Thoracic Outlet Syndrome: Diagnostic Considerations and the Role of EMG/NCS

The Clinical & Business Connection Newsletter

Clinical Insight

Thoracic outlet syndrome (TOS) remains one of the more diagnostically elusive conditions in the differential diagnosis for upper extremity paresthesia and pain. The neurogenic subtype accounts for the large majority of cases, with vascular (arterial and venous) subtypes comprising the remainder — each carrying distinct diagnostic and management implications.

Compression of the brachial plexus, subclavian artery, or subclavian vein within the scalene triangle, costoclavicular space, or subcoracoid space can produce a symptom picture that overlaps substantially with cervical radiculopathy, carpal tunnel syndrome, and ulnar neuropathy — making misdiagnosis common in primary and urgent care settings.

Where electrodiagnostic testing adds the most value:

• Localizing the lesion and distinguishing neurogenic TOS from lower brachial plexopathy or cervical radiculopathy

• Ruling out coexisting carpal tunnel or ulnar neuropathy, which can present concurrently and confound clinical exam findings

• Establishing a pre-treatment baseline to track functional change following conservative or surgical intervention

• Supporting surgical decision-making in refractory cases being considered for first-rib resection or scalenectomy

Provocative maneuvers (Adson’s, Roos/EAST, Wright’s) remain useful screening tools but have limited specificity in isolation. Combining a thorough electrodiagnostic workup with vascular imaging when indicated gives referring physicians a defensible, evidence-based basis for treatment planning — and spares patients the delay of a trial-and-error approach.

If your patient complains of numbness, tingling, or weakness, HOEMG is just a click away to help you get to the bottom of the problem and manage your patients more effectively. Visit: www.EMGreferral.com

References

1. Hooper TL, Denton J, McGalliard MK, et al. Thoracic outlet syndrome: a controversial clinical challenge. Braz J Phys Ther. 2010.
2. Illig KA, Donahue D, Duncan A, et al. Reporting standards of the Society for Vascular Surgery for thoracic outlet syndrome. J Vasc Surg. 2016.
3. Ferrante MA, Ferrante ND. The thoracic outlet syndromes: Part I. Overview of the thoracic outlet syndromes and review of true neurogenic thoracic outlet syndrome. Muscle Nerve. 2017.

Business Success Strategy

Tax-Saving Strategies for the Medical Office: The R&D Tax Credit

Most physician practice owners assume the federal Research & Development (R&D) Tax Credit under IRC Section 41 is reserved for tech and pharmaceutical companies. In reality, medical and rehabilitation practices routinely perform qualifying activities without ever claiming the credit — leaving real, dollar-for-dollar tax savings on the table.

What can qualify at a practice level:

• Developing or refining a new clinical protocol or treatment pathway

• Customizing or adapting diagnostic equipment or software workflows for your patient population

• Testing new approaches to improve diagnostic accuracy, turnaround time, or patient outcomes

• Building or modifying data-tracking systems used to evaluate treatment effectiveness

To qualify, an activity generally needs to satisfy a four-part test: it must have a permitted business purpose, rely on hard science (medical, engineering, or computer science principles), aim to eliminate uncertainty about how to achieve a result, and involve a process of experimentation — such as testing, modeling, or systematic trial and evaluation of alternatives.

For qualifying small businesses, the credit can in some cases offset payroll tax liability directly, not just income tax — which matters for practices that are profitable but pay relatively little in income tax after deductions.

This is general information, not tax or legal advice specific to your practice. The R&D credit has specific documentation requirements and is frequently scrutinized on audit, so any practice considering it should work with a CPA or tax specialist experienced in R&D credit studies to confirm eligibility and substantiate qualifying activities.

Spotlight on Excellence

Kranthi Bairam

MSPT, PT

Kranthi Bairam is a physical therapist with over six years of experience. Holding a PT, MSPT, and D-EDX, he has three years of experience in electromyography and nerve conduction studies. He works with patients to identify issues such as pain, numbness, and abnormal nerve function, as well as conditions like carpal tunnel syndrome, peripheral neuropathy, and other neuromuscular diseases. By utilizing advanced diagnostic techniques, he provides accurate assessments and treatment plans for optimal patient care.

What he enjoys the most about his job as a physical therapist and EMG specialist is identifying the root cause of the problem for the patient and providing an accurate diagnosis.

Areas of expertise:

• Manual Therapy
• EMG Testing
• Sports Rehabilitation

Updates You Should Know

The Introduction to EMG, Nerve Conduction Studies, and Musculoskeletal Ultrasound Imaging course just wrapped — and it was a phenomenal success.

Hands-On EMG Testing hosted the American Academy of Clinical Electrodiagnosis (AACE) and the American Academy of MSK Ultrasound (AAMU) for the Introduction to EMG, Nerve Conduction Studies, and Musculoskeletal Ultrasound Imaging with 40+ clinicians gathering for two days of intensive, hands-on training.

Attendees left with:

• Real-world skills in EMG, nerve conduction studies, and MSK ultrasound imaging
• The clinical context needed to make more confident, accurate referrals
• 20.5 CEUs (physical therapy professionals) or 20.5 CMEs (physicians and medical providers)
• A direct connection to the HODS Leadership Team, who works personally with your admin and marketing staff to tailor strategies for your practice and market

The energy in the room was electric — and the demand is only growing!

Want in on the next one? For all upcoming dates and locations please visit emgintro.com.

How We Can Help

Hands-On EMG Testing serves physicians and patients across several locations in Manhattan, Queens, the Bronx, Brooklyn, and Long Island.

To refer a patient, please use our online referral form. To learn more about our services, email in**@********mg.com, or call +1 (855) 248-4021.

If you are interested in incorporating our Medical Diagnostic Model into your practice to provide immediate testing results and create a strong business opportunity, please contact Dr. Dimitrios Kostopoulos at di**@********mg.com.