Physical therapist Erica Sigman uses her own experience with thoracic outlet syndrome to successfully treat patients like Alyse Fragosa, who went through years of pain and misdiagnosis until finding the right healthcare team.

BY JAMIE WETHERBE MA ’04

ALYSE FRAGOSA TEARS UP WHEN SHE TALKS about Erica Sigman DPT ’09, assistant professor of clinical physical therapy.

“It’s amazing to find someone who understands what you’re experiencing and how to treat it,” Fragosa says. “I feel incredibly blessed to have met her. I get so emotional talking about it, but it’s been an emotional journey.”

For years, Fragosa suffered from thoracic outlet syndrome (TOS), a condition caused by compression of the nerves, veins or arteries in the thoracic outlet, the area between the neck and shoulder, often causing pain in the shoulder, neck, arm or hand, along with numbness in the fingers.

“My TOS journey began in January 2017 with chronic, daily pain ranging from a three to a seven,” Fragosa says. “I met Erica in January 2023 and experienced my first pain-free day in March 2023.”

TOS can affect people across all ages, backgrounds and body types, although it’s more commonly diagnosed in women ages 20 to 50.

Common causes can be situational — a car accident, repetitive injury or pregnancy — or biological, for instance, being born with an extra rib can cause compression or the “pinch.” Fragosa speculates she developed TOS through repetitive overuse of her arm while using a cell phone and computer, combined with poor posture.

A painful, debilitating diagnosis

Since the symptoms of TOS can mimic other disorders, the condition can be difficult to diagnose.

“It doesn’t show up on testing — for instance, an MRI of the cervical would be unremarkable,” says Sigman, director of USC Physical Therapy (HSC) and co-director of USC’s orthopedic physical therapy residency program. “Same with nerve conduction studies and electromyography — those would typically be normal.”

Sigman first became interested in treating TOS because she has the condition herself. “The pain was to the point where I almost had to take a medical leave,” she says. In terms of treatment, “I basically figured out how to do the exercises myself, but it was not easy. And I realized how tricky the diagnosis is, and how painful and disabling TOS can be.”

At the onset of Fragosa’s TOS, she experienced pain in her right inner elbow, forearm, wrist, pinky and ring fingers, and less in her thoracic outlet. “One day, I struggled to hold a pen and write my name at work,” she says. “At the beginning, it affected my job as a CPA but gradually impacted other areas of my life.”

TOS impaired Fragosa’s ability to complete certain tasks and engage in activities she enjoyed; she even declined a promotion at work. “I struggled working on a computer, using a mouse and using my phone,” she says. “I couldn’t plant flowers, chop vegetables, cook, wash dishes or drive for more than an hour. I loved oil painting but was too afraid to hold a paintbrush.”

Physician and physical therapist team up

Over the course of five years Fragosa saw several specialists — an orthopedic surgeon, rheumatologist, vascular surgeon, chiropractor and a spinal surgeon — who thought she might have conditions like myofascial pain syndrome or fibromyalgia.

“I kept getting misdiagnosed,” she says. “I had this unexplainable, chronic pain there seemed to be no treatment for.”

A venogram finally revealed the issue in Fragosa’s thoracic outlet, and she was diagnosed with TOS. She was referred to Michael Bottros, a clinical pain medicine physician at Keck Medicine of USC and leader in the diagnosis and treatment of TOS, and started receiving Botox injections about every three months to create more space in the thoracic outlet.

Fragosa was also referred to Sigman for active physical therapy. Fragosa had undergone PT in the past — including treatments like traction, ultrasound, and heat and ice therapy — but hadn’t experienced relief long term.

“It helped reduce my pain, but I wasn’t getting permanently better,” she says.

Sigman’s approach to treating TOS is methodical, initially getting nerve pain under control through manual therapy and mobility stretches. “I go really slow at first, to the point where I might not even see a patient the entire 30-minute treatment time,” she says. “I think that’s where a lot of PTs and patients go wrong. If you treat too much at once, the patient gets flared up, and they don’t want to come to physical therapy, making it a failed treatment.”

Once nerve pain has calmed, Sigman gradually builds a program of self-mobilizations and exercises designed to meet a patient’s specific functional goals.

“It’s a Rubik’s Cube where you have to unlock things in a certain sequence,” says Fragosa, whose routine includes 20 stretches and strengthening exercises. “Erica would pick an exercise, see how I responded to it, and then determine the next step. It’s not a one-size-fits all approach.”

Treatment born out of firsthand experience

As Bottros and Sigman started seeing success in treating TOS patients, the providers received an increasing number of referrals. “My name was on a TOS Facebook support group, and it spread like wildfire,” Sigman says. “I feel like my success in treating TOS was directly related to the fact that I’ve experienced it myself.”

Though Fragosa had experienced a few flare-ups, the combination of Botox injections and physical therapy has allowed her to manage her symptoms and stay pain-free for more than a year.

“Erica not only created an excellent routine for me but also gave me hope for recovery. She supports me in living my life fully — taking vacations, flights, long drives and new challenges in my career,” Fragosa says. “She reassures me that if I have a flare-up, she’ll help me get back to my baseline. She’s a TOS success story herself.”