

Thoracic outlet syndrome
The right brachial plexus, viewed from in front.
SpecialtyVascular surgery, thoracic surgery
SymptomsPain, weakness, loss of muscle at the base of the thumb, swelling, paleness, bluish coloration[1][2]
Usual onset20 to 50 years of age[1]
TypesNeurogenic, venous, arterial[1]
CausesCompression of the nerves, arteries, or veins in the superior thoracic aperture (thoracic outlet), the passageway from the lower neck to the armpit[1]
Risk factorsTrauma, repetitive arm movements, tumors, pregnancy, cervical rib[1]
Diagnostic methodNerve conduction studies, medical imaging[1]
Differential diagnosisCarpal Tunnel Syndrome (wrist), Rotator cuff tear, cervical disc disorders, fibromyalgia, multiple sclerosis, complex regional pain syndrome,[1] pectoralis minor syndrome[3]
TreatmentPain medication, surgery[1][2]
Frequency~1%[4]

Thoracic outlet syndrome (TOS) is a condition in which there is compression of the nerves, arteries, or veins in the superior thoracic aperture, the passageway from the lower neck to the armpit, also known as the thoracic outlet.[1] There are three main types: neurogenic, venous, and arterial.[1] The neurogenic type is the most common and presents with pain, weakness, paraesthesia, and occasionally loss of muscle at the base of the thumb.[1][2] The venous type results in swelling, pain, and possibly a bluish coloration of the arm.[2] The arterial type results in pain, coldness, and pallor of the arm.[2]

TOS may result from trauma, repetitive arm movements, tumors, pregnancy, or anatomical variations such as a cervical rib.[1] The diagnosis may be supported by nerve conduction studies and medical imaging.[1] TOS is difficult to diagnose and there are many potential differential diagnoses as well as other diseases that are often co-occurrent with TOS.[5]

Initial treatment for the neurogenic type is with exercises to strengthen the chest muscles and improve posture.[1] NSAIDs such as naproxen may be used for pain.[1] Surgery is typically done for the arterial and venous types and a decompression for the neurogenic type if it does not improve with other treatments.[1][2] Blood thinners may be used to treat or prevent blood clots.[1] Due in part to inconsistent definitions and diagnostic criteria among TOS research, the true incidence of TOS is unknown; estimates have ranged from as low as a handful per 100,000 to around 1% of the population.[4][6] It is more common in women than men and it occurs most commonly between 20 and 50 years of age.[1] The condition was first described in 1818 and the current term "thoracic outlet syndrome" first used in 1956.[2][7]

Signs and symptoms

Only 1% of people with carpal tunnel syndrome have concomitant TOS.[8]

Repetitive motions can cause enlargement of muscles which causes compression of veins. Besides, overuse injury of the upper limbs causes swellings, small bleeding, and subsequent fibrosis which would cause the thrombosis of the subclavian vein, leading to Paget–Schroetter disease or effort-induced thrombosis.[8]

Pemberton's sign is a clinical sign elicited by having the patient hold their arms above their head for 1 minute. The development of facial plethora, cyanosis, inspiratory stridor and non-pulsatile elevation of the JVP is indicative of TOS.[9]

TOS can be related to cerebrovascular arterial insufficiency when affecting the subclavian artery.[10] It also can affect the vertebral artery, in which case it could produce vision disturbances, including transient blindness,[11] and embolic cerebral infarction.[12]

TOS can also lead to eye problems and vision loss as a circumstance of vertebral artery compression. Although very rare, if compression of the brain stem is also involved in an individual presentation of TOS, transient blindness may occur while the head is held in certain positions.[11] If left untreated, TOS can lead to neurological deficits as a result of the hypoperfusion and hypometabolism of certain areas of the brain and cerebellum.[13]

TOS has similar symptoms to pectoralis minor syndrome (PMS), which usually results from compression of the brachial plexus beneath the pectoralis minor muscle (while neurogenic TOS is caused by compression of the same nerves above the clavicle).[14] Unlike TOS there are typically few headaches or neck pain in patients with PMS only, instead there is pain in the chest area.[15] Initially, it was believed that 95 percent of patients with TOS had nerve compression in the scalene area, but in the twenty-first century it is now recognized that the majority have nerve compression under the pectoralis minor, either by itself or in addition to the scalene area.[16] One study of 100 patients diagnosed with neurogenic TOS found that 75 percent had neurogenic PMS and 30 percent in fact had PMS without TOS.[3][16]

Causes

Thoracic outlet syndrome

TOS can be attributed to one or more of the following factors:[17]

  • Congenital abnormalities are frequently found in persons with TOS. Bone abnormalities include the presence of a cervical rib and a prolonged transverse process.[17] Soft tissue abnormalities include scalene muscle hypertrophy, the presence of a fourth scalene muscle (scalenus minimus), or connective tissue abnormalities.[18]
  • Trauma (e.g., whiplash injuries) or repetitive strain is frequently implicated.[17]
  • Injury, such as first rib fracture or clavicle fracture.[18]
  • Rarer acquired causes include tumors (especially pancoast tumor), hyperostosis, and osteomyelitis.[17]

Up to 15% of neurogenic TOS cases are idiopathic.[19]

Diagnosis

Historically, TOS has been difficult to diagnose, and has been considered a diagnosis of exclusion.[20] However, recent efforts have been made to define TOS and formalize diagnostic criteria in an attempt to make TOS research consistent.[21] The criteria for the three types of TOS—neurogenic, venous, and arterial—differ; for example, a diagnosis of venous or arterial TOS requires medical imaging, while neurogenic TOS does not, though such imaging is useful in excluding conditions that share similar symptoms.[21] In rare cases when doctors find objective findings of nerve compression not attributable to another condition, it is called "true" neurogenic TOS. However, when there is no specified pathological evidence, it is called "disputed" neurogenic TOS.[22] The value of this clinical distinction has also been challenged in recent years.[21]

Several provocative tests have seen use in clinical examinations. For neurogenic TOS, common tests include the elevated arm stress test (EAST), also called the Roos stress test, and the upper limb tension test (ULTT). These tests have high sensitivity but low specificity, meaning their main value is in potentially excluding neurogenic TOS as a diagnosis, but testing positive should raise suspicions that neurogenic TOS may be present.[23][24] Adson's sign and the costoclavicular maneuver lack specificity and sensitivity and should make up only a small part of the mandatory comprehensive history and physical examination undertaken with a patient suspected of having TOS. Additional maneuvers that may be abnormal in TOS include Wright's test, which involves hyperabducting the arms over the head with some extension and evaluating for loss of radial pulses or signs of blanching of the skin in the hands indicating a decrease in blood flow with the maneuver. The "compression test" is also used, exerting pressure between the clavicle and medial humeral head causes radiation of pain and/or numbness into the affected arm.[25]

Doppler arteriography, with probes at the fingertips and arms, tests the force and "smoothness" of the blood flow through the radial arteries, with and without having the patient perform various arm maneuvers (which causes compression of the subclavian artery at the thoracic outlet). The movements can elicit symptoms of pain and numbness and produce graphs with diminished arterial blood flow to the fingertips, providing strong evidence of impingement of the subclavian artery at the thoracic outlet.[26] Doppler arteriography does not utilize probes at the fingertips and arms, and in this case is likely being confused with plethysmography, which is a different method that utilizes ultrasound without direct visualization of the affected vessels. Doppler ultrasound (not really 'arteriography') would not be used at the radial artery in order to make the diagnosis of TOS. Finally, even if a Doppler study of the appropriate artery were to be positive, it would not diagnose neurogenic TOS, by far the most common subtype of TOS. There is plenty of evidence in the medical literature to show that arterial compression does not equate to brachial plexus compression, although they may occur together, in varying degrees. Additionally, arterial compression by itself does not make the diagnosis of arterial TOS (the rarest form of TOS). Lesser degrees of arterial compression have been shown in normal individuals in various arm positions and are thought to be of little significance without the other criteria for arterial TOS. [citation needed]

MRI scan can show the anatomy of the thoracic outlet, the soft tissues causing compression, and can show directly the brachial plexus compression.[8]

It has been reported by advanced physiotherapist Rob Patterson that the UK lags behind the US on obtaining a diagnosis for the condition.[27]

Classification

By structures affected and symptomatology

There are three main types of TOS, named according to the cause of the symptoms; however, these three classifications have been coming into disfavor because TOS can involve all three types of compression to various degrees. The compression can occur in three anatomical structures (arteries, veins and nerves), it can be isolated, or, more commonly, two or three of the structures are compressed to greater or lesser degrees. In addition, the compressive forces can be of different magnitude in each affected structure. Therefore, symptoms can be variable.[28]

  • Neurogenic TOS includes disorders produced by compression of components of the brachial plexus nerves. The neurogenic form of TOS accounts for anywhere from 80 to 95% of all cases of TOS.[29][6]
  • Venous TOS is due to compression of the subclavian vein.[29] This makes up about 4 to 20% of cases.[2][6]
  • Arterial TOS is due to compression of the subclavian artery.[29] This is less than one percent of cases.[2] However, this type maybe mistakenly provided as a diagnosis when the patient may actually have NTOS. This is due to misconceptions regarding loss of pulse and compression with arm elevation without any signs of damage, a clot or an aneurysm to the artery.[30]

By event

There are many causes of TOS. The most frequent cause is trauma, either sudden (as in a clavicle fracture caused by a car accident), or repetitive (as in a legal secretary who works with his/her hands, wrists, and arms at a fast-paced desk station with non-ergonomic posture for many years) . TOS is also found in certain occupations involving much lifting of the arms and repetitive use of the wrists and arms [citation needed]. remity activity can lead to a specific subtype of venous TOS known as Paget–Schroetter syndrome, which involves thrombosis of the subclavian vein and typically occurs in otherwise young and healthy individuals.[31]

One cause of arterial compression is trauma, and a recent case involving fracture of the clavicle has been reported.[32]

The two groups of people most likely to develop TOS are those with neck injuries due to traffic accidents and those who use computers in non-ergonomic postures for extended periods of time. TOS is frequently a repetitive stress injury (RSI) caused by certain types of work environments{{Citation needed|date=February 2018

By structure causing constriction

  • Anterior scalene syndrome (compression on brachial plexus and/or subclavian artery caused by muscle growth).
  • Cervical rib syndrome (compression on brachial plexus and/or subclavian artery caused by bone growth).
  • Costoclavicular syndrome (narrowing between the clavicle and the first rib) – diagnosed with the costoclavicular maneuver.


Treatment

Evidence for the treatment of thoracic outlet syndrome as of 2014 is poor.[33]

Physical measures

  • One commonly prescribed set of stretches includes moving the shoulders anteriorly (forward – called "hunching"), then back to a neutral position, then extending them posteriorly (backward, called "arching"), then back to neutral, followed by lifting the shoulders up as high as possible, and then back down to neutral, repeated in cycles as tolerated.
  • Another set of stretches involves tilting and extending the neck opposite to the side of the injury while keeping the injured arm down or wrapped around the back.
  • Occupational or Physical therapy can include passive or active range of motion exercises, working up to weighted or restricted sets (as tolerated).

TOS is rapidly aggravated by poor posture. Active breathing exercises and ergonomic desk setup and motion practices can help maintain active posture.{{Citation needed|date=February 2018} weak due to prolonged (years of) "hunching" and other poor postures.[citation needed]

Medications

In a review, botox was compared to a placebo injected into the scalene muscles. No effect in terms of pain relief or improved movement was noted. However, in a six-months follow-up, paresthesia (abnormal sensations such as in pins and needles) was seen to be significantly improved.[33]

Surgery

Surgical approaches have also been used successfully in TOS. Microsurgery can be used approaching the area from above the collar bone (supraclavicular) followed by neurolysis of the brachial plexus, removal of part or all of the anterior scalene muscle, and the release of the underlying (subclavicular) blood vessels. This approach avoids the use of resection, and has been found to be an effective treatment.[34] In cases where the first rib (or a fibrous band extending from the first rib) is compressing a vein, artery, or the nerve bundle, part of the first rib and any compressive fibrous tissue, can be removed in a first rib resection and thoracic outlet decompression surgical procedure; scalene muscles may also need to be removed (scalenectomy). This allows increased blood flow and the reduction of nerve compression.[35] In some cases there may be a rudimentary rib or a cervical rib that can be causing the compression, which can be removed using the same technique.

Cases

Sports

Several Major League Baseball players, especially pitchers, have been diagnosed with thoracic outlet syndrome, including Robert Stock,[36] Stephen Strasburg, Chris Archer, Matt Harvey,[37] Chris Carpenter,[38] Jaime Garcia,[39] Shaun Marcum,[40] Matt Harrison,[41] Clayton Richard,[42] Nate Karns,[43] Noah Lowry,[44] and Zack Wheeler.[45] Starting pitcher Chris Young, who previously struggled with shoulder problems, underwent surgery for TOS in 2013 and felt "completely different" post-recovery.[46] Young exceeded expectations on his return to the major leagues at age 35, becoming a valuable member of the 2014 Seattle Mariners' starting rotation.[47] In July 1980, Houston Astros starting pitcher J.R. Richard collapsed while playing a game of catch, and was found to have experienced a stroke due to severe blockage of his right carotid artery. Given the fact that shortly beforehand, he had been found to have near-total obstruction of the arteries supplying his right arm, he was eventually diagnosed with extensive arterial thoracic outlet syndrome. Although he attempted a comeback, his professional baseball career was effectively ended.[48]

NHL defenseman Adam McQuaid was diagnosed with TOS in September 2012, and as a result was nominated for the Bill Masterton Memorial Trophy.[49] Forward Chris Kreider was diagnosed with a malformed rib in 2017. Kreider dealt with multiple symptoms prior to the diagnosis, such as shortness of breath on the ice, swelling/numbness in his right arm, coughing up blood and a blood clot in his right arm. Kreider underwent successful surgery to resect a rib in January 2018 (the same surgery as TOS) and has performed well since returning to the Rangers.[50]

NBA guard Markelle Fultz was diagnosed with TOS in December 2018, which is considered to be the reason Fultz could not perform in the NBA as he did in college.[51][52]

UFC fighter Matt Serra had a rib removed to alleviate TOS.[53]

British rock-climber and 2024 Olympic gold-medalist Toby Roberts was diagnosed with TOS in late 2025.[54]

Music

Musician Isaac Hanson had a pulmonary embolism as a consequence of thoracic outlet syndrome.[55]

The Japanese band Maria disbanded in 2010 due to drummer Tattsu's TOS which made it impossible for her to continue playing.[56]

In 2015, singer Tamar Braxton had to leave Dancing With The Stars due to TOS.[57]

See also

References

  1. ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 1.15 1.16 1.17 "NINDS Thoracic Outlet Syndrome Information Page". December 28, 2011. https://medlineplus.gov/thoracicoutletsyndrome.html. 
  2. ↑ 2.0 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 "Thoracic outlet syndrome". The Journal of the American Academy of Orthopaedic Surgeons 23 (4): 222–32. April 2015. doi:10.5435/jaaos-d-13-00215. PMID 25808686. 
  3. ↑ 3.0 3.1 Sanders, Richard J.; Rao, Neal M. (2010). "The Forgotten Pectoralis Minor Syndrome: 100 Operations for Pectoralis Minor Syndrome Alone or Accompanied by Neurogenic Thoracic Outlet Syndrome". Annals of Vascular Surgery 24 (6): 701–708. doi:10.1016/j.avsg.2010.02.022. PMID 20471786. 
  4. ↑ 4.0 4.1 (in en) Vascular and Endovascular Surgery: A Comprehensive Review (8 ed.). Elsevier Health Sciences. 2012. p. 524. ISBN 978-1-4557-5386-4. https://books.google.com/books?id=XN5dI55iwbMC&pg=PA524. 
  5. ↑ Povlsen, Sebastian; Povlsen, Bo (2018). "Diagnosing Thoracic Outlet Syndrome: Current Approaches and Future Directions". Diagnostics 8 (1): 21. doi:10.3390/diagnostics8010021. PMID 29558408. 
  6. ↑ 6.0 6.1 6.2 Illig, Karl A.; Rodriguez-Zoppi, Eduardo; Bland, Travis; Muftah, Mayssan; Jospitre, Elodie (January 2021). "The Incidence of Thoracic Outlet Syndrome". Annals of Vascular Surgery 70: 263–272. doi:10.1016/j.avsg.2020.07.029. ISSN 1615-5947. PMID 32771464. https://pubmed.ncbi.nlm.nih.gov/32771464. 
  7. ↑ "Clinical incidence and prevalence: basic data on the current scope of the problem." (in en). Thoracic Outlet Syndrome. London: Springer Science & Business Media. 2014. pp. 25–28. ISBN 978-1-4471-4366-6. https://books.google.com/books?id=vgvABAAAQBAJ&pg=PA25. 
  8. ↑ 8.0 8.1 8.2 "Thoracic Outlet Syndrome: A Comprehensive Review of Pathophysiology, Diagnosis, and Treatment". Pain and Therapy 8 (1): 5–18. June 2019. doi:10.1007/s40122-019-0124-2. PMID 31037504. 
  9. ↑ Talley, Nicholas; O'Connor, Simon (in en). Talley and O'Connor's Clinical Examination, 10th Edition. p. 189. 
  10. ↑ "[The thoracic outlet compression syndrome and its vascular complications]". Zentralblatt für Chirurgie 110 (8): 449–56. 1985. PMID 4002908. 
  11. ↑ 11.0 11.1 "Rotational vertebrobasilar insufficiency as a component of thoracic outlet syndrome resulting in transient blindness. Case report". Journal of Neurosurgery 81 (4): 617–9. October 1994. doi:10.3171/jns.1994.81.4.0617. PMID 7931599. 
  12. ↑ "Arterial thoracic outlet syndrome with embolic cerebral infarction. Report of a case". Panminerva Medica 42 (4): 295–7. December 2000. PMID 11294095. 
  13. ↑ "Neck and brain transitory vascular compression causing neurological complications. Results of surgical treatment on 1,300 patients". The Journal of Cardiovascular Surgery 37 (6 Suppl 1): 155–66. December 1996. PMID 10064369. 
  14. ↑ Sanders, Richard J.; Annest, Stephen J. (2014). "Thoracic outlet and pectoralis minor syndromes". Seminars in Vascular Surgery 27 (2): 86–117. doi:10.1053/j.semvascsurg.2015.02.001. PMID 25868762. 
  15. ↑ Sanders, Richard J.; Donahue, Dean M. (2021). "Pathology and Pathophysiology of NTOS" (in en). Thoracic Outlet Syndrome. Springer International Publishing. p. 59. ISBN 978-3-030-55073-8. 
  16. ↑ 16.0 16.1 Sanders, Richard J.; Annest, Stephen J. (2021). "Anatomy of the Thoracic Outlet and Related Structures" (in en). Thoracic Outlet Syndrome. Springer International Publishing. pp. 38, 43. ISBN 978-3-030-55073-8. 
  17. ↑ 17.0 17.1 17.2 17.3 "Thoracic outlet syndrome: definition, aetiological factors, diagnosis, management and occupational impact". Journal of Occupational Rehabilitation 21 (3): 366–73. September 2011. doi:10.1007/s10926-010-9278-9. PMID 21193950. PMC 3526474. http://www.hal.inserm.fr/inserm-00555517/document. 
  18. ↑ 18.0 18.1 Panther, Eric J.; Reintgen, Christian D.; Cueto, Robert J.; Hao, Kevin A.; Chim, Harvey; King, Joseph J. (2022). "Thoracic outlet syndrome: a review". Journal of Shoulder and Elbow Surgery 31 (11): e545–e561. doi:10.1016/j.jse.2022.06.026. PMID 35963513. https://linkinghub.elsevier.com/retrieve/pii/S1058274622006097. 
  19. ↑ Sanders, Richard J.; Donahue, Dean M. (2021), "Pathology and Pathophysiology of NTOS", in Illig, Karl A.; Thompson, Robert W.; Freischlag, Julie Ann et al. (in en), Thoracic Outlet Syndrome, Cham: Springer International Publishing, pp. 53–60, doi:10.1007/978-3-030-55073-8_7, ISBN 978-3-030-55073-8, https://doi.org/10.1007/978-3-030-55073-8_7, retrieved 2026-03-15 
  20. ↑ Thompson, Robert W. (2021-01-25), "Diagnosis of neurogenic thoracic outlet syndrome: 2016 consensus guidelines and other strategies" (in English), Thoracic Outlet Syndrome: Second Edition (Springer International Publishing): pp. 67–97, https://profiles.wustl.edu/en/publications/diagnosis-of-neurogenic-thoracic-outlet-syndrome-2016-consensus-g/, retrieved 2026-03-15 
  21. ↑ 21.0 21.1 21.2 Illig, Karl A.; Donahue, Dean; Duncan, Audra; Freischlag, Julie; Gelabert, Hugh; Johansen, Kaj; Jordan, Sheldon; Sanders, Richard et al. (2016-09-01). "Reporting standards of the Society for Vascular Surgery for thoracic outlet syndrome" (in English). Journal of Vascular Surgery 64 (3): e23–e35. doi:10.1016/j.jvs.2016.04.039. ISSN 0741-5214. https://www.jvascsurg.org/article/S0741-5214(16)30191-4/fulltext. 
  22. ↑ Chang, Min Cheol; Kim, Du Hwan (2021-07-26). "Essentials of thoracic outlet syndrome: A narrative review". World Journal of Clinical Cases 9 (21): 5804–5811. doi:10.12998/wjcc.v9.i21.5804. ISSN 2307-8960. PMID 34368299. 
  23. ↑ Illig, Karl A.; Donahue, Dean M. (2021), "NTOS for the Primary Care Team: When to Consider the Diagnosis?", in Illig, Karl A.; Thompson, Robert W.; Freischlag, Julie Ann et al. (in en), Thoracic Outlet Syndrome, Cham: Springer International Publishing, pp. 61–65, doi:10.1007/978-3-030-55073-8_8, ISBN 978-3-030-55073-8, https://doi.org/10.1007/978-3-030-55073-8_8, retrieved 2026-03-15 
  24. ↑ Hong, Jennifer; Ali, Zarina S.; Heuer, Gregory G.; Zager, Eric L. (2021), "Neurogenic TOS in Children", in Illig, Karl A.; Thompson, Robert W.; Freischlag, Julie Ann et al. (in en), Thoracic Outlet Syndrome, Cham: Springer International Publishing, pp. 323–332, doi:10.1007/978-3-030-55073-8_33, ISBN 978-3-030-55073-8, https://doi.org/10.1007/978-3-030-55073-8_33, retrieved 2026-03-15 
  25. ↑ "Thoracic Outlet Syndrome". Nicholas Institute of Sports Medicine and Athletic Trauma. http://www.nismat.org/ptcor/thoracic_outlet. 
  26. ↑ "Thoracic outlet syndrome". Mount Sinai Hospital, New York. http://www.mountsinai.org/Other/Diseases/Thoracic%20outlet%20syndrome. 
  27. ↑ "Under the radar". Chartered Society of Physiotherapy. July 19, 2017. https://www.csp.org.uk/frontline/article/under-radar. 
  28. ↑ "Recurrent neurogenic thoracic outlet syndrome". American Journal of Surgery 187 (4): 505–10. April 2004. doi:10.1016/j.amjsurg.2003.12.050. PMID 15041500. 
  29. ↑ 29.0 29.1 29.2 "Current management of thoracic outlet syndrome". Current Treatment Options in Cardiovascular Medicine 11 (2): 176–83. April 2009. doi:10.1007/s11936-009-0018-4. PMID 19289030. 
  30. ↑ "Arterial TOS Diagnosis". January 1, 2022. https://www.tosoutreach.com/arterial-tos-diagnosis. 
  31. ↑ Kuhn JE, Lebus GF, Bible JE (2015). “Thoracic Outlet Syndrome.” Journal of the American Academy of Orthopaedic Surgeons, 23(4):222–232. doi:10.5435/JAAOS-D-13-00215.
  32. ↑ "Persistent subclavian artery stenosis following surgical repair of non-union of a fractured clavicle". Grand Rounds 10: 55–8. 2010. doi:10.1102/1470-5206.2010.0012. http://www.grandroundsjournal.com/articles/gr100012. 
  33. ↑ 33.0 33.1 "Treatment for thoracic outlet syndrome". The Cochrane Database of Systematic Reviews 2014 (11). November 2014. doi:10.1002/14651858.CD007218.pub3. PMID 25427003. 
  34. ↑ "Thoracic outlet syndrome: A multidisciplinary problem with a perspective for microsurgical management without rib resection". How to Improve the Results of Peripheral Nerve Surgery. Acta Neurochirurgica Supplementum. 100. 2007. 145–7. doi:10.1007/978-3-211-72958-8_31. ISBN 978-3-211-72955-7. 
  35. ↑ "Thoracic outlet syndrome". Agri 17 (2): 5–9. April 2005. PMID 15977087. 
  36. ↑ "Robert Stock impresses in first start since 2021, but Mets lose to Sandy Alcantara, Marlins," Daily News, August 2, 2026.
  37. ↑ DiComo, Anthony (13 February 2017). "Harvey determined to regain dominant form". MLB News. https://www.mlb.com/news/matt-harvey-on-surgery-recovery-and-future-c215878796. 
  38. ↑ "Carpenter's throwing session canceled". MLB.com. 2 July 2012. http://stlouis.cardinals.mlb.com/news/article.jsp?ymd=20120702&content_id=34329980&notebook_id=34329996&vkey=notebook_stl&c_id=stl. 
  39. ↑ "Garcia to have season-ending surgery for nerve issue". MLB.com. 5 July 2014. http://mlb.mlb.com/news/article.jsp?ymd=20140705&content_id=83180830&notebook_id=83180716&vkey=notebook_stl&c_id=stl. 
  40. ↑ "Marcum needs thoracic outlet syndrome surgery". Rotoworld.com. 9 July 2013. http://www.rotoworld.com/headlines/mlb/403266/marcum-needs-thoracic-outlet-syndrome-surgery. 
  41. ↑ Fort Worth Star-Telegram (September 7, 2013). "Foul Territory: Rangers' Matt Harrison facing surgery for thoracic outlet syndrome on right shoulder". Sportsblogs.star-telegram.com. http://sportsblogs.star-telegram.com/foul_territory/2013/09/rangers-matt-harrison-facing-surgery-for-thoracic-outlet-syndrome-on-right-shoulder.html. 
  42. ↑ "Clayton Richard's Story". Washington University School of Medicine in St Louis. http://tos.wustl.edu/Patient-Features/Clayton-Richards-Story. 
  43. ↑ Jul 15, A. P.; ET, 2017 at 6:21p (2017-07-15). "Nate Karns out for season due to thoracic outlet surgery" (in en-US). http://www.foxsports.com/kansas-city/story/kansas-city-royals-nate-karns-out-season-thoracic-outlet-surgery-071517. 
  44. ↑ "San Francisco Chronicle: Lowry's agent lashes out". Sfgate.com. May 20, 2009. https://www.sfgate.com/giants/article/Lowry-s-agent-lashes-out-3230991.php. 
  45. ↑ Casella, Paul (August 23, 2025). "Wheeler needs thoracic outlet surgery, out for rest of season". Philadelphia: Major League Baseball. https://www.mlb.com/news/zack-wheeler-out-for-remainder-of-2025-season. 
  46. ↑ "Nationals Journal: Back from injury, Chris Young hopes to be part of the Nationals". The Washington Post. March 12, 2014. https://www.washingtonpost.com/blogs/nationals-journal/wp/2014/03/12/back-from-injury-chris-young-hopes-to-be-part-of-the-nationals/. 
  47. ↑ "Mariners' Chris Young has strong case for Comeback award". 710Sports.com. August 18, 2014. http://mynorthwest.com/258/2590557/Mariners-Chris-Young-has-strong-case-for-Comeback-award. 
  48. ↑ Robbins, Mike (2004). Ninety Feet from Fame: Close Calls With Baseball Immortality. New York: Carroll & Graf Publishers. p. 167. ISBN 0-7867-1335-6. https://archive.org/details/ninetyfeetfromfa0000robb/page/767. 
  49. ↑ Marrapese-Burrell, Nancy. "McQuaid a Masterton Trophy Finalist". Boston Globe. https://www.bostonglobe.com/sports/2013/05/14/mcquaid-named-masterton-finalist/U7OcZCJz2O6ds0QfR0XMVJ/story.html. 
  50. ↑ Kaplan, Emily (2 August 2018). "Inside Chris Kreider's journey back to the ice". ESPN. http://www.espn.com/nhl/story/_/id/24257571/nhl-new-york-rangers-chris-kreider-recovery-blood-clots-journey-back-ice. 
  51. ↑ "Markelle Fultz diagnosed with nerve condition". NBA.com. http://www.nba.com/article/2018/12/04/markelle-fultz-shoulder-specialist-neurogenic-thoracic-outlet-syndrome. 
  52. ↑ Wojnarowski, Adrian. "76ers' Markelle Fultz expected to miss 3-6 weeks for shoulder rehabilitation". ESPN. http://www.espn.com/nba/story/_/id/25453907/markelle-fultz-philadelphia-76ers-expected-miss-3-6-weeks-shoulder-rehabilitation. 
  53. ↑ Burke, Tim (2013-05-22). "Health scare leads to former UFC champion Matt Serra probably walking away from MMA". Bloody Elbow. http://www.bloodyelbow.com/2013/5/22/4356004/ufc-matt-serra-retiring-champion-mma-news. 
  54. ↑ Toby Roberts (January 26, 2026). How I lost my ability to climb... Retrieved March 19, 2026 – via YouTube.
  55. ↑ "Anson Brother's Health Scare 'I Could Have Silently Died'". People (New York) 68 (17): 96. 22 October 2007. http://www.hanson.net/site/hanson/blog_entry/1?entry_id=5832. Retrieved 1 January 2008. "Isaac hanson talks about surviving a life-threatening blood clot--and how his family is helping him cope.". 
  56. ↑ "MARIA今後の活動に関するお知らせ" (in ja). MARIA6. http://www.maria-6.com. 
  57. ↑ "Tamar Braxton Opens up About Health Crisis, Rib Removal". ABC News. 17 December 2015. https://abcnews.go.com/Entertainment/tamar-braxton-reveals-rib-removal-dwts-scare/story?id=35820114. 
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