Principles and the 24-hour response rule
The pathway is intended for neurogenic TOS and progresses according to movement quality, tissue irritability and function. After each load change, assess the response over 24 hours. A meaningful or lasting flare requires stepping back and adjusting with the therapist.
Nonoperative and preoperative pathway: PRE‑1 to PRE‑4
PRE‑1 — settle symptoms and reduce load
Education on provocative positions, diaphragmatic breathing and arm support; gentle neck, scapular and shoulder movement within a non-provoking range.
Suggested options: Figure 1 for scapular setting, Figure 2 for breathing and Figure 9 for supported mobility.
PRE‑2 — scapular control and baseline endurance
Progress to scapular setting, low row, serratus press and wall slide at low load, with therapist-selected neural sliders.
Suggested options: Figures 1, 4, 5 and 6; Figures 3 and 8 only when selected by the therapist after examination.
PRE‑3 — strength and function
Gradual strengthening of serratus, lower trapezius and shoulder stabilizers; graded exposure to work or sport without loss of control or persistent flare.
Suggested options: Figures 4–7, increasing range and load only while movement quality remains controlled.
PRE‑4 — readiness for activity or surgery
Stable function, load-management skill and a clear home plan. If surgery is planned, rehearse breathing, positioning and safe early movement.
Use Figures 3–7 as a base and gradually integrate work- or sport-specific tasks.
After surgery: POST‑0 to POST‑5
POST‑0 — early protection
Wound and pain care, calm breathing, short walks, and elbow, wrist and finger movement as directed. Do not stretch or load the surgical field against restrictions.
Figures 1 and 2 may support positioning and breathing; Figure 9 only when shoulder movement is expressly allowed.
POST‑1 — controlled mobility
Progress shoulder and neck range, gentle scapular control and scar care only when cleared. Aim for quality without compensation or symptom escalation.
Suggested options: Figures 1, 2 and 9 within surgical restrictions and without stretching the operative field.
POST‑2 — activation and endurance
Gradually recruit serratus, lower trapezius and shoulder-girdle muscles with low load and controlled repetitions.
Suggested options: Figure 4, followed by Figures 5 and 6 according to control and symptoms.
POST‑3 — strength and daily function
Increase load, range and duration according to response; add light carrying and gradually higher work tasks.
Suggested options: Figures 3–7. Figure 8 remains a therapist-tailored exercise only.
POST‑4 — return to work and sport
Graded exposure to patient-specific tasks, including overhead activity only after criteria are met.
Integrate Figures 3–7 into graded functional practice matched to the patient’s goals.
POST‑5 — independence and prevention
A maintenance plan, load regulation and early recognition of flare. The treating team determines the timing of each transition.
Select only the exercises from Figures 1–9 required for the individual maintenance plan.
Illustrated exercise options
Evidence and selected references
This is an evidence-informed clinical framework, not a validated universal guideline. Published evidence does not define one dose or timetable for every patient.
- O’Sullivan J, Rushton C, Bateman M, et al. Physical assessment and rehabilitation for neurogenic thoracic outlet syndrome: a scoping review. Hand Therapy. 2026. doi:10.1177/17589983251411877.
- Hock G, Johnson A, Barber P, Papa C. Current Clinical Concepts: Rehabilitation of Thoracic Outlet Syndrome. Journal of Athletic Training. 2024;59(7):683–695. doi:10.4085/1062-6050-0138.22.
- Chim H, Hagan RR; INTOS Workgroup. Consensus Recommendations for Neurogenic Thoracic Outlet Syndrome. Plastic and Reconstructive Surgery – Global Open. 2024;12(8):e6107.
- Luu D, Seto R, Deoraj K. Exercise rehabilitation for neurogenic thoracic outlet syndrome: a scoping review. Journal of the Canadian Chiropractic Association. 2022;66(1):43–60.
- Collins E, Orpin M. Physical Therapy Management of Neurogenic Thoracic Outlet Syndrome. Thoracic Surgery Clinics. 2021;31(1):61–69.
- Watson LA, Pizzari T, Balster S. Thoracic outlet syndrome Part 2: conservative management. Manual Therapy. 2010;15(4):305–314.
- Ahmed AS, Graf AR, Karzon AL, et al. Pectoralis minor syndrome: pathoanatomy, diagnosis and management. JSES Reviews, Reports, and Techniques. 2022;2(4):469–488.
- Levine NA, Rigby BR. Thoracic Outlet Syndrome: Biomechanical and Exercise Considerations. Healthcare. 2018;6(2):68.
Protocol source
This page was adapted from the clinical “TOS AYMAN Rehab” document supplied for the project. Exercises are therapist-selected options, not a mandatory list for every patient.