Thoracic Outlet Syndrome is one of the most commonly underdiagnosed conditions affecting the upper extremity. Understanding what “underdiagnosed” truly means is critical for patients and clinicians alike.
In clinical practice, underdiagnosis does not mean that Thoracic Outlet Syndrome is rare. It means the full clinical picture is missed.
A common scenario begins when a patient presents with numbness and tingling in the fingertips. They are told they have carpal tunnel syndrome. That diagnosis may be accurate, but it may also be incomplete.
A widespread assumption in healthcare is that a person is entitled to only one diagnosis. Human physiology does not work that way.
In my clinical experience, it is extremely common for individuals to present with multiple overlapping compression syndromes occurring at the same time.
A patient may have carpal tunnel syndrome at the wrist, median nerve entrapment in the forearm, hyperabduction syndrome at the shoulder, and Thoracic Outlet Syndrome at the base of the neck.
Each of these conditions can produce similar symptoms, including numbness, tingling, weakness, fatigue, and pain. When only one site is identified and treated, improvement is often partial or short-lived.
This is where underdiagnosis becomes costly.
When treatment focuses only on the wrist while ignoring shoulder mechanics and thoracic outlet compression, valuable time is lost. Early opportunities to reduce inflammation, muscle guarding, and nerve stress are missed.
By the time the broader pattern is recognized, patients are often on visit nine or ten, frustrated by lack of progress and questioning their diagnosis.
This is not a failure of effort by the patient. It is a failure of systems-based evaluation.
Nerve tissue does not exist in isolation. Compression at one location lowers the nerve’s tolerance to stress everywhere else along its course.
If the nerve is already compromised at the neck, it becomes far more sensitive to compression at the shoulder, forearm, or wrist. Treating one site while ignoring others leaves the system overloaded.
This explains why symptoms often persist despite what appears to be “successful” treatment of a single condition.
It also explains why imaging and nerve studies may appear inconclusive. Tests are often designed to isolate one region rather than assess cumulative stress across the entire nerve pathway.
Patients are frequently told their symptoms are confusing, inconsistent, or unexplained. In reality, the pattern is simply incomplete.
Thoracic Outlet Syndrome is commonly missed because its symptoms overlap with many other diagnoses. Carpal tunnel syndrome, cubital tunnel syndrome, cervical radiculopathy, and shoulder impingement can all coexist with TOS.
Because distal conditions are easier to image, explain, and operate on, they are often treated first. The thoracic outlet remains unaddressed.
This sequential approach leads to underdiagnosis. The clinician treats what is most obvious, while the primary bottleneck remains active.
At Team Doctors®, evaluation emphasizes identifying all contributing compressive mechanisms at the same time rather than discovering them one by one after months of stalled progress.
When multiple compression points are recognized early, care becomes more efficient and far less frustrating for the patient.
Instead of asking, “Which diagnosis is correct?” the more useful question becomes, “Where is this nerve being stressed along its entire path?”
This broader perspective helps explain why posture, repetitive strain, and inflammation interact across regions rather than acting independently.
Forward head posture increases scalene tone. Shoulder depression narrows outlet space. Forearm overuse tightens fascial tunnels. Wrist positioning adds another layer of stress.
Each factor alone may seem minor. Together, they exceed the nerve’s tolerance.
Underdiagnosis does not just delay answers. It delays recovery potential.
When nerve tissue is exposed to prolonged compression, secondary changes can occur. The nervous system becomes more reactive, and symptoms may escalate.
Patients often describe increasing sensitivity, fatigue, or weakness that spreads beyond the original area of complaint. These changes are not psychological. They reflect cumulative nerve stress.
Understanding this layered model reframes expectations. Relief rarely comes from a single intervention when multiple compression points are involved.
Education changes expectations. Comprehensive assessment changes outcomes.
When patients finally understand why previous treatments failed, the experience becomes validating rather than discouraging.
Thoracic Outlet Syndrome is not rare. It is frequently overlooked because it requires a systems-level view of the upper extremity.
Recognizing underdiagnosis early allows clinicians and patients to move forward with clarity instead of frustration.
When the full constellation of compression is addressed, the clinical picture finally makes sense—and so does the path forward.
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References
- Roos, D. B. “Thoracic Outlet Syndrome Is Underdiagnosed.” Muscle & Nerve 22, no. 1 (1999): 126–129.
- Sanders, Richard J., and Neal S. Pearce. “Neurogenic Thoracic Outlet Syndrome.” Journal of Vascular Surgery 36, no. 3 (2002): 669–676.
- Upton, A. R. M., and A. J. McComas. “The Double Crush in Nerve Entrapment Syndromes.” The Lancet 302, no. 7825 (1973): 359–362.
- Urschel, Harold C., and R. B. Razzuk. “The Neurovascular Compression Syndromes of the Thoracic Outlet.” Annals of Thoracic Surgery 50, no. 3 (1990): 484–490.
Dr James Stoxen DC., FSSEMM (hon) He is the president of Team Doctors®, Treatment and Training Center Chicago, one of the most recognized treatment centers in the world.
Dr Stoxen is a #1 International Bestselling Author of the book, The Human Spring Approach to Thoracic Outlet Syndrome. He has lectured at more than 20 medical conferences on his Human Spring Approach to Thoracic Outlet Syndrome and asked to publish his research on this approach to treating thoracic outlet syndrome in over 30 peer review medical journals.
He has been asked to submit his other research on the human spring approach to treatment, training and prevention in over 150 peer review medical journals. He serves as the Editor-in-Chief, Journal of Orthopedic Science and Research, Executive Editor or the Journal of Trauma and Acute Care, Chief Editor, Advances in Orthopedics and Sports Medicine Journal and editorial board for over 35 peer review medical journals.
He is a much sought-after speaker. He has given over 1000 live presentations and lectured at over 70 medical conferences to over 50,000 doctors in more than 20 countries. He has been invited to speak at over 300 medical conferences which includes invitations as the keynote speaker at over 50 medical conferences.
After his groundbreaking lecture on the Integrated Spring-Mass Model at the World Congress of Sports and Exercise Medicine he was presented with an Honorary Fellowship Award by a member of the royal family, the Sultan of Pahang, for his distinguished research and contributions to the advancement of Sports and Exercise Medicine on an International level. He was inducted into the National Fitness Hall of Fame in 2008 and the Personal Trainers Hall of Fame in 2012.
Dr Stoxen has a big reputation in the entertainment industry working as a doctor for over 150 tours of elite entertainers, caring for over 1000 top celebrity entertainers and their handlers. Anthony Field or the popular children’s entertainment group, The Wiggles, wrote a book, How I Got My Wiggle Back detailing his struggles with chronic pain and clinical depression he struggled with for years. Dr Stoxen is proud to be able to assist him.
Full Bio) Dr Stoxen can be reached directly at teamdoctors@aol.com
