Neurogenic Thoracic Outlet Syndrome in Division 1 Collegiate Athletes: Presentation, Diagnosis, and Treatment

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Abstract
Objective: Athletes who engage in repetitive upper-extremity exercise are susceptible to neurogenic thoracic outlet syndrome (nTOS). We sought to identify typical presenting symptoms and common findings on diagnostic workup, in addition to evaluating rates of return to play following various treatment interventions. Design: Retrospective chart review. Setting: Single institution. Participants: Medical records of Division 1 athletes containing the diagnosis of nTOS between the years 2000 and 2020 were identified. Athletes with arterial or venous thoracic outlet syndrome were excluded. Independent Variables: Demographics, sport, participation status, clinical presentation, physical examination findings, diagnostic workup, and treatments provided. Main Outcome Measures: Rate of return to play (RTP) to collegiate athletics. Results: Twenty-three female and 13 male athletes were diagnosed and treated for nTOS. Digit plethysmography showed diminished or obliterated waveforms with provocative maneuvers in 23 of 25 athletes. Forty-two percent were able to continue competing despite symptoms. Of the athletes who were initially unable to compete, 12% returned to full competition after physical therapy alone, 42% of those remaining were able to RTP after botulinum toxin injection, and an additional 42% of the remaining athletes RTP after thoracic outlet decompression surgery. Conclusions: Many athletes diagnosed with nTOS will be able to continue competing despite symptoms. Digit plethysmography is a sensitive diagnostic tool for nTOS to document anatomical compression at the thoracic inlet. Botulinum toxin injection had a significant positive effect on symptoms and a high rate of RTP (42%), allowing numerous athletes to avoid surgery and its prolonged recovery and associated risks. Clinical Relevance: This study demonstrates that botulinum toxin injection had a high rate of return to full competition in elite athletes without the risks and recovery needed for surgical intervention, suggesting that this may be a good intervention especially among elite athletes who only experience symptoms with sport-related activities.

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