Mechanically loaded neurodynamics for post-surgical rehabilitation of arterial thoracic outlet syndrome in an endurance athlete: a case report

Arterial thoracic outlet syndrome (aTOS) is a rare condition, but it has an elevated incidence among athletes due to high mechanical demands placed on the upper extremities. Post-surgical rehabilitation guidelines for aTOS are not well defined, especially in high-performance populations. Mechanically loaded neurodynamics (MLND) is a novel technique that introduces controlled external load during neurodynamic movements to optimize neurovascular adaptation and musculoskeletal function. A 47-year-old professional long-distance cyclist presented with left upper extremity pain, paresthesia, and vascular symptoms three weeks after undergoing left first rib and cervical rib resection with scalenectomy for aTOS. The patient had significant scapular dyskinesis, thoracic spine hypomobility, glenohumeral joint stiffness, and posture-related thoracic outlet compression, alongside hyperalgesia and allodynia in the ulnar nerve distribution. A structured 11-week physical therapy protocol was implemented, including traditional and MLND techniques, progressive scapular and thoracic mobility training, and sport-specific strengthening. MLND was introduced to progressively load neural tissues in median, ulnar, and radial nerve distributions while addressing musculoskeletal impairments that contribute to thoracic outlet compression. The patient demonstrated a significant reduction in pain and neurological symptoms, resolution of allodynia, restoration of full active range of motion, ≥ 93% limb symmetry index in strength testing, and an improvement in DASH score from 86.7 to 2.5. The athlete returned to unrestricted cycling at her previous level within 3.5 months post-operation. No adverse effects were reported with MLND use. This case highlights the potential role of MLND in accelerating recovery following thoracic outlet surgery in athletic populations. The approach emphasizes progressive mechanical loading to stimulate neurovascular adaptation and addresses the underlying musculoskeletal impairments contributing to neurovascular compression. Given the absence of standardized protocols for aTOS rehabilitation, MLND may serve as a safe and effective intervention. Future research should further investigate its mechanophysiological effects and clinical efficacy through controlled trials.