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Shoulder Pathology Masquerading as Thoracic Outlet Syndrome in Pediatric and Young Adult Patients: Diagnosis and Treatment of Secondary Thoracic Outlet Syndrome
Mila Colizza, BA
1, Ann R Schwentker, MD
2, Melissa Miller, APRN, CNP
3, Kaitlynn N Jackson, BS
4, Shital N Parikh, MD
2; Kevin J. Little, MD
4,5(1)University of Cincinnati, Cincinnati, OH, (2)Cincinnati Childrens Hospital and Medical Center, Cincinnati, OH, (3)Division of Pediatric Plastic Surgery, Cincinnati Children's Medical Center, Cincinnati, OH, (4)Cincinnati Children's Hospital Medical Center, Cincinnati, OH, (5)University of Cincinnati College of Medicine, Cincinnati, OH
Introduction: Thoracic outlet syndrome (TOS) can be primary-intrinsic to pathology within the thoracic outlet-or secondary-occurring with shoulder dysfunction. However, the relationship between TOS and shoulder pathologies remains poorly characterized. We aimed to describe the incidence of shoulder pathologies in pediatric and young adult populations with TOS to better understand how concomitant shoulder issues are best treated in this patient population.
Methods: We reviewed the charts of patients seen at a tertiary care pediatric hospital who met the criteria for diagnosis of TOS between the years of 2010 and 2025. Patients with an additional diagnosis of shoulder injury or pathology were included in the analysis. Patients with shoulder injury occurring after initial TOS diagnosis or a confounding diagnosis precluding definitive TOS or shoulder diagnosis were excluded.
Results: Of 226 TOS patients identified in total, 35 met inclusion criteria for secondary TOS. This cohort included 26 females (74.3%) and 9 males (25.7%) ranging in age from 14 to 30 with an average age of 17.1 (SD = 3.13) at the time of presentation. The most common shoulder pathology among this cohort was posterior labral tear (n = 9, 25.7%) followed by other labral tear (n = 8, 22.9%) and multidirectional instability (MDI, n = 6, 17.1%). Other shoulder pathologies included rotator cuff tendinitis or tear, scapular dyskinesia, sternoclavicular subluxation, acromioclavicular (AC) joint separation or subluxation, and impingement (Table 1).
Overall, of the 35 patients with secondary TOS, 16 (45.7%) were successfully managed nonoperatively for TOS by managing the shoulder pathology, including 8 patients treated surgically at the shoulder. Another 18 underwent TOS surgical treatment, of whom 8 had previously had shoulder surgery and 1 underwent shoulder treatment post TOS release. One patient is still undergoing evaluation for TOS surgical treatment.
Conclusion:Posterior labral tears and other labral tears were the leading shoulder pathology among adolescents and young adults with secondary TOS, comprising approximately half of the cohort. There should be consideration of shoulder pathology, particularly posterior labral tear, as a possible contributing factor to the development of TOS. Contributory shoulder pathology should be ruled out or managed prior to surgical intervention for TOS, as approximately half of all patients with secondary TOS can be managed without thoracic outlet decompression surgery.
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