Winning Hands Massage
Thoracic Outlet Syndrome (TOS)
In addition to the nerve related symptoms, TOS frequently presents
circulatory symptoms, such as color and temperature changes in the hand and
non-nerve related numbness. This can, however, be used to help identify the
actual problem.
TOS is a family of conditions that affect enervation and circulation of the
hand and arm and cause a variety of symptoms, including pain, tingling,
numbness, and both color and temperature changes. TOS not only can, but
frequently does, mimic the symptoms presented with true CTS. (The Thoracic
Outlet is basically the upper chest and shoulder area).
There are many possible causes, but five primary possibilities. One is a
subluxed cervical vertebra or herniated cervical disc causing impingement on
the involved nerve. The four main ones, however, are Anterior Scalene
Syndrome, Middle Scalene Syndrome, Pectoralis Minor Syndrome, and
Costoclavicular Syndrome. The first three involve impingement or entrapment
by chronically contracted muscles. The fourth is impingement or entrapment
between the Clavicle and first rib, and which may or may not involve
secondary muscle issues as well.
There are four orthopedic tests to determine if any of the above four
conditions are involved: Adson’s (Anterior Scalene), Travell’s Variation on
Adson’s (for Middle Scalene), Wright’s Hyperabduction (Pec Minor), and the
Costoclavicular Syndrome Test. All involve monitoring the radial pulse at
the wrist while performing a variety of motions with the client’s head/neck
or arm/shoulder. If the pulse stops in less than 30 seconds during any of
the tests, it is a positive indication for that condition.
I personally no longer bother with the any of the tests because I have found
that I can actually assess and treat much faster just using energy.
The specific symptoms, however, can be very suggestive and informative in
quickly determining precisely which condition(s) are involved. Basically,
are the symptoms nerve or circulation related? Nerve issues can be caused by
any or all of the above conditions. Not so circulation problems. Just two of
the conditions (Pec Minor and Costoclavicular) can affect the arterial blood
supply. A visual assessment can usually suffice to determine which is
actually involved. Anyone with a “rolled-in,” hunched, shoulder posture will
be susceptible to Pec Minor Syndrome. It is very common with office workers,
anyone spending extended periods at a computer, wait staff from carrying
trays, taxi drivers, hair dressers, and casino card dealers, just to name a
few.
All of these conditions can be treated energetically. The muscle related
ones can be treated using the Origin-Insertion technique. Costoclavicular
can be treated by “two-pointing” the ends of the Clavicle, similar to a Rib
Head Release. By comparison, a currently popular medical treatment for
Costoclavicular Syndrome is to surgically remove the first rib.
TOS is referred to as syndromes plural because they represent a “family” of
conditions that basically manifest with identical symptoms. Unfortunately,
these are essentially the same symptoms present with CTS, pain and numbness
in the hand and wrist. With a symptom driven mind-set, the all too frequent
misassumption is that the hand or wrist hurt, therefore it must be CTS.
Anytime I work with someone who suspects on their own or who has been told
they have CTS, I do the following evaluations: Phalen’s, Symptoms, ADL
(Activities of Daily Living), and Posture. The first two will generally rule
out CTS, while the second two help identify the actual problem. What is their
occupation? Do they spend long hours at a computer, on the phone, behind the
wheel of a car? Are they a hairdresser or wait person? Is she a mother who
cradles an infant in one arm for extended periods? Do they regularly do
things that will roll their shoulder up and in? What is their normal
posture? Are the shoulders squared, thumbs to the front with the arms
hanging loose at the side? Or do they present a pronounced medial rotation
of the shoulder, arm and hand?
Before discussing TOS in specific detail, a bit of basic anatomy for those
not fully up to speed with it is in order. The “Thoracic Outlet” or Brachial
Plexus is simply fancy language for the broad, flat area on the chest,
directly medial to the shoulder joint. The shoulder joint itself, however,
is the most complex joint in the body, performing all possible actions:
abduction, adduction, lateral and medial rotation, flexion and extension.
There are three bones that actually comprise the shoulder complex: Humerus,
Scapula and Clavicle. In addition, there are 18 major muscles that are
involved in performing these actions. These include the four rotator cuff
muscles (Supraspinatus, Infraspinatus, Subscapularis, and Teres Minor),
Teres Major, Trapezius, Levator Scapula, Coracobrachialis, Biceps Brachii,
Triceps Brachii, Deltoid, Rhomboid Major and Rhomboid Minor, Pectoralis
Minor, Pectoralis Major, Latissimus Dorsi, Sternocleidomastoid, and Serratus
Anterior. And whatever primary action any muscle performs, it does not do so
by acting in isolation. Other muscles either assist as synergists or act in
opposition as antagonists. Consequently, treatment of “structural” issues
always requires identifying and working with those secondary muscles as
well, both for identifying the actual cause of the problem and for
successfully treating the problem.
As for the scapula itself, most people tend to think of it as “just” the
shoulder blade, a bone in the upper back by the shoulder. That may be where
the bone is primarily located, but the various muscles that attach to it
affect other areas of the body as well. For purposes of TOS, understanding
two specific aspects of the scapula is critical. One is the Acromion
Process, the tip at the far lateral top of the spine of the scapula that
“dog legs” around the point of the shoulder. The other is the coracoid
process of the scapula, which is a tiny protrusion from the underside of the
scapula that projects to the front, directly beneath the acromion process.
Regardless of specific cause, two effects of lateral shoulder rotation are
(1) potential displacement or subluxation of the clavicle caused by the
acromion process of the scapula applying pressure against the lateral end of
the clavicle at the acromioclavicular joint and (2) chronic contraction of
the pectoralis minor muscle, which inserts on the coracoid process. These
are the two primary effects. A secondary possible effect if clavicular
pressure is sufficient, is a downward pressure at the sternal end that
transfers to the first rib. This can stretch muscles that attach to the
first rib, such as the scalenes, which also attach to the cervical vertebra.
It will also stretch the Rhomboid muscles in the back and pull on the
Levator Scapula.
As stated earlier, TOS is a “family” of conditions that present similar
symptoms. For bodyworkers, however, the four primary ones fortunately also
fall within our abilities to successfully treat. These are Pectoralis Minor
Syndrome, Costoclavicular Syndrome, Scalene Anterior Syndrome, and Scalene
Medius Syndrome. Pec Minor Syndrome is caused by a chronically contracted
pec minor muscle impinging the nerves and blood vessels that supply the hand
and arm. Costoclavicular Syndrome is an entrapment of those nerves and blood
vessels between the clavicle and the first rib. The scalenes involve
compressive impingement of the nerves (and nerves only) which enervate the
hand and arm.
There are four standard Orthopedic tests that are used to determine which,
if any, of the above syndromes are present. They are Adson’s Test for
Scalene Anterior, Travell’s Variation on Adson’s for Scalene Medius,
Wright’s Hyperabduction for Pectoralis Minor, and the Costoclavicular
Syndrome Test. All of them involve monitoring the radial pulse at the wrist
while the client performs specific motions. For all of them, the test is
positive if the pulse fades or ceases altogether after 30 seconds. If the
pulse remains steady and strong, it is a negative result – that particular
condition is not present. I personally don’t bother with any of the tests
because it takes a minimum of five minutes to perform them all, just
unilaterally. If you do bilateral testing, you are talking about ten minutes
total time. Instead, working energetically, the sense of energy alone tells
me if work needs to be done. If it does, the evaluation AND treatment is
performed simultaneously and in less time than just doing the standard tests
with no treatment.
Knowing the interrelationships/interactions of the various muscles (anatomy
and kinesiology) gives me a pretty good preliminary idea of what might be
involved before I even touch the person. Medial rotation of the shoulder is
suggestive of pec minor involvement. If circulatory symptoms are present, I
know that pec minor and Costoclavicular are both possibilities but the
scalenes are not because the scalenes affect nerves only and not blood flow.
More importantly, I also know that for long-term, chronic situations, it
will be necessary to identify and address secondary issues that have been
masked by the primary symptoms. The PRIMARY symptom and problem might be
Pectoralis Minor Syndrome, but what overall effect does contraction of Pec
Minor have on the scapula and other muscle attachments? Back pain from
stretched Rhomboids? Neck pain from a stretched Levator Scapula? Maybe the
REAL underlying problem is a chronically contracted Sternocleidomastoid
(SCM) muscle on the opposite side, caused by a long ago, untreated, whiplash
injury. Far fetched? Unilateral contraction of the SCM laterally flexes the
head/neck to the same side but rotates the head to the opposite side. Turn
your head to the right and notice the stretch/pull that results on the
medial top edge of your left scapula because that action also stretches the
Levator Scapula on the left. The point is that you need to look at the body
as an interconnected system, and not just a collection of isolated parts and
pieces.
The two primary techniques I use to treat all of the TOS variants are
Origin-Insertion for muscle issues, bone two-pointing for bone related, and
a combination of the two where I do both simultaneously. Pec Minor Syndrome
is treated by placing the fingertips of one hand against the coracoid
process of the scapula (insertion point of pec minor) and the fingertips of
the other hand in reasonable approximation of the origin points of pec
minor. I say reasonable approximation because the actual origin points are
the anterior surfaces of the 4th, 5th, and 6th ribs. Anatomy being what it
is, these points are found beneath the breast tissue. Considering all
ramifications, legal and otherwise, of accessing via direct contact with the
breast tissue, prudence dictates approximating the origin points by making
contact just above the breast tissue. Costoclavicular is treated by placing
the fingertips of one hand against the A-C (acromioclavicular joint) at the
lateral end of the clavicle and the other hand at the Costoclavicular joint
at the sternum. I treat the scalenes by placing the tips of the fingers
along the upper, inside edge of the clavicle directly above the first rib
because the clavicle prevents making direct, easy, contact with the first
rib. The side of my first finger then rests along the side of the neck where
the scalenes insert on the transverse processes of the cervical vertebrae.
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