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Keywords

Clinical Practice in Athletic Training

Abstract

Introduction: Thoracic Outlet Syndrome (TOS) is a rare and complex condition caused by the compression of neurovascular structures in the thoracic outlet. TOS is estimated to affect 3 to 80 individuals per 1,000,000 annually, with neurogenic TOS accounting for approximately 95% of cases. Athletes who perform repetitive overhead motions are at higher risk due to increased stress on the brachial plexus. Diagnosis can be challenging as symptoms such as pain, numbness, and weakness, often mimic other conditions such as nerve entrapment or tendon pathologies. Treatment for TOS typically begins with a conservative approach, including postural correction and strengthening, activity modification, and anti-inflammatory medication. Additional treatments may involve cortisone injections for inflammation control and botulinum toxin to relax overactive muscles. Surgical interventions such as first rib resection and scalenectomy are used for cases where conservative management has failed. This case is notable due to the rarity of first rib resection in adolescent athletes with TOS. These procedures are typically considered a last resort and normally performed on adult patients. The limited and short-term relief observed with botulinum toxin injections in this athlete shows the unpredictability of treatment responses. Patient Information: This case involves a 17-year-old varsity softball catcher who developed progressive shoulder and neck pain after consecutive practices in which she engaged in high volumes of repetitive overhead throwing motions. Initially, she reported mild discomfort but her symptoms rapidly worsened, making her unable to participate in practice effectively. She reported sharp, radiating arm pain, significant fatigue, and decreased grip strength, which affected her athletic performance and her daily activities. Evaluation revealed tenderness in the scalene and clavicular regions, and positive Allen’s and Adson’s tests. Initial differential diagnoses included medial epicondylitis and ulnar nerve entrapment. Intervention: The athlete continued practicing and throwing in games as tolerable, relying on conservative management and rehab. Her rehabilitation followed a six-month rehabilitation plan that focused on postural correction and scapular stabilization. While conservative treatment focused on manual therapy to address muscular tightness. After no significant response, she was referred to the team physician. Electromyography and nerve conduction studies ruled out primary nerve entrapments, while magnetic resonance imaging confirmed neurogenic TOS caused by brachial plexus compression. Treatment for this diagnosis included botulinum toxin injections into the scalene muscles to provide temporary relaxation. In cases of TOS, botulinum toxin helps reduce muscle tension and spasms in the scalenes, which can alleviate compression on the brachial plexus and surrounding neurovascular structures. By relaxing these muscles, more space is created within the thoracic outlet, potentially reducing nerve irritation and easing symptoms such as pain, numbness, and weakness in the affected arm. The effects of the injection typically last a few months, but this athlete only reported about 30 minutes of relief. With continued significant compression and persistent symptoms, surgical intervention was warranted and led to a first rib resection and scalenectomy to decompress the neurovascular structures. Outcomes: Following surgery, the athlete underwent a structured rehabilitation program, including a progressive throwing regimen. Full return to play was achieved within 4-6 weeks, with marked improvements in strength, pain reduction, and overall function. Long-term follow-up showed sustained symptom relief and a successful return to competitive softball without limitations. Clinical Bottom Line: This case highlights the complexity of managing neurogenic TOS in adolescent athletes and highlights the importance of timely diagnosis, individualized treatment, and a structured rehabilitation plan. The rare surgical intervention in a young athlete illustrates the need for a multidisciplinary approach when conservative treatments are insufficient. This case provides valuable insights into the evolving role of botulinum toxin injections and emphasizes the importance of early surgical consideration to optimize outcomes.

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