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Treatment Work - Conditions

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.

Pec MinorThe 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.

CostoclavicularAll 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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