Treatment of TOS

Conservative Treatment of Neurogenic TOS

Conservative treatment remains the primary treatment modality in patients with neurogenic TOS.

Conservative treatment is the primary approach in almost all patients with neurogenic TOS. Neurogenic TOS is rarely, if ever, a surgical emergency. Therefore, treatment planning and trials can be much more deliberate and staged. Progress can be judged over these trials, and surgery may be avoided in many patients with neurogenic TOS. Conservative treatment types may be performed sequentially or in conjunction with one another. Although the medical literature does not prove superiority of one form of conservative therapy over another, authorities widely accept conservative approaches as the first step in treatment.

Conservative treatment neurogenic TOS

Physical Therapy

Physical therapy remains one of the mainstays of conservative treatment of patients with neurogenic TOS. Physical therapy aims to reduce pain and improve function. Physical therapists help their patients recover from sports injuries, trauma, or strokes, improve flexibility or movement, and learn to use a cane or function with a splint.

Physical therapists must undergo specific training, including a masters degree or a doctorate. They also must pass a qualifying examination, and are licensed in every state. It is important to remember that just like physicians, physical therapists often specialize within their field. Thus, a patient should strive to work with a physical therapist who is knowledgeable about and experience in the treatment of neurogenic TOS.

Physical therapists who treat patients with neurogenic TOS may use one or more of the following techniques:

  • Massage therapy
  • Postural correction
  • Breathing control and retraining
  • Electrical stimulation
  • Stretching
  • Superficial heat or deep heat therapy (ultrasound may be used)
  • Myofascial release, including mobilization and manipulation
  • Education

The ENVEST (Edgelow Neurovascular Entrapment Syndrome Treatment) technique was developed by a widely-recognized physical therapist, Peter Edgelow. The ENVEST technique is widely known as a specialized and effective technique for treatment of neurogenic TOS patients. Dr. Edgelow taught his technique to many hundreds of physical therapists, and it is worth finding a therapist who is familiar and experienced with this technique. You can read more the ENVEST technique here.


Chiropractic focuses on the relationship between the structure and function of the body. Primarily, chiropractors manipulate the spine to achieve balance, with the intention of maintaining or restoring balance and normal function. However, chiropractors often add a number of other therapies to spinal manipulation. For example, many chiropractors offer electrical stimulation, relaxation techniques, laser therapy, and counseling on diet, exercise and health.

Many patients with neurogenic TOS utilize chiropractic as a central and critical component of their treatment program. Chiropractors contribute significant hands-on therapy and time with patients. Patients often form a productive therapeutic alliance with their chiropractor, among other team members.


Appropriate use of drugs plays a key role in the conservative treatment of patients with neurogenic TOS. Several classes of drugs may be used:

Pain drugs-Direct treatment with pain medication is almost always a part of the regimen. Pain medications may include NSAIDs (non-steroidal anti-inflammatory drugs) such as ibuprofen, or stronger opiates such as fentanyl in severe flares. In general, opiate pain medications have significant risks, including addiction, and are only used in a short-term plan or flare.

Nerve-stabilizing drugs-These drugs were originally developed to treat depression or seizures. However, they have been found to help desensitize irritated nerves and to reduce the pain signals created by these nerves. Examples include anti-depressants, such as Elavil, and anti-seizure drugs such as Lyrica, Cymbalta, and Neurontin.

Evidence has also recently been published regarding the use of medical marijuana in chronic pain patients. Marijuana has been shown to work effectively with opiates, decreasing the dose of opiates required while lowering pain to a greater extent than opiates alone.

Occupational Therapy

Occupational therapists help patients perform activities regardless of disability or injury. Stated another way, occupational therapists do not aim to cure or treat patients. Instead, they evaluate the patient’s current condition and provide the means by which the patient can perform their normal occupations. Occupations in this case are defined as the every day activities of the patient.

Conservative treatment of neurogenic TOS

Often successful, if started promptly


Many people have seen images of a person being treated with a number of tiny needles in their skin. Traditional acupuncture practitioners believe that the chi (pronounced ‘chee’) in the body must be balanced. Neuroscientists suggest that the needles stimulate nerves or blood vessels, or perhaps stimulate release of the body’s natural pain relievers. Acupuncture has been deemed effective by organizations such as the World Health Organization (WHO) and the National Center for Complementary and Integrative Health (NCCIH) in the treatment of a number of conditions, including headache, low back pain, rheumatoid arthritis, knee pain and neck pain. There is not a large volume of scientific evidence supporting the effectiveness of acupuncture, but many patients experience relief from acupuncture treatments. Acupuncture may provide significant additional relief in neurogenic TOS patients receiving other conservative treatments. Most states require non-physician acupuncturists to pass a qualifying examination.

Massage Therapy

Massage therapy performed in conjunction with other conservative treatments may increase effectiveness of those treatments. Scientific studies of massage therapy are often preliminary and conflicting. However, there is some evidence that massage therapy may provide relief for patients with chronic neck pain or low back pain, knee pain, or depression. Massage therapists are regulated in most states.

Scalene Block

Gage and Parnell in 1947 likely performed the first anterior scalene block. In 1998, the procedure was revisited by Jordan and Machleder. Currently. a number of TOS surgeons rely on this procedure to make surgical decisions.

A doctor performs a scalene block by injecting a medication into the anterior scalene muscle. Doctors may choose a short-acting anesthetic for diagnostic purposes, or a longer-acting agent for temporary relief of pain. In addition to the anterior scalene muscle, some doctors inject the middle scalene muscle, the subclavius muscle, or the pectoralis minor muscle.

No clear evidence has been published regarding the mechanism that creates relief of symptoms from these injections. There are varying levels of evidence regarding the effectiveness of these injections. Nonetheless, at least empirically, many TOS patients do experience relief from these injections.

More discussion to follow regarding these injections.