Shoulder surgery helps ease pain when 2 disorders overlap, study finds

Surgery to relieve pressure on nerves or blood vessels near the shoulder may ease symptoms such as pain and tingling and improve daily function in people with hypermobile Ehlers–Danlos syndrome (hEDS) who also have thoracic outlet syndrome (TOS), a small U.S. study suggests.

However, for most patients, relief was tied to TOS symptoms, and surgery did not ease those likely caused by hEDS, the researchers noted.

TOS is a group of disorders that occurs when nerves or blood vessels become compressed as they pass through the thoracic outlet, the space between the collarbone and first rib, on their way to the arm. The condition can result in pain, tingling, or weakness in the shoulder and arm — symptoms exacerbated in people who also have hEDS, a connective tissue disorder marked by joints that move beyond the usual range, which can also cause pain.

In this study, researchers at the University of California, Los Angeles, sought to learn more about what occurs when the two conditions overlap — and to assess the impact of surgical treatment. According to the team, “the coincidence of these syndromes may affect the prognosis of interventions for TOS.”

The results showed that 13 of 16 participants who underwent surgery experienced at least some symptom relief. However, complete resolution was seen for just three of those 13.

Moreover, the researchers say the data suggest that surgery may address symptoms caused by TOS-related compression without eliminating those related to hEDS or other coexisting conditions.

“These findings support careful evaluation, thoughtful patient selection, and realistic counseling when considering thoracic outlet decompression in patients with concurrent hEDS,” the team wrote.

The study, “The Intersection of Hypermobile Ehlers-Danlos Syndrome and Thoracic Outlet Syndrome,” was published in the journal Annals of Vascular Surgery.

Ehlers-Danlos syndrome (EDS) comprises a group of genetic disorders that affect connective tissue, which provides support and structure to tissues and organs throughout the body. hEDS, a type of EDS, is marked by hypermobility and is often accompanied by chronic pain and other health problems.

Most cases of TOS, meanwhile, also involve nerves — with the condition then known as neurogenic TOS — which can cause arm pain, tingling, weakness, and fatigue. Venous TOS, in contrast, involves compression of a vein and can lead to blood clots.

Examining surgery results for people with hEDS and TOS

In people who have both hEDS and TOS, loose connective tissue, differences in how the joints and surrounding structures move, and coexisting health problems may add to symptom burden and complicate prognosis. These factors can also make it harder to determine how much of a person’s symptoms is due specifically to TOS and to predict how much relief surgery for that condition might provide.

Now, the UCLA team used medical records from people treated for TOS between January 2024 and January 2026 to better understand the surgical outcomes for individuals with both hEDS and TOS.

Among about 1,400 people with TOS, the researchers identified 28 with documented hEDS. Among them, 22 (79%) were women; the participants’ mean age was 35.5. Nearly 93% (26 patients) had neurogenic TOS, while two had venous TOS. Slightly more than half had symptoms affecting both sides of the body.

The group also had complex medical histories: 21 participants (75%) had previously undergone orthopedic surgery or other procedures involving the upper limbs, and together, they had a mean of 11.5 medical diagnoses listed in their records.

For neurogenic TOS, doctors used symptoms, physical examinations, imaging, nerve and muscle tests to help rule out other possible causes. Targeted injections that temporarily relaxed certain muscles were also used to help determine whether compression in those areas was contributing to symptoms.

Treatment initially focused on physical therapy, while surgery was reserved for participants with severe, persistent, and disabling symptoms that did not ease with nonsurgical treatment.

Pain eased for 80% of patients with surgery

Overall, 16 patients underwent surgery:  14 with neurogenic TOS and both with venous TOS. All had the first rib removed to create more room for the nerves and blood vessels passing through the thoracic outlet. Among participants with neurogenic TOS, 12 (86%) also underwent a procedure to release the pectoralis minor, a chest muscle that can contribute to nerve compression.

After an average follow-up of 653 days, or about two years, symptoms had completely resolved in three participants (19%) while easing in 10 (63%), the researchers found. The data showed that symptoms were unchanged in one participant and worsened in another. One participant developed recurrent narrowing of a vein that was treated with a procedure to widen it, after which symptoms completely resolved.

According to the researchers, the overall 81.3% rate of symptom lessening or resolution was within the 76%-93% range reported in previous studies of this surgery in the broader TOS population. Complete symptom relief, however, was less common among these individuals with co-occurring hEDS — 19% in this study compared with 30%-61% in previous studies.

Standardized assessments also pointed to better function after surgery. Mean QuickDASH scores, which measure symptoms and difficulty using the arm, shoulder, and hand in everyday activities, fell from 69.6 before surgery to 44.3. Such a significant decrease indicated improved upper limb function, according to the researchers.

Derkash scores, another measure used to assess outcomes after TOS surgery, also improved significantly, the data showed.

Still, symptoms sometimes returned. Three of the 14 participants with neurogenic TOS (21%) required additional surgery for recurrent symptoms, with four repeat operations performed in total. The researchers noted that symptom recurrence requiring another operation appeared more common than in the broader adult neurogenic TOS population.

The team suggested that loose ligaments and altered movement of the shoulder and shoulder blade associated with hEDS may contribute to a broader pattern of compression, potentially helping explain why symptoms can return in people with both conditions.

Surgery urged when symptoms are tied to shoulder condition, not hEDS

Altogether, the study backed the use of surgery, though the researchers noted that careful screening should be done when individuals are found to have both TOS and hEDS.

“These findings support the role of surgery in appropriately selected patients when clinical evaluation identifies thoracic outlet compression as a major contributor to symptoms,” the researchers wrote, noting, however, that surgery may not ease symptoms tied to hEDS, chronic pain, or other coexisting conditions.

“This distinction is important when counseling patients with hEDS, since decompression may relieve [TOS]-related symptoms without eliminating symptoms arising from … hypermobility,” the team wrote.