Thoracic outlet syndrome (TOS)
What is it?
Thoracic Outlet refers to the narrow passageway between your collarbone (clavicle) and your first rib. This passageway is crowded (you could say overcrowded – how did nature manage this?) with blood vessels, muscles, and nerves. Various stresses (posture, repetitive motion, heavy loads, etc.) can create neurovascular entrapment, i.e., Thoracic Outlet Syndrome.
The term has evolved from a strict medical model, which just involved congenital anomalies treated by surgery to prevent muscle wasting, to a functional model that treats the area by relaxing tension and restoring the normal relationship of bones and joints around the outlet region.
Symptoms:
- Swelling in the neck, arm or hand
- Bluish coloration of the hand
- Arm or hand feels weak, heavy, or tires easily
- Sleeping or lying down, a deep ache or tingling in the neck, shoulder, arm or hand
- Abnormal sensation along the inside forearm and palm
- Weakness in the gripping muscles of the hand
- Lessening of fine motor control in the hand
- Cramping in the inner forearm (writer’s cramp)
- Pain in various surfaces in the arm and hand
- Tingling and numbness in the neck, shoulder, arm or hand
Causes
- Breathing – tense, shallow breathing
- Poor posture – tensing the shoulders, slumping
- Carrying heavy loads – backpacks, book bags, purses
- Repetitive forward arm movements – typical in swimmers
- Congenital anomaly – an extra rib which can cause abnormal traction on the thoracic outlet.
Treatment
Treatment in this clinic begins with looking at the thoracic outlet in terms of its “four walls”, the supraclavicular, the costoclavicular, the axillary wall, and the posterior cervical-thoracic wall. Musculoskeletal testing measures flexibility, tensile and compressive condition of the tissues (tensegrity), postural strengths and weaknesses, bone and joint mobility, and motor coordination of the region.
Standard practice often consists in testing to determine which of three categories of TOS the symptoms fall into (as per Wikipedia):
- Scalenus anticus syndrome (compression on brachial plexus and/or subclavian artery caused by muscle growth) - diagnosed by using Adson's sign with patient's head turned outward
- Cervical rib syndrome (compression on brachial plexus and/or subclavian artery caused by bone growth) - diagnosed by using Adson's sign with patient's head turned inward
- Costoclavicular syndrome (narrowing between the clavicle and the first rib) -- diagnosed with costoclavicular maneuver, and pectoralis minor testing.
However valuable, this analysis gives an incomplete picture compared to an examination of the entire container- the four walls – in order to determine all the factors inhibiting normal function.
Treatment Specifics
Treatment may involve:
- Body mechanics and movement patterns analysis is used to determine the quality of your work posture, sleep posture, and any other prolonged static postures.
- The therapist evaluates the condition of your spine: is it hypermobile or hypomobile in the thoracic region, and what is its condition above and below the critical region.
- Hands-on: a large part of your treatment may involve a hands-on manual therapy experience to myofascially release the areas of compression in the four walls of your thoracic outlet.
- Massage of myofascial trigger points is also a critical part of this therapy. Travel & Simmons trigger points are points in the muscle that have become stirred up by chronic stress on the muscle, such as chronic repetitive motion, or static holding postures.
- Home stretching of your trigger points is a big part of the rehab process. Your therapist will show you very specific stretches for every trigger point that she finds.
- Spine and joint manipulation is an advanced skill practiced by chiropractors and osteopaths and can be a critical technique in releasing neurovascular entrapment. In TOS, tension in your body can cause ribs or vertebrae to lock up, creating a traction or compression of the connective tissue, which then irritates nerves and blood vessels. .
- The main element of stabilization and complete recovery is exercise. A very specialized specific program is created for your body type. One needs to know how to lengthen and open up the region, and how to precisely strengthen and unload the region.
- Breathing exercises are not a small part of the program. In fact, these are often introduced in the beginning to restore normal function of the thoracic outlet, rib cage etc.. Most people breathe too shallowly, creating great static tension inside the chest wall that makes the upper ribs stiffen, and thus stimulating the sympathetic nervous system, which in turn elevates muscle tone (the bad kind), further tightening the thoracic outlet. The goal in breathing programs is to teach you how to shift into the parasympathetic nervous system, which promotes healing.
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