"Background: Thoracic outlet syndrome is a rare disorder that affects less than 200,000 people in the United States per year. This Level 4 Case study presented a 19-year-old (170cm, 61kg) NAIA college volleyball player with over 13 years of volleyball experience as a setter. The patient reported to the AT complaining of paresthesia and swelling in the hands, pain and tightness in the arm and neck, and states that symptoms would subside during times of rest and return during activity in sport. Upon examination post-practice, the patient demonstrated poor upper extremity posture, tenderness in upper extremity musculature, swelling and discoloration of the hands. The patient tested positive for a diminished radial pulse during the Adson`s Test for TOS and was retested using an ultrasound doppler which confi rmed a decreased pulse. The patient also displayed a weak pulse during the Allen Test for TOS but did not test positive during the Military Brace Test or Roos Test. When referred out for imaging, X-ray revealed a lack of cervical spine curvature but no displaced clavicle or rib. The patient described no previous history of any of these symptoms and stated that it did not start until her activity changed when she began to set long distances with a weighted volleyball. Differential Diagnosis: Nerve root impingement, Cervical spine stenosis, Carpal tunnel syndrome, Thoracic Outlet Syndrome. Treatment: Patient was diagnosed with Vascular Thoracic Outlet Syndrome (VTOS) Patient began treatment immediately after the initial evaluation with the goals to correct posture, decrease pain and point tenderness and decrease paresthesia. The treatment plan for this athlete was comprised of Neurodynamics for the median and radial nerve, manual therapy which consisted of massage and instrument assisted soft tissue mobilization of the musculature of the arm and shoulder, stretching of the neck and shoulder, corrective exercises to strengthen the posterior aspect of her shoulder to help with postural correction, and thermal modalities. In this particular case, this treatment plan helped reduce symptoms; she did not feel numbness during participation, no swelling, and no pain in arms. Minimized tightness in surrounding musculature was also noted after 2 weeks of therapeutic intervention. Uniqueness: Thoracic Outlet Syndrome is a rare condition affecting less than 200,000 individuals yearly. TOS is categorized as vascular or neurogenic and the vascular cases are further subcategorized as arterial or venous. Of the limited reported cases, most cases present as neurogenic. This case is further unique since the patient was symptom free and participating fully in intercollegiate volleyball without incident until a weighted ball was introduced. Conclusions: This case highlighted the diagnosis and treatment of a patient suffering from Thoracic Outlet Syndrome. This case further highlighted the success of a conservative management plan addressing the patient`s poor upright posture. The combination of the modalities, stretching exercises, manual therapy and Neurodynamics has improved the patient`s symptoms and allowed her to continue participating in her sport almost completely symptom free. Athletic trainers need to be aware and recognize the early symptoms and ensure appropriate referrals are made to provide a positive clinical outcome and return to activity. Research has suggested that clinicians utilize the Halstead maneuver, Wright`s test and Cyriax release test and due to the varied ranges of sensitivity and specifi city evaluators should be cautious of the results when performing the Adson`s and Roo`s Tests. However, in this specifi c case, the Adson`s Maneuver did assist in the proper clinical diagnosis but the Roo`s test supported the current literature."
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