Thoracic Outlet Syndrome ICD-9 353.0
Tips For Better Health
Ask the doctor, Dr James Stoxen DC





by Dr James Stoxen DC

Table of Contents

The Sonny Burke Story

Chapter I      What is Thoracic Outlet Syndrome? (TOS)
Chapter II     Anatomy 
Chapter III    The TOS Controversy
Chapter IV    History, Cause, and Patient Presentations
Chapter V     Physical Examination Findings
Chapter VI    Diagnostic Tests 
Chapter VII   Standard of Care Approaches - Surgical and Non-Surgical 
Chapter VIII  Frequently Asked Questions 
Chapter IX    Case Histories of Patients 
Chapter X     The Human Spring Approach to Treatment and Prevention



Patients come from around the world for treatment for Thoracic Outlet Syndrome by Dr. James Stoxen DC at Team Doctors. The results are not predicated on visits with our approach. The results come with how many hours Dr Stoxen spends resetting the mechanism. For those of you from outside Chicago, we have accelerated treatment plans that allow you to be treated all day for several days in a row until the condition is resolved to MMI.


A note from Dr Stoxen….. 

“Thoracic outlet syndrome is one of the most commonly misdiagnosed, mistreated, under-treated conditions in medicine. Many of my patients come to me from around the world. They have commonly already been to many of the top specialists in a few branches of medicine and have tried many standard treatment approaches and yet are still suffering.  I have had some patients that have been to over 20 doctors before coming to Team Doctors. The reasons why these standard approaches fail and the keys to proper examination, treatment, and prevention are revealed in this complete article below.

This article gets over 6,000 views a month. Because of it’s importance, I am in the process of writing a book about thoracic outlet syndrome. When the book is complete this article will be removed from the site.  If you find this information invaluable print the article now and sign up for our newsletter so we can let you know when it’s released.”

Please feel free to ask any question you like and even share your experience in the comments section at the bottom.  I promise I will respond quickly and decisively.”

-Dr. James Stoxen DC


The Sonny Burke Story:

Sonny Burke is a music legend. The Roselle native played piano for Smokey Robinson for 34 years.  As a top studio musician he played on over 200 record albums and 1000 musical assignments including the entire Saturday night fever album, Jackson 5, Dancin Machine, and other Grammy award-winning artists.

One day Sonny couldn’t play at all….he was completely numb and too weak play. He couldn’t even button his shirt.

“It had been going on for four years. I couldn’t even make a fist,” he said. “I went to five top doctors.  First they told me I had ulnar nerve entrapment. I had surgery for that and it did nothing. While I was recovering from surgery the numbness and tingling started spreading across my left hand then went up my entire left arm.   A few weeks later my right hand started going numb.   I progressively lost my grip strength, which baffled all the top doctors I went to. Lastly they diagnosed me with diabetic neuropathy. They said nothing could be done about that.  I had to live with it.

Yet now the legendary pianist is back playing again. “I can’t believe it,” says Burke. “In three weeks my hand strength has gone from 2% to almost normal.”

I had given up hope for a cure for my numbness and severe weakness after seeing 5 top doctors who operated on me and did every test and treatment they knew, including surgery.  They finally told me there was nothing that could be done so I had to retire from music.” 

“Then I was introduced to Dr Stoxen by a friend backstage at a Steely Dan Concert.”

Sonny Burke didn’t have ulnar nerve entrapment, he didn’t need surgery, and he didn’t have diabetic neuropathy.

His real problem was called Thoracic Outlet Syndrome (TOS).

“When he told me he had diabetic neuropathy I didn’t think I could help him. My only hope was that he was misdiagnosed. When he told me he watched TV in bed…then I knew it could be TOS,” said Dr. James Stoxen of Chicago. The expert lectures on the condition worldwide.

Burke may still be suffering….if Steely Dan hadn’t recently come to Chicago.

Dr Stoxen worked that night backstage with the group (and over 200 other visiting top recording artists). At dinner Steely Dan’s bass player, Freddie Washington, saw how helpless his friend Burke had become, he brought Sonny backstage to meet Dr Stoxen.

“After a thorough exam, the diagnosis was obvious,” says the chiropractor. “This is one of the most common, and commonly misdiagnosed, conditions in America.”

And the biggest cause of the problem?

“By far,” says Stoxen, “it’s watching too much TV in bed, leaning back in the car while driving, poor posture and ergonomics at the computer, text messaging, and other hand held apparatus. In fact, this problem barely existed until all-night programming.”

The problem for Sonny was this.  While on tour for months at a time, his routine was to lay in bed for hours watching TV while propped up with a pillow waiting for the limo to come take him to the show.

“We don’t realize it but we keep our 8-10 pound head suspended from our neck by contracting neck muscles called the scalenes.  Those muscles run from the back of the head to the first and second rib.”

“The head weighs as much as a bowling ball,” says Stoxen. “Watch TV in bed, even with a pillow, and those muscles are constantly contracted for hours at a time. It’s similar to holding a ten pound weight at arm’s length. What happens? Your scalenes go into constant spasm, they fatigue and then they contract constantly in a spasm compressing the neck and the outlet which the nerves, arteries and veins pass through to the arm.”

The scalenes swell compressing the artery, vein and nerves as they pass through them, they lift the first rib up constantly which brings it closer to the collar bone and the chest muscles pull the shoulder and collar bone down too.

That combination of events compresses the nerves and vessels against the overlying collarbone, and causes the symptoms of TOS. Besides weakness, those symptoms can include tingling, neck pain, shoulder problems, and headaches.  When it’s really bad it can cause clot formation, loss of the limb, permanent disability or even death,  if the clot releases.

Dr. Stoxen says, “unfortunately, most TOS patients are misdiagnosed and many receive unnecessary surgery.  “Like Mr. Burke they’re mistakenly told they have herniated disc with a pinched nerve, diabetic neuropathy, carpal tunnel syndrome, or just think the patient is psychologically effected.”

To treat Burke’s real problem, first Stoxen had him move his TV out of his bedroom and advised him to sit up straight at all times. Next he repositioned the structures surrounding the thoracic outlet with a combination of unique hands on procedures he has developed followed by a specially designed rehabilitation exercise program.

“It takes me several hours to completely rebuild the area of his neck and shoulders surrounding the outlet by hand,” he says. “Gradually, (after about ten treatments) the blood flow returns to the arms and hands, the feeling came back and Sonny’s strength came back.”

Doctors and patients do not realize how much work is involved in reversing thoracic outlet.  Some cases can take 10 – 35 hours of hard core deep tissue to clear this up.  It is analogous to unraveling a pile of frozen steak and entwined wires with your bare hands.

Many patients with Burke’s symptoms ultimately get surgery. In 22 years of practice I have not sent a single patient for neck surgery and I treat some tough cases.”

“If you’ve noticed those tingling or weakness of your hands you may want to look at all your options instead of rushing into surgery.” says Stoxen. “Your real problem may be treatable with these methods.


Do you have Thoracic Outlet Syndrome? Do you feel this pain in your neck, arm or hand. It’s often an electrical or throbbing feeling that travels down your arm and can make your hands weak. In this book you will find every thing you ever wanted to know about Thoracic Outlet Syndrome.



What is Thoracic Outlet Syndrome?

Thoracic outlet syndrome, also called thoracic outlet disorder which is a group of symptoms such as arm and neck pain or under shoulder pain, caused by pressure against the bundle of nerves and/or the arteries and veins that originate at the spinal cord at the neck as they pass through the scalene muscles, over the first rib and under the pectoralis minor and clavicle (collar bone), or collar bone muscle.

The other diagnostic labels that have been used to describe thoracic outlet syndrome are: Cervical rib syndrome, scalenus anticus syndrome, costoclavicular syndrome, hyper abduction syndrome, pectoralis minor syndrome, brachiocephalic syndrome, nocturnal paresthetic brachialgia, fractured clavicle-rib syndrome, deep vein thrombosis (Paget-Schroetter syndrome), superior outlet syndrome, naffziger syndrome, subcoracoid pectoralis minor syndrome, first thoracic rib syndrome, costoclavicular compression syndrome and cervical rib and band syndrome.

Thoracic Outlet Syndrome or the diagnosis of Thoracic outlet syndrome is the name given to several similar problems that can include arm pain from the neck which involves compression of the nerves and blood vessels of the area where your neck attaches to your body — the lower neck / upper chest region. It can also entail a pinching off of an artery that runs underneath the clavicle (subclavian artery). This causes arm numbness, arm tingling, or your arm in pain and often times pain in the hands that is often mistaken for carpal tunnel syndrome.

Thoracic Outlet Syndrome (TOS) is not only difficult to diagnose, many physicians deny its very existence. The truth is that inside the medical community, Thoracic Outlet Syndrome (TOS) is not well understood, difficult to image, and carries a great deal of controversy and disagreement over how best to treat it. In this article I will explain diagnosing for thoracic outlet syndrome, testing for thoracic outlet syndrome, symptoms of thoracic outlet syndrome and treatment for thoracic outlet syndrome.

This is one reason why so many people who have been told they have thoracic outlet syndrome contact me, a thoracic outlet syndrome specialist. Many of you are getting thoracic outlet treatment yet you may still be experiencing thoracic outlet pain, headaches, achy hands, tingling in the fingers, shoulder pain, below neck pain, upper back pain, chest pain with arm pain, swelling in the hands and even loss of grip strength thinking thoracic outlet surgery is the only option.

Some patients have symptoms of nerve compression, which causes severe neck pain, repeated migraines, shoulder pain, and a sense of tiredness or heaviness in the arm caused by thoracic outlet syndrome. Other symptoms of thoracic outlet syndrome may include tenderness over the neck muscles or around the collarbone, pressure on these areas causing pain or tingling in the arm, pain in the shoulder or arm with neck movements, and tenderness in the armpit. Even odd sensations in the face or ringing in the ear or ear pain can be caused by thoracic outlet syndrome.

The nerves supply sensation and muscle power to the arms and the arteries and veins provide blood supply to the arm. The pressure against these structures is caused by tight swollen scalene muscles, in the neck, shoulder and chest muscles as well as an elevated first rib with a depressed collarbone. There are many areas nerve compression, for these arteries and nerves to get compressed.

That is why it is helpful to understand the thoracic outlet anatomy so you can differentiate between venous thoracic outlet, arterial thoracic outlet syndrome, (vascular thoracic outlet), cervical ribs thoracic outlet syndrome, carpal tunnel syndrome. Thoracic outlet brachial plexus compression (neurogenic thoracic outlet), pectoralis minor thoracic outlet syndrome, or maybe you have all of the above!


Watch above as Dr. James Stoxen DC gives the lecture presentation Thoracic Outlet Syndrome at the 12th Annual World Congress on Anti-aging Medicine Mandalay Bay Hotel and Casino, Las Vegas Nevada December 4, 2004

Next Chapter I, What is Thoracic Outlet Syndrome 

 Chapter I


What is thoracic outlet syndrome?


Thoracic Outlet Syndrome

Thoracic Outlet Syndrome

Thoracic Outlet Syndrome (TOS) occurs when the nerves, veins and arteries that pass through the thoracic outlet become compressed. The thoracic outlet is the space between your collarbone (clavicle) and your first rib. This narrow passageway is crowded with blood vessels, nerves and muscles. (For more information from mayo clinic and the picture above, click here)

Some patients have severe pain at the neck, stiff neck, repeated migraines, shoulder pain, neck and should pain (feels like (Polymyalgia rheumatica) and a sense of muscle tiredness or heaviness in the arm caused by thoracic outlet syndrome. Other symptoms of thoracic outlet syndrome may include tenderness over the neck muscles or around the collarbone, pressure on these areas causing pain or tingling in the arm, pain in the shoulder or arm with neck movements, and tenderness in the armpit. Even odd sensations in the face or ringing in the ear or ear pain can be caused by thoracic outlet syndrome. The nerves supply sensation and muscle power to the arms and the arteries and veins as well as the nerves on the neck, provide blood supply to the arm. The pressure against these structures is caused by tight swollen scalene muscles, in the neck, shoulder and chest muscles as well as an elevated first rib with a depressed collarbone. Nerve entrapment or nerve compression can occur because there are many areas for these arteries and nerves to get compressed.


Thoracic Outlet Anatomy

Thoracic Outlet Anatomy

That is why it’s important for you to understand the thoracic outlet anatomy so you can differentiate between venous thoracic outlet, arterial thoracic outlet syndrome, (vascular thoracic outlet), cervical ribs thoracic outlet syndrome, Polymyalgia rheumatica, thoracic outlet brachial plexus compression (neurogenic thoracic outlet), carpal tunnel syndrome, pectoralis minor thoracic outlet syndrome or maybe you have all of the above! Thoracic outlet syndrome is a very controversial subject. In fact a lot of doctors don’t think it exists. Thoracic outlet syndrome is the most difficult neurovascular compression syndrome of the extremities to manage and that is because it has a variability of complaints. It also has a difficulty in the patient compliance in the treatment and reduction of the causative factors.

History of Thoracic Outlet Syndrome

First of all, this problem is not a new problem. Galen who made the first mention of the cervical rib first mentioned it in the 2nd century AD. In 1910 Murphy gave mention of the effectiveness of the first rib resection. In 1927, Adson brought up the scalenectomy without cervical rib resection. In 1956 Deete coined the term Thoracic Outlet Syndrome.

Experience helps

Team Doctors Chiropractic Treatment and Training Centers has been around for about 57 years. It has been a practice in our family for many years. Since 1986 we have had over 30,000 new patients. From 1992 – 2012 we have had approximately 4,000 new patients with some form of peripheral nerve symptoms originating either in the neck or lower back. Statistically, we have numerous cases of thoracic outlet syndrome. We have had a great amount of experience in working with patients with thoracic outlet syndrome.

Next, Chapter II - Anatomy of Thoracic Outlet Syndrome Three Areas of Compression

 Chapter II


Anatomy of Thoracic Outlet Syndrome


Thoracic Outlet Syndrome – Three Potential Areas of Compression

     Thoracic outlet syndrome is the often misdiagnosed cause of neck pain, shoulder pain and arm disability. It is thought to be neurovascular compression seen at the thoracic outlet, which is something that anatomists can’t agree on. The actual name doesn’t properly describe the condition.

Thoracic Outlet Areas Of Compression

Thoracic Outlet Areas Of Compression

3 areas of potential regions of compression consisting of:

  1. The Inter Scalene Triangle
  2. The Costoclavicular Space
  3. The Intrapectoral Space

The Inter Scalene Triangle

This is bordered by the anterior and middle scalenes. The supraclavicular bundle consisting of the subclavian vein, the subclavian artery and the brachial plexus emanate from this triangle and it’s an area where any one of these structures can become compressed and cause symptomatology.

The Costoclavicular Space

The area below the clavicle and above the first rib represents the costoclavicular space. Few patients and doctors understand that the ribs actually go up this high at the face of the neck.

The Interpectoral Space

The last space is the interpectoral space and that is in the area of pectoralis minor and that area can be an area of compression.

Arteries, Veins and Nerves pass through the Thoracic Outlet

Doctors should be aware of these multiple areas of compression and have an understanding of what symptoms can be related to each one of these areas so they can better treat the patient. The three-neurovascular structures that pass through the thoracic outlet area are the brachial plexus consisting of cervical nerves C5, C6, C7, C8 and T1. The subclavian artery is the artery that supplies the arm with blood, oxygen and nutrients. The subclavian vein drains the blood away from the arm and back to the heart.

What is Venous Thoracic Outlet Syndrome?

Venous thoracic outlet syndrome (TOS) is also known as Paget-Schroetter syndrome or subclavian vein effort thrombosis. Paget determined that the symptoms of the upper extremity (ie, arm swelling) were a result of subclavian vein thrombosis. Von Schroetter further proposed that the upper extremity venous symptoms were a result of thrombosis of the subclavian vein at the thoracic outlet. At the level of the thoracic outlet, the subclavian vein passes over the first rib, anterior to the insertion of the anterior scalene muscle. This space is called the costoclavicular space and is located between the clavicle and subclavius muscle, superior to the subclavian vein with the first rib being inferior to the subclavian vein.

Venous TOS is a result of extrinsic compression of the subclavian vein, which results in injury of the vein, and eventual, stenosis (narrowing) and thrombosis (clotting). The most common causes of extrinsic compression of the subclavian vein are a narrow costoclavicular space or muscular hypertrophy of the subclavius or anterior scalene.

A symptom of Venous Thoracic Outlet Syndrome is pitting edema of the arm

The symptoms of venous TOS are caused by subclavian vein thrombosis and/or stenosis. The symptoms involve the upper extremity (arm), and include: arm swelling, arm heaviness or aching of the arm, and cyanosis. An individual may notice prominent, distended veins in the upper chest and shoulder region as well as pitting edema of the arm (pictured above), distending veins and dilated collateral veins. Especially after activities which require repetitive use of the involved extremity.  Rarely, a pulmonary embolism may occur.

Paget–von Schrötter disease, is a form of deep vein thromboisis (DVT), in which blood clots form in the veins of the arms.  These DVTs typically occur in the axillary or subclavian veins.

 Read Chapter III – Thoracic Outlet Syndrome controversy

 Chapter III


Thoracic Outlet Syndrome controversy

Thoracic Outlet Syndrome is controversial in the medical community.

Here is why…

Under diagnosed or over diagnosed

Some physicians say that this syndrome is under-diagnosed. I read a letter to the editor in a surgical publication, which said that this physician said it was under-diagnosed and that more thoracic outlet syndrome actually existed, while other physicians say it was over-diagnosed. We say that it is under-diagnosed.

No Gold Standard Test Exists

The problem with this syndrome and the difficulty with this syndrome is that many physicians say there is no gold standard tests for thoracic outlet syndrome. In order to diagnose thoracic outlet syndrome you have to put together an array of historical findings, physical findings and a couple of provocative orthopedic tests in the region of the neck and shoulder to be able to make that diagnosis.

The Most common Treatment is Surgery

The most common treatment today for thoracic outlet syndrome is surgery. According to the literature, if you have a group of 500 patients only 10% will respond to conservative therapy, which leads to 90% goiing to surgery. Doctors often times give up on initiating conservative therapy and go directly to surgery. We have to put ourselves in the position of the patient. As you can see on the graphic above we have a thoracic outlet surgery of the neck. There are many tiny important structures in this area.  Patients are in great fear of surgery, especially in the neck so the answer is no patient wants to have this surgery.

Surgery is unnecessary with the right approach

We have a very high rate of recovery from thoracic outlet syndrome with conservative care, and I am very happy to present that form of treatment to you today. I have not referred a patient for surgery for a thoracic outlet syndrome in 18 years of practice. That includes thousands of patients over these 18 years. I was very shocked when I looked into the literature. I am aware of the rhizectomy, removal of the first rib. I was curious about other therapies so I reviewed over 325 scientific papers that discussed conservative methods of therapy, including stretching and what the procedures and protocols were used to treat these patients conservatively.

Why Current Conservative Therapy is Unsuccessful

I think that after reading this, you will find out why these treatments were unsuccessful. You are going to have a better understanding of the most common cause of this syndrome. I feel that with a better understanding of what causes this syndrome, you will have better results with conservative therapy of this syndrome.

Read Chapter IV-History, Causes and Patient Presentations 

Chapter IV


History, Causes and Patient Presentations 


Symptoms of Thoracic Outlet Syndrome

Any and all of these structures can be compressed leading to an array of symptomatology. Thoracic outlet syndrome relates to nerve and vascular compression symptoms; it leads to upper back and neck pain, shoulder complaints, numbness and even extremity weakness.

Some of the more severe symptoms of thoracic outlet syndrome are upper extremity emboli, which occur when the blood supply is diminished when the clot is released into the arm. The arm can become ischemic and an area distal to the emboli can become gangrene, even in very rare situations. Another serious complaint that is not listed in the literature is unnecessary surgery; if more appropriate conservative methods can be used, then surgery would not be necessary. If you told the patient that you were going to do surgery to remove structures from the neck such as the ribs and muscles, the patient may not be too keen on this surgery. They may very well become scared.

Symptoms and Signs Vary in intensity

There are varying degrees of subluxations that have the rib elevated in perhaps less than that amount on that particular patient; in other words,  there are rib subluxations that do not illicit a full blown thoracic outlet syndrome, but when stressed, you will have to say that the patient because of the biomechanics of the ribs, the ribs are subluxated, but not enough to cause numbness or compression of the subclavian artery vein and brachial plexus. However, when put in a provocative position, they are subluxated just enough to cause the positive test, but not enough to cause brain symptoms in the patient.

Subclavian Artery Compression Signs and Symptoms

You can have subclavian aneurysms and when the compromise of compression of the structures gets severe leading to ischemic, causing weakness of the arm and hand and grip strength, you can have potentially dangerous accidents related to dropping of things by the patient.

Thoracic outlet venous syndrome symptoms

In extreme cases of thoracic outlet veinous syndrome may occur.  The veins can become severely occluded and will not allow the blood to escape from the arm and pitting edema may occur.

Symptoms of TOS

The common symptoms of thoracic outlet syndrome usually begin with some stiffness in the upper thoracic area like in the ribs around the neck area, specifically in the traps and the upper back. Other symptoms of Thoracic Outlet Syndrome may include;

  • Pain, numbness, and tingling in the pinky and ring fingers, and the inner forearm
  • Pain and tingling in the neck and shoulders (carrying something heavy may make the pain worse)
  • Signs of poor circulation in the hand or forearm (a bluish color, cold hands, or a swollen arm)
  • Weakness of the muscles in the hand

Why do patients with TOS have upper back pain and sometimes shortness of breath at times?

The pain and stiffness travel from the upper thoracic area and patients sometimes complain of chest pain in the upper thorax area. They also may complain of difficulty breathing. They talk about stiffness, and labored breathing and don’t realize it until you bring it to their attention. “Have you noticed lately that your chest feels tight and you have not been able to breathe as well?” And they will answer, “Yes, as a matter of fact I did.” It wasn’t something they were thinking about because they don’t understand the connection.

Why does this happen?

In fact, the reason the patient has a shortness of breath is because when the first rib subluxates in superiorly the intercostals muscles which connects the ribs actually allow not only for the first rib to subluxate superiorly, but the first rib takes the second, third, fourth and fifth ribs with it, because they’re connected. So what you are going to see is superior subluxation of the ribs of the upper thoracic spine and not just the first and second.

Why do so many patients with TOS have headaches too?

The other common symptom patients have with TOS is recurring headaches. The reason why is that they are in a reclining position watching television. Their neck in this position for so long that when they get up, their neck is more in a straightened, military or retrolisthesis position. If they leave their head in this position, they will not be able to see where they are going.

It may seem silly, but postural reflexes kick in and an extension of the C0, C1, and C2 vertebra occurs to compensate for the tucking mechanism caused by the spastic scalenes. This hyperextension at level skull C1, C2, plus axis complex will actually cause compression of the first and second nerve of the spine and radiating headache pain as a result of this compression of the nerves and suboccipital regions.

What are thoracic outlet syndrome causes?

Certain positioning will often make thoracic outlet symptoms worse. For example, leaning back relaxing on the couch or recliner, a sitting with a reclined car seat, and the most common, sitting back working at your computer desk.  Some of you do all of the wrong things and its no wonder you have a bad case of thoracic outlet syndrome.

Although one of the most common causes of thoracic outlet syndrome is a history of a whiplash injury, I feel that poor posture by leaning back or either side while sitting on the couch, leaning back in the bed, leaning back in the car or leaning to the side while performing computer work is the most common causes of thoracic outlet syndrome.  Some of you go to the chiropractor for treatment, they help you then you go home and sit leaning back causing the thoracic outlet to come back in less than a few hours. 

Thoracic Outlet Syndrome has all sorts of causes. These can range from physical trauma (AUTOMOBILE ACCIDENTS) , anatomical anomalies (an extra pair of ribs located on the last neck vertebrae), although abnormally large swollen scalene muscles can be problematic as well), poor posture, gaining additional weight such as seen in OBESITY or pregnancy, and playing sports or having a job that involves lots of overhead movements. One of the most common of these jobs (even though it is not overhead) is keyboarding (working at a computer) for hours a day.

It has also been shown that if you get thoracic outlet symptoms while carrying a heavy backpack or wearing a heavy jacket, this might be a tip off that you have TOS. Any sort of heavy burden on the shoulder girdles can cause neurovascular compression in the “Thoracic Outlet” (Thoracic Outlet Syndrome).

Bottom line; there is a lot of potential for people to develop Thoracic Outlet Syndrome. But every cloud has a silver lining and in this article I will show you how I treat thoracic outlet syndrome symptoms and what you can do to prevent, self help tips for thoracic outlet and resources you can use to help you sort out your individual case.

I have found that the most common cause of thoracic outlet syndrome is a combination of things but primarily it is a superior subluxation of the first rib. In other words, the patient is fine for 30 years of their life, they come to you with some upper extremity symptomatology for approximately a year or some length of time and it is becoming worse.

What is the difference with the patient who was fine at 31 and then at 32 has these peripheral nerve and vascular symptoms? They have the same structures but different symptoms. They have no growths or tumors. All we have to do is find out what changed, reverse the change and the patient is treated properly.

Static Postural Stress and Traumatic Injury

The cause of thoracic outlet syndrome should be broken down into two main categories.

  1. Traumatic injury and
  2. Static postural stress.

Static Postural Stress (The most common cause of TOS)

I feel this is the most popular and the most common cause of thoracic outlet syndrome. It is where the position of the neck is held in a forward flexing position when the patient is leaning back which strains the scalene muscles because they must hold the head and neck from extending.

Static Postural Stress – Mechanism of Injury

In the literature I studied, it states that the neck is held in the extension position. This position does not cause a strain on the scalene or flexion muscles of the neck. For instance, if you were to take your arm and hold a purse or a liter of liquid and hold it out extended with your arm flexed at 90 degrees for one hour, pretty soon your biceps, tendons, and your joints in your elbow and your shoulders, muscles in your shoulder will become very soar stiff and your elbow will become inflamed.

Example 1: Reading or Watching TV in Bed

The same type of philosophy or theory is that if you are sitting in your bed with two pillows propping up your neck, watching your favorite television show in this position for approximately 1 – 2 hours, the scalene muscles will be in an a tonic contractile state for a very long period of time and the same thing will happen to these muscles. The scalene muscles attach on the first rib, so as the tension is increased on the scalene muscles, we feel that the scalene muscles elevate the first rib and cause the subluxation, the scalene muscles also become inflamed as a result of the subluxation, the entire area, as well as the scalene muscles will become inflamed and cause a compression of the thoracic outlet group of structures.

Example 2: Computer use/Reading or watching TV in bed

Computer use where you’re actually leaning back in a reclining chair, or reading in bed, as I have mentioned before, just as much as watching television in bed, which I feel is the most common cause, or laying on a recliner or sofa, with the neck in an extended position.

Example 3: Leaning back in the Car while Driving or on a Plane

Operation of a motor vehicle with the neck extended as well. Nowadays the car seat can be reclined; it can be straight and other various positions. A lot of young people think it’s really cool to lean the seat way back, and sit like this and they may be on a long route for half an hour, an hour or they may be in the car quite a bit; this constant stress on the anterior muscles causes imbalance and raise the first ribs and causes the compression and thoracic outlet syndrome.

The Human Spring Theory and Thoracic Outlet Syndrome

Compression of the thoracic outlet is what leads to the major symptoms and signs of thoracic outlet syndrome.

So, if you understand how the body responds to the earths gravity, you will be able to understand how thoracic outlet develops.  Understanding how it develops or the cause is the most important component to recovery and prevention.

In the human spring model we evaluate the body as a spring mechanism which has 7 floors of interacting spring mechanisms that act like a spring. This seven floor structure acts like a giant spring to recycle energy and protect the body from the approximate estimate of 250,000,000 impacts or collisions it has with the earth (steps) in a lifetime.

How does the bodies joints and muscles or floors of human spring, respond to gravity?

Here are some basic laws, which govern the health and integrity of the spring mechanism:

1. The bodies spring mechanics are best maintained when in constant movement.
2. The human spring is best maintained when perpendicular to the earths gravitational pull. (standing or sitting straight)
3. When the human spring is moving (walking, running or sport) the optimum position when fully loaded is perpendicular to earths gravity.

How Does The Body Respond To Gravity?  VERY IMPORTANT!!!!

When the body leans out of the perpendicular position to gravity, muscles act on body parts to maintain them in the position resisting the gravitational pull on the body part.

For example: If you lean your head to the left, the scalene muscles and neck muscles on the right contract to maintain the head in this position or to keep the head from falling to the ground.

For example: If you lift your arm in front of you, the pectoralis minor, anterior deltoid and neck muscles on that side contract to maintain that position or to keep the head from falling to the ground.

Repetitive movements such as lifting weights running or walking are healthy for the body until you have exceeded the yield point.

The longer you have to hold your head or arm in one position the brain begins to make that spasm or contraction of the muscle a permanent spring compression condition like thoracic outlet syndrome, herniated discs or degeneration of joints.

Therefore,  if you lean to the left for one hour, your right side muscles of your neck will contract to maintain the head position against gravity and soon this muscle will contract 24 hours a day compressing the spring mechanism.

When it compresses the spring mechanism it causes these problems:

Because the spring is compressed on that side, it is essentially preloaded with internal force.

When we lift something we have the force of what we are lifting plus the internal force of the spasms compressing the joints added on which leave the structures vulnerable to acute deformity like a herniated disc or degeneration with each movement like knee or hip joint degeneration leading to a possible joint replacement surgery.

If you have preload compressive force from a scalene and neck muscle tension from leaning at the time of the lift or because you leaned too much causing a constant contraction of these muscles you will have the internal force of the spasm and the external force of the lifting movement combined to exert potentially damaging forces on the discs of the neck and the structures that come out between them.

Abnormal internal compressive forces can occur anywhere along the 7 floors of the body leading to compression conditions like foot pain

The body is a giant spring with 7 floors of spring:

Spring Floor 7 – The head-neck
Spring Floor 6 – The spine/chest
Spring Floor 5 – The hip
Spring Floor 4 _ The knee
Spring Floor 3 – The ankle mortise
Spring Floor 2 – The subtalar joint
Spring Floor 1 – The arch

The overloaded stress on the other structures could manifest as:

Compression of Floor 7-6

  • Headaches
  • Neck Pain
  • Herniated Disc in the NeckOverload of Stress Can Manifest Compression
  • Pinched Nerve In the Neck
  • Upper Back Pain
  • Mid Back Pain
  • TOS

Compression of Floors 6, 5, 4, 3, 2, 1

  • Herniated Disc in the Back
  • Lower Back Pain
  • Sciatic Nerve Pinched

Compression of Floors 5, 4, 3, 2, 1

  • TFL & illiotibial band syndrome
  • gluteus medius pain

Compression of Floors 4, 3, 2, 1

  • Knee Pain

Compression of Floors 3, 2, 1

  • plantar fasciitis
  • heel spurs
  • heel pain
  • foot pain
  • tibialis posterior tendon dysfunction
  • ankle sprain
  • shin splints

If you have TOS you should be checked for compression of the entire spring mechanism of your body from floor 1-7 to really do a thorough job of diagnosing and treating the body to maximum medical improvement. The human spring model and approach is something you really must look into to fully understand the state of your over all health.

TOS is more than just a neck problem!

Many doctors and therapists think there is only one set of muscles which compress the the artery vein and nerves in the thoracic outlet area.  With thoracic outlet you have two floors of muscles which act together to compress these structures. If you don’t do enough deep tissue work to release the constant painful contractions of these muscles you will still have some compression to release of the area.

Floor I – This consists of the muscles from the shoulder and rib cage to the neck
Floor II – This consists of the muscles from the rib cage to the shoulder

To determine the cause of why you have the TOS we need to determine what is causing the constant strain on the muscles of floor I, floor II or both floors simultaneously. I will give you the most common activities that do this. Compression of Pectoralis Minor

Compression at level II – This spasmed pectoralis minor and or the latissimus dorsi can act together to compress the area.

The swollen spasmed pectoralis minor by itself can compress the artery, vein and nerves as they pass beneath it at level II.

Pectoralis Minor – draws the scapula down and forward – and elevates the ribs 3, 4, and 5

If the pectoralis minor muscle is in spasm it will pull the shoulder girdle or compress the shoulder (shoulder blade, collar bone and arm) which will pull the neck and head down or compress the area of the neck spring.

So if you are holding any object in front of you for an extended period of time you could be causing a strain your pectoralis minor that could lead to a spasm of it.


This can also happen with musical instruments, pens, computer mouse, books and serving trays.

Compression at Level I – This swollen spasmed pectoralis minor will pull the shoulder girdle (shoulder blade, collar bone and shoulder) down compressing level II.

When the shoulder is compressed down it causes a strain on level I structures putting them in spasm and compressing this area too.

Latissimus Dorsi – pulls the arm down which pulls the shoulder girdle down compressing level II. When the shoulder is compressed down it causes a strain on level I structures putting them in spasm and compressing this area too.

Compression at level I

Scalene Muscles – They originate from the side of the neck vertebra but only c 2 3 4 5 6 and 7 and and insert onto the first and second ribs. Thus they are called the side neck muscles.

When they contract they lift the first and second rib towards the neck and they pull the neck down to the side when one contracts at a time or to the front when both contract at the same time.

So when you lean back in a chair your 9 pound head is kept from falling backward by the scalenes. So if you are leaning back in the couch, head board of the bed or in the car seat resting your upper body against these structures your head is dangling. Your scalenes contract constantly to maintain the head in this position.

If you lean to the right the scalene on the left is constantly pulling and vice versa.

This strain can cause them to go in a spasm compressing the structures in floor one constantly.

So if a patient comes in with scalene spasm on the left with symptoms on the left I can guarantee they are sitting on the right side of the couch leaning to the right forcing the left scalene to hold the head in the leaned position.

If a patient comes in with symptoms on both the right and left then they are most likely watching tv or reading in bed or doing something leaning backwards with almost equal strain on both scalenes.

Traumatic Epidemiology

Traumatic epidemiology such as whiplash is seen in sports or car accidents can cause TOS.

Read Chapter V - Physical Examination Findings

 Chapter V


Physical Examination Findings

Cervical Range of Motion

Cervical range of motion and flexion. We have a decreased range of motion and stiffness in the lower cervical and upper thoracic area. Cervical range of motion that I have seen is not the most prevalent range of motion but it is apparent and the patients that usually complain of pain in the upper thoracic area around C6, C7, and T1. During extension when they extend the back, they may feel a pinching sensation in the first and second thoracic ribs in the spine area. Their rotation usually is pretty good. I find that most of them can rotate about 70 – 75 degrees.

Rotation is not as significantly altered as lateral flexion. With these patients you try lateral flexion, and they’re getting maybe 5, 10 or at the most 15 degrees when normal is 45 degrees. Also what you’re seeing in lateral flexion is that when you laterally flex the left, the right scalene will become prominent. You place your finger on it and it may feel tense. It feels like a palpable hard band and it’s very stiff. When the range of motion in the cervical area and the anatomical structures are affected as well as the biomechanics become abnormal in the neck area.

Spasms in the Scalenes

In this particular slide, we’re talking about postural evaluation. What you’re going to do is sit in a chair in your office and you’re going to demonstrate the posture that the patient is in that causes the tension on the anterior scalene muscles which is the gentleman in the bottom picture and the lady who is leaning back in the chair. You and I both know that this is how many of us and a lot of children sit; and a lot of people have thoracic outlet syndrome.

Swelling in the supraclavicular area and around the neck

The swelling in a supraclavicular space is amazing to me because it’s so obvious and so blatant but few doctors ever notice it. I have had numerous patients who have come to me with swelling in the supraclavicular space. They have been to several physicians, none of which has made comments in their notes. The swelling comes from the inflammation, which results from the joint inflammation.

Supraclavicular Swelling

Supraclavicular Swelling

Example of Sever Supraclavicular swelling

As you can see on the top picture here, you can see the upper border of the clavicle on the patient and this patient below was involved in a motor vehicle accident at a fairly high speed. She has bilateral thoracic outlet syndrome. As you can see from the photograph, the superior border of the clavicle is obliterated. Also, you don’t see the sternocleidomastoid muscles and we don’t see any muscles structure in these patients and they are thin. In thinner patients, it is more obvious. There is really no fat there. So it’s not fat, it’s swelling. You should look for swelling of the supraclavicular space in your patients.

TOS can be subclinical and still signs of supraclavicular swelling can be noted I have patients who come in my office for a lower back adjustment. They look at me and when I see the left side of the supraclavicular space is swollen,

I ask them “Do you have numbness in your left hand periodically, more than in your right hand?” In nine times out of ten, they’ll say, “Yes, and how did you know?” Like I’m a magician.

How did you know I had numbness in my hand?

There is no documentation in the forms the patient filled out where they note their symptoms? Nobody had mentioned to the staff or me about this symptom, and they weren’t even interested in discussing it with us. They came in for their lower back. It was an incident that had started approximately one, two or perhaps six months ago. But just by my observation, the supraclavicular space was swollen and the patient, I feel, had this thoracic outlet syndrome.

Subtle Right Hand Swelling or Edema in Thoracic Outlet Syndrome

Subtle Right Hand Swelling or Edema in Thoracic Outlet Syndrome

note; the example above shows how subtle the right hand swelling or edema can be. This patient did not realize the right hand was more swollen then the left. They started to see a difference when a photo was taken of both hands to compare the two.

Swelling in the hands

Usually it’s better to take a photograph of the hands and evaluate it that way. I found that this can be a very helpful tool, because sometimes you don’t see it at first, and it can be seen well through a photograph. The second thing is to look at the tendons. If the tendons have been obliterated by edema, you might be looking at a patient who has had difficulty in drainage of the blood from the extremity. It kind of balloons out and they’re going to get a little tingling – that’s when it’s starts to affect the arterial supply. In this situation, the patient becomes a little worried and it is at that time that the patient usually comes to see you.

These are actual pictures of patients that have thoracic outlet in my office.  This particular patient that you see with the hands on the top picture is the lady in the previous picture that had the supraclavicular swelling. As you can see on the right hand, it is much larger than the left. In fact, this enlargement is a swelling and is a result of the fact that the venous return is blocked because of the superior rib subluxation or some intrascalene type of compression on the subclavian vein not allowing the blood to escape from the hand. On the lower picture, we have a gentleman who has the same syndrome.

Not only does his right hand appear to be bigger, but the wrist and forearm also appear to be bigger. I saw vaguely that there were some differences in the hands, but when I took a photograph of the patient, it became very obvious. My feeling is that this is something you should you use as a tool because it brings out the differences more strikingly.

Manual Muscle Testing and TOS Rotator Cuff Muscle Testing

Shoulder Orthopedic Tests Because of all the attachments in the neck and the shoulder area, you’re also going to find that the shoulder range of motion is going to be affected. It’s affected or decreased in 44% of thoracic outlet syndrome according to a very large study that I reviewed. What happens is the elevation of the first rib causes an ultra biomechanics of the shoulder, because se the shoulder articulates on the dome that is re presented by the first, second and third ribs. Therefore, if you’re going to alter the foundation by which the structure by which the structure moves upon, you’re going to cause damage to that structure. It’s no different from the structures of a building affecting the first, second and third floors. It’s very simple.

Rotator Cuff Syndrome and TOS

Other muscles originating from the chest, neck and shoulder are further affected predisposing the patient to rotator cuff syndromes and impingement syndromes. The first muscle that is affected is the superspinatus. I am going to demonstrate to you the biomechanics of what goes wrong. The first rib subluxates, causing a rising of the clavicle, and as a result added tension is placed on the superspinatus.

The superspinatus muscle test is usually weak, and I’d say that on 50 – 60% of those patients that have long standing thoracic outlet syndrome for more than 3 or 4 months. You need to also do an evaluation of the shoulder mechanism because this usually is the second area of emphasizing of the thoracic outlet syndrome.

Muscle groups that are commonly affected are the anterior cervical muscles as I mentioned to you because of the fact that you’re holding the muscles in a contracted position for a long time. These muscles should not be put in a contracted position for this long of a time and that’s why they become weak and spastic and lead to elevation of the first rib.

The supraspinatus as I had mentioned and also the latissimus dorsi intrinsic muscles of the fingers – when you’re doing your physical examination you should measure the strengths of the intrinsic muscles of the fingers because that’s the first area of weakness that you’re going to find that the patient will experience when they start to lose grip strength and strength in the hand as a result of a fairly lengthy compressive forces, the forces that are occurring in the brachial plexus, subclavian vein.

Rotator Cuff Muscle Testing

The rotator cuff in advanced cases does not take long to evaluate, and is necessary and important, therefore you should do it. In the x-ray findings, you’re going to find a loss or a cervical curve or a retrolisthesis, called a military spine, whiplash spine.

I don’t care what you call it. The bottom line is that either

  1. It’s straight or
  2. It’s curved in the opposite direction of the way it’s supposed to be.

What you have to understand is that the cervical curve is designed in such a way to function as a curve. If you take the spine out of its position and normal alignment, you’ll find that the joints are going to wear out faster. It’s compared to your vehicle being out of alignment; the tires are going to wear out faster. Any moving part of machinery, will wear out faster.

Tests and Diagnosis

Diagnosing thoracic outlet syndrome can be difficult because the symptoms and their severity can vary greatly among people with the disorder. To diagnose thoracic outlet syndrome, your doctor may do a physical exam and ask about your medical history.

Physical exam- Your doctor will perform a physical examination to look for external signs of thoracic outlet syndrome, such as a depression in your shoulder, a pale discoloration in your arm or limited range of motion.

Medical history- Your doctor will also likely ask about your medical history and symptoms, as well as your occupation and physical activities.

Provocation tests- Provocation tests are designed to reproduce your symptoms. The tests may help your doctor determine the cause of your condition, and also will help rule out other causes that may have similar symptoms.

Some of the more common provocation tests that can suggest the presence of thoracic outlet syndrome include:

(+) Hyperabduction Maneuver – Wrights Test

The Hyperabduction Maneuver or Wrights Test examines neural tissue compromise through thorac-coraco-pectoral gate or axillary interval. The patient is seated with arms at the side.  The radial pulse is palpated. From a sitting position and with the help of your doctor, you’ll hold your arm up and back (hyperabduction), rotating it outward, while your doctor checks your pulse to see if it’s diminished. As in the Adson’s maneuver, your doctor will want to know if your symptoms are reproduced during the test.

This will place a strain on the thoracic outlet bundle and subclavian artery vein and, the brachial plexus because if the pectoralis is in a spasm or tension, not allowing the shoulder to move properly, then of course, the nerve and vascular structures will be compromised and the patient will have symptoms. What you’re talking about is abduction at about 280 degrees, you’re going to take the radial pulse and it will elicit a decrease or diminish radial pulse or you will not be able to feel the radial pulse at all.

Roos Test

Roos Test

(+) Roos Test

The patient complains of subsequent numbness immediately following the test. Now normally nerves don’t act that way; usually vascular structures act that way. The elevated arms test or Roos test is considered the most reliable test for thoracic outlet syndrome where the patient is placed in this position, opening and closing the hand for approximately 3 minutes. You know, the movement of the hand should stimulate blood flow into the arm, but in these particular patients, blood flow is not good enough due to the compressive forces that are brought out by the malposition of the ribs and the structures in the thoracic outlet area. So this is the most reliable.

Adsons Test

Adsons Test

(+) Adsons Test

The Adson’s maneuver is when a patient takes a deep breath and holds it. As the patient takes a deep breath, obviously, the thoracic ribs will elevate. Holding the breath will keep the ribs in that position. They are going to hyperextend the neck, which is going to cause the scalene muscles to be stretched back across the subclavian artery vein and the brachial plexus area. If the patient has an elevated rib, this involves the scalene muscles, in fact that will cut off the air supply or cause the compression of brachial plexus muscles and illicit the numbness. In fact, what we find is that the symptom is reduced arterial blood flow. There is no more pulse within 3 to 5 seconds. The patient then complains of numbness. You ask the patient, “Is your arm going numb?”. The patient answers “Yes, it is.”. You don’t say anything; the patient says “you know, I’m feeling some tingling sensations in my fingers. The costaclavicular test narrows the costaclavicular space by bringing the clavicle close to the first and second rib.

When the patient draws the shoulder downward, that causes the compression of the subclavian artery vein and the brachial plexus. Positive tests are when the radial pulse is diminished. These diagnostic tests are very good to show that there is some compressive force in the thoracic outlet area, but by no means do they point toward immediate surgery.

(+) Costoclavicular Test

False Positives suggest TOS is over diagnosed

Because I feel that this posture of leaning back to watch television, leaning back in the car in multiple positions, and many automobile traumas: everyone in the United States has had on average of at least one car accident in their life. Therefore, these traumas as well as sports injuries, to affect the anterior cervical area are so prevalent that I believe that some are clinical, and others subclinical. Some of these provocative tests were performed on normal individuals. These patients were probably not normal. More detailed evaluations of the motion of the first rib, certainly whether that rib was in a good position, or aligned properly or whether it was affected should have been performed. These evaluations were not done according to the literature. So we cannot say that false positives were elicited. But we may say that it’s a possibility that we found subclinical of thoracic outlet syndrome and not necessarily false positives. I hope you understand that.

Manual Muscle Testing

When evaluating thoracic outlet syndrome, one of the physical evaluations, which is very important in your physical, is you want to do manual muscle testing. A doctor who is astute in manual muscle testing can usually isolate muscles that have been put into a tonic protective spasm or a weakened position. After a lot of practice, you can become very skillful at this technique.

Superior Rib Subluxation or First Rib Motion Palpation

The spinal examination will yield a superior subluxation on one or both of the first ribs. Various different studies of motion of the first ribs having the doctor placing the thumb on the first rib in the back on the neck and actually tilting the head to the side in extension – what you’re finding is that rib does not move. Usually what is supposed to happen is that it is supposed to disappear down into the thorax and then bringing you back to allow it to reappear.

What you’re finding is that you have an endplate or end field, which is very stiff. Normal mobility does not disappear. It feels like it’s immobile; that’s when it’s not moving. What happened if the ribs do not move? Ribs have to move in order for normal respiration to occur. They have to move up and back. If the ribs do not move, the patient will have labored breathing.

The first rib can subluxate either from trauma or static postural stress from a car accident or sports injury. I feel that while trauma is a very significant source of damage to the neck, static postural stress is a more common cause of thoracic outlet syndrome. We are going to talk about that more. Some mention of static postural stress is made in the literature but it is my opinion that there needs to be more discussion of static postural stress as the cause of thoracic outlet syndrome.

Costal Chondral Junction Subluxation

Costal Chondral Junction Subluxations As we mentioned before, subluxation of the upper thoracic vertebral segments in costa chondral and costa junctions or joints- As I mentioned before, when the rib subluxates superiorly, due to the fact that it is connected through the intercostals muscles, to the 2nd, 3rd and 4th ribs. What you’ll find here is arthritic changes. I’m going to go over that in a minute. You’re going to look for that on the radiographs you’re going to look at the chondral costal junctions, costal vertebral transverse junctions, and you’re going to look for increase in the white calcium deposits and buildup of white calcium deposits on these joints.


“I believe that locating the exact area of nerve compression is important, but what I have been finding in my clinical work is that the majority of these tests are positive when you have thoracic outlet syndrome. Doctors may complain that these tests create many false positives. There very well could be a valid explanation for this. When the first rib elevates and causes a compressive force upon the brachial plexus, subclavian vein and artery, then we would say that the rib, is subluxated to a large degree.”

-Dr. James Stoxen DC

Read Chapter VI – Diagnostic Tests for TOS

 Chapter VI


Diagnostic Tests For Thoracic Outlet Syndrome

What are the diagnostic tests for thoracic outlet syndrome?

Thoracic outlet syndrome is commonly misdiagnosed because it can mimic other nerve compression syndromes such as carpal tunnel syndrome, cubital tunnel syndrome or radial nerve compression. Because thoracic outlet imaging or MRI aren’t as helpful in diagnoses and often times an old disc herniation can confuse a doctor into thinking it is not thoracic outlet syndrome when it really is.  That is why you really need to understand where where the thoracic outlet obstruction and thoracic outlet compression of the nerves or arteries or both happens.

I would estimate that thoracic outlet syndrome is misdiagnosed by doctors about 80% of the time. I have all the tests listed and explained for thoracic outlet syndrome in this article. It should help you better self-diagnose thoracic outlet syndrome if you don’t think your doctor is on the right track.

Diagnosis is difficult, because there is no gold standard test, so historical tests and physical findings are extremely important and the diagnosis is based on these historical and physical findings which are corroborated by perhaps some diagnostic and imaging testing, nerve conduction, sensory, velocity testing and SSEP tests, if you care to use those. We haven’t had the need to use those tests because we are treating the patients clinically.

When to order diagnostic tests

I like to order diagnostic imaging tests when I’m not getting the results that I’m looking for, rather than order these tests on every patient that walks into the office. I feel that clinically if I can help the patient within the first two weeks, I’m on the road to recovery and there is no need to order these diagnostic tests.

Of course, if I’m not getting the results that I’m looking for, and I may have to dig deeper to find something I’m looking for, that’s when I order these tests. Like I said, there is no gold standard test we’ve been going over and over it again for thoracic outlet syndrome. The clinical judgment has to be used. There are some diagnostic tests such as electrophysiological evaluation, multi-detector CT and 3-D reconstruction, Venography, Magnetic Resonance Angiography, Radiography, Doppler ultrasonography and SSEP potentials.

1. X-ray Examination Radiography:

When you take your x-rays, you’re going to take cervical flat plate films and thoracic, AP lateral films. The first thing we do when we evaluate the patient is to look for the bilateral cervical ribs. You know what? Cervical ribs are in less than 1% of the population. As I mentioned before, we have seen many thousands of cases. A lot of these patients have had x-rays taken as a result of traumas and peripheral nerve type of neuropathy. We are not finding cervical ribs on a lot of patients. I would say that it’s not less than 1%; it’s less than 1/10th of 1% or less. I remember, maybe 1 case of cervical ribs out of the entire array of patients that I have seen in approximately 18 years of practice including 2-4,000 new patients per year. You’re looking at variable heights of the first ribs as well as you’re looking for the intercostals space. The spaces between the ribs should be equal. If there’s a greater space on the right than on the left, then obviously on the right there have been some ribs elevated. Or on the left, some ribs have subluxated inferiorly. You’re looking for the arthritic changes in costal transverse junctions. That’s arthritic change movement as a result of lack of movement or poor movement or aberrant movement in these ribs. You’re looking for military neck, retrolisthesis and degenerative joint disease in the first rib in the sternum as well as in the costal transverse junctions.

Retrolestisis is a common finding in TOS

We’re going to find that this retrolisthesis is found in 80% of the patients. Why? Because like I said, attachment of the scalene muscles is on the anterior portion of the anterior process of C2, C3, C4, C5 and C6 and when you have to hold the head up for a very long period of time what it does is it actually pulls the curvature out of the spine and this is not a very good thing long term.

Also as a result of the malposition of the first rib, you’re going to find degenerative joint disease and the sternal costal junction. In other words, when the first rib loops around to the front, it attaches to the sternum. If you look very carefully, a lot of time you’re going to find a lot of calcium deposits and deformation in the joint. Many people overlook this. It’s been overlooked quite a bit. You’re also going to see degenerative joint disease of the costal transverse of the upper ribs.

Costochondral arthritic changes

Here’s a picture I found in a book discussing how the patient had just gotten out of surgery In fact and had the left cervical rib removed as a result of long standing thoracic outlet syndrome that did not respond to conservative care. And if you look very carefully where the arrows are on the right what I found is that on the cervical rib, the first, second, third and fourth ribs, there is a fairly large amount of calcium deposit that’s on the costal transverse junctions and the costaclavicular junctions you’ll see the darkened areas of the joint space and adjacent to that area you’ll see the calcium deposits, which means that the normal biomechanics have been altered and that is evidence of what I had mentioned before that when the first ribs are elevated, because of those ribs, the intercostals connect the ribs 1, 2, 3 and 4 together that when the first rib elevates, it brings all the other ribs along with it. It does affect locking the costal transverse joints and causing degenerative joint disease in that area.

2. Electrophysiological Test

When to order Electrophysiological Tests Electrophysiological tests from three or four of the literature that I read, said that it was effective in determining thoracic outlet brachial plexus bundle compression. What you have to understand about the brachial plexus is that they distribute themselves superior to inferiorly 5,6,7,8 T-1. The most commonly affected is T-1 because it’s closer to the first rib causes numbness downward to the ulnar distribution.

What I’m finding is the whole arm is numb. However, according to the studies, impairment of the nerve conduction, primarily F-waves were decreased in amplitude in the ulnar and sometimes the median nerve. Obviously, the ulnar nerve is more T-1/C-8 distribution than the median, which represents more of the gamut of the brachial plexus. This could help localize the brachial plexus lesion and may help to rule out segmental systemic neuropathy such as herniated disc in a particular area of the cervical spine.

You’re not going to find this a very effective test if you do not have access to an MRI or have not ordered it yet. We see this impairment after the arms are raised in a provocative position in other words, the F-wave is normal and the patient is in a neutral position when the arm is raised in a provocative position as in Adsons, Hyperabduction Maneuver, Costaclavicular Maneuver, you will see that the symptoms of the F-wave will be diminished

Only for a long-standing anomalies and severe atrophy The most recent studies of these symptoms are related to thoracic outlet syndrome and the electrophysiological test is that this test is only used for a long-standing anomalies and severe atrophy because in the initial phase of this problem, the F-waves are not diminished and you’re not going to find this a very effective test for a recent onset of thoracic outlet syndrome. Therefore, I don’t feel it’s really necessary.

Do I order these tests in my office? No I don’t.

The reason is that because like I said before, I only order the tests when I’m not getting the results. I’ve never really had a problem with thoracic outlet syndrome in my office. I’m getting very good results with it, so there is no need to expose the patient to diagnostic tests which are medically unnecessary. You must document the need for a diagnostic test.

When to order Electrophysiological Tests

A need for a diagnostic test is used to differentially diagnose or determine to a better extent what is wrong with the patient. If I feel that the patient is recovering in the first five or six visits and making progress, I am going to continue with care, it looks like I am on track, and I am not going to order these diagnostic tests. If the patient takes a turn for the worse, or I’m not getting the results I’m looking for, certainly I will order the diagnostic tests to look into it further to determine whether I haven’t seen what I need to see or I need to see something that I can’t seen based upon the orthopedic tests, the history or physical examination I performed. That ‘s obviously protocol for any type of orthopedic, chiropractic or neurological type of practice.

3. Multi-directional CT and 3-dimensional reconstructions

Multi-directional CT and 3-dimensional reconstructions: There has only been one study, which I have seen. It reports to be very promising. I don’t know I haven’t had much time to look into it. There is not much literature on this. I am not going to run out and order multi-directional CT on every patient that walks in my office with tingling in the fingertips. As I mentioned previously, I use these tests sparingly. Doctors use these tests more often on patients – that’s your clinical judgment

4. Venography

One author stated that Venography was the only reliable diagnostic tool to diagnose thoracic outlet syndrome.

5. Doppler ultrasonography

Doppler ultrasonography was another test that was mentioned in a few studies. There was no real discussion of the reliability or sensitivity of this particular test. It was considered as promising.

6. Magnetic Resonance Angiography

Magnetic Resonance Angiography consists of taking an MRI of the patient in the normal position, and then another MRI is taken of the patient in the provocative position. This MRI must be done in an open MRI scanning unit because of the fact that you have to alter the position of the patient’s arms. It cannot be done in a closed MRI scanning unit. That’s something you have to understand. Also, you have to find a radiologist who understands thoracic outlet syndrome, anatomy, biomechanics, as well as being willing to do two MRI’s of the body: one in the provocative position and one in the normal position. This was done by one particular group of practitioners looking for a way of diagnosing with diagnostic imaging the thoracic outlet. I don’t think it should be done routinely in practices.

7. CT Angiography

This is a very interesting test, which I found in the literature that showed a visual of the thinning of subclavian artery as it passed through the intrascalene muscles. It was very nice evidence that this actually occurs.

 Read Chapter VII - Thoracic Outlet Syndrome Treatment

 Chapter VII


Thoracic Outlet Syndrome Treatment

What are thoracic outlet syndrome treatments?

Lets keep this simple.  If thoracic outlet is a compression of the thoracic outlet by various structures then you have to decompress the thoracic outlet by moving these structures out of the way.



One of the treatments for thoracic outlet syndrome is posture correction which can be the key to easing or preventing thoracic outlet symptoms. Often while typing, the chest muscles become tight, the shoulders round forward, and the chin juts forward. This tightens the neck muscles that then pull the 1st rib up and narrow the space in which the nerves, arteries and veins pass through the thoracic outlet. Shallow breathing can also over-develop the around the thoracic outlet muscles and cause a narrowing of the space.

Conservative therapy vs Surgery

I always start every treatment with a 30 minute deep tissue massage treatment of the shoulders, chest, back neck, arms, forearms, hands and even the skull to warm up the area.

Conservative Management is Challenging because I have found that you have to administer deep tissue for over an hour on the first visit just to get through all the muscles that are compressing the outlet.   Insurance doesn’t pay for a visit that long but I do it anyway.  I don’t know if other doctors are willing to park over patients this long to get these spasms fully treated.

I have spent up to 30 hours doing deep tissue on severe thoracic outlet syndrome cases.  They were headed for surgery and did not want it so you just do what it takes, right?

The outcome may not have been successful if I would have treated them for the standard of care amount of time or gave them an adjustment without the extensive deep tissue.

Conservative management has been very challenging with thoracic outlet syndrome. The majority of the patients, over 90 %, in most cases are having surgery of the neck to remove the first rib or a cervical rib in the neck and also surgery to remove muscles in the neck. I don’t know about you, but no surgery looks very exciting for patients and it can be a very depressing and frightening experience for patients.

If the surgery is in the knee it’s not as bad. If it’s in the neck it’s very scary. It’s very close to the head and there is the possibility of infection. Patients are very frightened of any type of surgery of the neck because it’s a very sensitive area, and physicians have to be aware of that. We sometimes become numb to these factors and as physicians we should put ourselves in the patient’s position and work a little harder at finding better options to surgery like conservative therapy.

Case Study Example

One of my patients who came to me that we were treating and told me what he was experiencing in the last 6 months before he came to our office. His wife remarked that he dropped full cups of coffee without any warning. He dropped tools. He had difficulty performing his job. He was a paramedic and he was dropping tools and when you are dropping things you can have dangerous accidents. These finite movements of the hand, which are very important in some occupations, become very compromised. It is very dangerous in some occupations become compromised and you can have dangerous situations because of this…

Address the Root Cause

Most common Cause is Static Postural First Rib Subluxation However, what we talked about before, which in my opinion is the most common cause of thoracic outlet syndrome is static posture epidemiology. As you could see in this picture, we have this gentleman who is leaning back in the chair, you can’t see it, but his thorax is approximately at a 75-degree angle. He is watching television.

As you can see, in order to keep his head from flipping backwards, because he is on an angle, he has to tense up the anterior cervical muscles, including the scalenes to keep his head in that position. The head weighs about 8 or 9 pounds and that may not seem like a lot of weight, but if you had to sit in that position, it would certainly take its toll on the anterior scalene middle scalene and the anterior muscles.

You must address the abnormal ergonomics or posture. You have to repeat it daily and keep talking about it until they can’t stand hearing about it any more. You have to address their sleeping posture. A patient asks about pillow. A pillow can’t be too thick because it causes strain on one side. It can’t be too thin, because it causes strain on the other side.

The pillow should provide a nice comforting support for the head and allow the neck to be in a neutral position throughout the sleeping. That’s all, and the patient has to go out to look into that. They have to research it themselves and find a pillow that’s going to work for them. What I recommend is that when they’re at a store, they can lay down and look in a mirror to see whether their neck is in a neutral position or not. Is it straight? Yes or no. If it is angled, then it’s no good. Don’t buy it. No other neck stretching exercises are recommended.

Static Neck Extension or Neck Flexion?

In the literature, it discusses the posture of leaning forward, as in looking at the computer that is not a good posture for thoracic outlet syndrome. As I mentioned before, the static posture of leaning forward really puts more pressure on the extensor muscles, which does not really compromise any nerve structures. However only in a case of hyperextension or maybe a disc injury, but those are only seen with traumatic injuries and not necessarily with static postures. What we’d rather say is the causative factor, is that when the patient leans back, the anterior muscles have to maintain the head in this position for a long period of time as in the picture with the girl seated at the end of the slide.

Static Posture Self Test

If you take your hand and place it on your anterior muscles on either side of your trachea and your esophagus, and you lean back you’ll note that there will be a hardening or tension of these muscles. You’ll be able to see for yourself just by palpating your neck, and as I mentioned before, even if you’re holding a small item for a long period of time, the amount of tension can cause damage to the joints and the muscles.

A careful History can help you differentiate these other syndromes with TOS Something to keep in mind though, the history of the patients is fairly common and repeatable. When we are faced with a patient who may have thoracic outlet syndrome, it is extremely important that we do a careful history to determine what type of lifestyle this patient has, and ask pertinent questions to see if they have the causative factors that create this problem. Like I mentioned before, I usually ask the patient, “Are you reading in bed” Do you have a television set in your bedroom? Do you watch TV in bed and how many hours a day? And look to the patient who is going to underestimate that time, they don’t want you to think that they are lying in bed all day and watching television. If they tell you it’s 5 hours a day, you could pretty much guarantee it’s between 8 and 10 hours a day. When we press the patient for the truth, they usually tell us that it’s more time.

Medication – Why medication alone will not work

In fact, I’d like to note that the actual changes in the biomechanics are reducing the pain, and not the painkillers. If we use the painkillers, we don’t know whether our treatment is effective. I think that is worse than actually diminishing some of the pain. The patient can handle it. You tell the patient that the pain is a warning signal telling us whether our treatment is working. It’s a guide that tells us whether we are being successful in the treatment of their condition. Sure I don’t mind if a patient takes medication prior to bed in order to sleep at night. However, the use of medication, I think is unnecessary. I have never had a patient absolutely beg me for medication. ‘Please, please, find me a medical doctor to get me some drugs so that I could sleep at night.’ I’ve just never had it happen – not in 18 years. Therapeutic exercises that were mentioned in the literature are contraindicated. No wonder they are not getting results. As I mentioned, stretching, or lateral bending, neck rotation exercises, and flexion exercises can actually lift the ribs and make it worse. This is something that I don’t recommend; in fact, it’s contraindicated, and if you do it, you may not get any better. That’s the way it is.

Manipulation – Why superior first rib correction is a necessity

Manual manipulation is also a key component to successful outcome of thoracic outlet syndrome. Superior first rib subluxations cause compression of the thoracic outlet area, so therefore manual first rib adjustments inferiorly are the only treatment procedure that will establish normal biomechanics in position of the first rib. Included on the costal transverse and the costovertebral junction. You also have to adjust the upper thoracic spine. Thoracic rib subluxation must be reduced and must be reestablished or you will not get the patient well. I don’t care how much therapy you use, how much medication you give the patient, how much stretching exercises, you’re not going to get the results until you move the first rib. If I could not adjust the first rib, nobody in my office would be well. I rely on that specifically as a way of opening up the thoracic outlet spaces. Without it, I don’t think I would have any success whatsoever. It’s mandatory.

When treating these areas, you need to manipulate or bring motion back into those ribs; you have to have a fairly good technique for adjusting those ribs, because ribs have funky movement. They are difficult to treat and adjust, because of their attachment on the two areas of the vertebral spine and their motion is very strange. Sometimes when adjusting ribs, the patient can feel sharp pain during the adjustment and then relief immediately after. I use a very gentle technique.

I have had rib problems from a car accident in the past and I understand it better because I have experienced it. I have studied manual spine manipulation techniques of the ribs in great detail and feel confident about it. I know that in the beginning it is quite difficult to master the art of manipulating ribs because of their strange configuration. You really have to practice it.

Can you correct both the abnormal biomechanics causing TOS and recurring headaches at the same time?

As I had mentioned to you, these headaches are fairly common in thoracic outlet patients. You’re going to have to make a decision when you make correction of the spinal misalignment. I found that if you try to correct the upper neck and the lower neck, sometimes there is a problem and there is too much stimuli to the spine. Sometimes you have to work on the lower neck to realign or correct the subluxation of the first rib and do some neuromuscular re education or muscle deep tissue work to the upper cervical region to prepare it for adjustments later. After the TOS has calmed down in about a week or two you can start to work on the C0 C1/2 subluxations which cause the headache symptoms. I think it’s a better approach to treat these patients clinically, based on my experience.

Physiotherapy – Why therapy is difficult alone

Physiotherapy such as ultrasound on the upper thoracic area and the lower cervical can help to reduce the inflammatory process and promote healing. Physiotherapy such as electrical muscle stimulation can help to reduce the spasms in the upper thoracic area. I do not recommend it around the scalenes because you have the carotid sinus in that area. We do not use electrical muscle stims on the anterior cervical area. However, we do use it on chest muscles, as long as it is not near the heart. We do use it on the upper thoracic ribs. It does provide comfort and it does reduce spasms for the patient and it promotes healing.

Stretching – Why some stretching makes this condition worse

Actually what I found is that stretching of the neck is actually contra-indicated in this syndrome because the attachment of the scalene muscles between the 2nd, 3rd, 4th, 5th and 6th cervical and the first rib, so by laterally stretching and flexing the muscle on the left, what is actually happening is that the patient is using the scaling to levitate or elevate the first rib on the left side. So in fact, when you’re stretching the neck, you’re in fact subluxating the neck even further into a position of superior subluxation. In the literature, it discusses the treatment for thoracic outlet syndrome is to laterally flex and stretch the neck, and if you’re wondering why you’re not getting good results, because laterally flexing the neck actually makes the condition, in my opinion, worse.

Manipulation – Why improper manipulation makes it worse

Superior First Rib Correction is a necessity Our goal in mind in the treatment of this patient is to lower or bring the ribs inferiorly and to reduce the tension of the scalene muscles. Those are the two main goals of therapy. By positioning the rib in a lower position, it will allow more space in the costaclavicular area for the structures to pass. There are no real muscles that actually pull that rib down, so it has to be manipulated. It has to be manually adjusted. I haven’t been able to find any other way to reposition the first rib or cervical ribs, other than manual adjustments.

Scalene Muscle Spasms must be reduced

Of course you can remove some of the muscle spasms and some of the tension on the first rib, the muscles that actually attach on the first rib, being the scalene muscles. If you are going to reposition the rib so that it allows for better passage of the structures, then you’re going to have to manipulate it with the least amount of restriction to motion as possible.

Neuromuscular Re-education

The goal of this phase is to eliminate the protective muscle spasms that are actually tonic and constant in the cervical spine in the chest and region in what I call neuromuscular re-education. It’s basically called deep tissue; it’s also referred to as trigger point, Nemo technique. There are many names for it. I call it neuromuscular re-education. You use it on the scalenes, the muscles of cervical flexion, the clavicular division of the pectoralis minor and the subclavius muscle which is an often overlooked muscle, pec major, latissimus dorsi, anterior dorsi, upper and middle trapezius and other rotator cuff muscles.

Understanding the Technique

Here we have a picture of the subclavian muscle, which is right underneath the clavicle. When that muscle is in tension, it can actually cause a compressive force on the brachial plexus and the subclavian artery vein. The way I do this, is I actually lay the patient on their side I hold the patient from their back and I put my thumb right up underneath the clavicle and push it right up underneath the clavicle and I hold that position. I say, “It hurts, doesn’t it?” they say, “Yes it does, a lot of pain”. I ask “Is it a 10 out of 10, 10 being the worse pain?” They answer, “Yes it is.” “Alright, what’s going to happen is that this pain is going to go down in chunks, it’s going to melt away? When it’s melted away to 0, I want you to tell me. But if you tell me that it’s melted down to zero, when in fact it’s a 1 or a 2, I guarantee you that tomorrow you will have achyness all over. So you’re going to do the right thing and tell me when it’s gone down to 0. Right? “Right.” Okay, let’s go to work. So I take my thumb, I shove it right up into the subclavian muscle, I apply deep tissue pressure, and I hold it, without moving and I wait for the muscle spasm to melt.

NMRE to the Scalenes

Here we have treatment of the scalene muscles. I’ll tell you that when you apply neuromuscular re-education, or deep tissue pressure of a constant variety to this muscle, it hurts badly. The patient is wincing. They are in a lot of pain. They’re begging you to stop. It recreates the numbness down the arm. Their arm is going numb; they can’t stand it any longer. I say “relax, cool down’. Sometimes I have to tell them a joke. I usually sing. That always works. Tell them it doesn’t hurt you as much as it hurts them. It’s going to be difficult to get them to talk because it’s close to the trachea and the esophagus area, but you have to be persistent and do it.

The importance of Scalene muscle NMRE

The bottom line is that if you don’t reduce the spasm, the scalene muscles will remain in tension and continually elevate the first rib. It has to be done. Pain will shoot all over the arm. They’ll complain of the shooting pain in the arm. Just get through it. It will be about 3 or 4 points. You’re going to work your way up to the base of the skull hitting all those points. There will be about 3 or 4 points on each side and they get through it. Pretty soon you’re going to go back and work that muscle each day. After about 10 treatments, if it’s done properly and you have not missed any muscle areas, that when you put a pressure on there, the pain will drop about approximately 10%, and the spasm will drop 10% per visit.

NMRE Technique

So after approximately 10 visits, plus or minus 1 or 2, you’re going to see that there really won’t be any pain in the scalene area. They are going to put the pressure there on that muscle and you’ll say remember when I put pressure on that muscle the first day and you almost jumped out of your skin, your hair stood up, and your eyes rolled to the back of your head, and you turned red and you looked like Don King? Yes. Well you don’t look like that anymore; you’re not feeling those pains any more, are you? And they say “No”. Okay it’s because you’re getting better. And you are getting better, aren’t you? Yes I am, in fact I am getting better. That’s what happens, they get better.

The neuromuscular re-education can also address the abnormal muscle spasms or tenacity of the spasticity of the area of the supraspinatus. And here we show the application around the supraspinatus in the top right. On the lower right you’re going to see where I’m going to apply the neuromuscular re-education to the lower cervical area so I can get a better adjustment of the first rib. That’s attachment of the rib to the lower thoracic spine area.

Why manipulation is not listed in the literature as an effective remedy for TOS The medical community has made 99% of the published articles and studies that have been made on thoracic outlet syndrome, whereas the chiropractic physicians are the only practitioners that actually make the correction of the rib in the inferior position. That is another reason why the literature states that conservative therapy for TOS results in a poor outcome and results are not good.

We’re not looking at any particular profession; we’re looking at a procedure that will decrease the pressure on neurovascular structures –Plain and simple. We’re not looking at who is better or who’s not. We’re looking at a procedure that is in the doctor’s bag of procedures that is going to be able to relieve the patient’s symptoms by way of repositioning the bone that is causing compression on the structures.

What are the thoracic outlet syndrome stretches?

I think stretching is great for the body at the right time and with the right problem.  However for very specific reasons I never recommend thoracic outlet stretches as I feel they make the condition worse.

What are the best thoracic outlet rehabilitation exercises?

After I feel the thoracic outlet is open and all muscle tension is normalized (all spasms reduced in the area) through thoracic outlet physical therapy then I will start thoracic outlet rehabilitation exercises. They are listed in this article.

Phase II is when all the muscle spasms have been reduced. You have to constantly re-evaluate the patient for spasticity of those postural muscles that were once involved because sometimes they slip and go back to reading in bed or reading on the couch, or they go back to watching TV in bed. You have to keep a careful eye on them and reinforce your recommendation for proper posture and proper anatomical position both at work, in the car, on the couch and in the bed – these are the main areas. Continue to manipulate the first thoracic rib. I read in one study that said wean the patient off the first thoracic rib adjustments after Phase I. It’s just the opposite. You maintain the adjustment of the first rib and here’s the situation. You cannot adjust the first rib. I urge you practitioners to find a physician or an allied health care professional that can perform manual manipulation and neuromuscular reeducation of these areas, because it’s about the patient. If you can’t do it, then you need to find somebody who can.

Therapeutic exercises or rehabilitation for thoracic outlet syndrome is only done after all spasms have been reduced and the subluxation is fairly well reduced. Do not incorporate exercises when there are spasms or pain still elicited upon deep tissue work and neuromuscular re-education.

Exercises to strengthen rotator cuff muscles, specifically the superspinatus, posture muscles like the trapezius and levator scapular will actually elevate the shoulder and take the pressure off the nerves and the arteries. Deep breathing exercises will also help because as I mentioned, the ribs are subluxated as a result of lifting of the first rib. The first rib has the tension on the intercostals muscles and they subsequently move the first rib as well.

Deep inspirations as well as flies and flat pull downs, incline and flat bench with deep inspirations. Take a big deep breath— stretch out the chest — and sometimes you’ll actually hear cracking or “tronar” as they say in Spanish – or a release of the sternal costal junctions. There is some release of pressure there and subsequent feeling of well-being.

What about thoracic outlet syndrome surgery?

I have not referred one patient to surgery for throracic outlet syndrome yet.  So, if you are facing surgery for thoracic outlet such as the thoracic outlet decompression surgery or the ribs resection thoracic outlet syndromesurgery, you should read this thoroughly and contact me by phone so we can talk about this. I have had many patients fly from around the world for all day intensive sessions.

When you’re looking at determining whether conservative care is recommended or surgery is recommended, always choose conservative care. According to literature conservative care was successful in only 10- 15% of the patients. As I mentioned previously, the reason I feel this is possible, is that if you do not tell the patients to stop sitting in this position for a long time, they are going to recreate the problem for you. You’re going to do some therapy, adjustments of the first rib and if they lay on the bed for 2 hours watching TV, these muscles are going to tighten up and lift the rib right back up again. So without really understanding causal relationship between posture and how it brings out thoracic outlet syndrome you won’t be very effective in reducing the causative factor and you’re not going to get the patient well.

Surgical Approach – When do you need surgery?

When do you need surgery? Surgery consultation should occur if the patient is compliant and still has not reached some relief after about 12 weeks. Surgery consists of removal of the first rib and scalenes. Surgery should be followed up with nerve gliding exercises. Surgery is either from the cervical area or the transactulate area. What I can tell you about this is that as I said before, in 18 years of practice with thousands of patients, I have not yet had one patient who went for surgery for scalenectomy or thoracic outlet syndrome type surgery. There is something to be said for that. Conservative care is a viable solution to thoracic outlet syndrome. More research needs to be done and people should take note of the findings that we have in this presentation.

According to literature, doctors were doing this hyperabduction, Adson’s costaclavicular tests and then saying okay it’s time to do surgery when the tests were positive. I believe that’s jumping the gun in a big way – something that we never did. I am shocked that this is happening. We find the same exact findings that orthopedics do and when we make correction of the first rib to lower it to remove the subluxation and to work on the muscles around the cervical thoracic area around the shoulder, these problems are going away.

If there were a way of treating this conservatively, who would want surgery? Nobody. Nobody wants to have an operation on his or her neck. Therefore, it is better to go through the course of conservative therapy. The results of surgery seems to be 65% long-term success rate, partially 20% of the population and 50% of the patients have no relief. So you went through surgery of your neck and your symptoms are the same. I don’t think that’s a good situation. The rate of occurrence is between 5 and 10% of these people who have 60% long-term partial relief and the reason is because of scar tissue. They recommend that nerve gliding exercises immediately after surgery will help to reduce the scar tissue formation causing the occurrence. Conservative care, I believe that if there was an insidious onset of thoracic outlet syndrome, that if we could see what changed and we could reverse the changes to the original positions or biomechanics that were present when the patients did not have pain, that we can actually normalize this condition and bring the patient back to normal.

Read Chapter VIII - Frequently Asked Questions About Thoracic Outlet Syndrome

Chapter VIII


Frequently Asked Questions About TOS

Why isn’t first rib manipulation in literature?

In my studies of the over 300 articles I read and studied very carefully, I do not find one mention of this factor in the treatment of the patient. Not one mention of this position or how it affects the first ribs. 90% of these patients get first rib or cervical rib resection or scalenectomy. Nine out of ten are getting surgery of the neck. I haven’t had one patient have neck surgery. It is very difficult for me to understand and that’s all I’m going to say.

Why some doctors think TOS doesn’t exist?

Thoracic Outlet Syndrome (TOS) is not only difficult to diagnose, many physicians deny its very existence.  The truth is that inside the medical community, Thoracic Outlet Syndrome (TOS) is not well understood, difficult to image, and carries a great deal of controversy and disagreement over how best to treat it.

The problem with this syndrome and the difficulty with this syndrome is that many physicians say there is no gold standard tests for thoracic outlet syndrome. In order to diagnose thoracic outlet syndrome you have to put together an array of historical findings, physical findings and a couple of provocative orthopedic tests in the region of the neck and shoulder to be able to make that diagnosis.

Does Cracking of the Neck make TOS worse?

In patients that stretch and crack their neck, sometimes if you ask them, they say they crack their neck 10 and 15 times a day. When I see a patient doing that, I tell them “You’re going to have stop cracking your neck. I have a way of correcting the urge.” With treatment, this urge will diminish. Soon, after a period of treatments, they will no longer feel the urge to crack their neck all the time, because the stiffness will be reduced.

What usually happens is that the subluxation is actually not in the neck; it’s in the upper thoracic area. Therefore, when the stiffness is in the upper thoracic and lower cervical area. When they self adjust or “crack” the neck they are using the lateral flexion and rotation maneuver to reposition the bones of the cervical spine. At the same time the scalenes are lifting the first rib closer to the structures, which emanate from the thoracic outlet.

There are so many supportive structures with the ribs, pectorals and the muscles of the upper back as well as in the shoulders. By moving or self adjusting, the only adjusting that is going to take place is in the middle cervical area, which only causes a hyper mobility as well as what I mentioned before, lateral flexion to the left side will actually have the scalene muscles elevating the rib even further causing further compression of those structures that emanate.

Does improper manipulation makes TOS worse? WHY?

Superior First Rib Correction is a necessity Our goal in mind in the treatment of this patient is to lower or bring the ribs inferiorly and to reduce the tension of the scalene muscles. Those are the two main goals of therapy. By positioning the rib in a lower position, it will allow more space in the costaclavicular area for the structures to pass. There are no real muscles that actually pull that rib down, so it has to be manipulated. It has to be manually adjusted. I haven’t been able to find any other way to reposition the first rib or cervical ribs, other than manual adjustments.

Why do patients with TOS have upper back pain?

The pain and stiffness travel from the upper thoracic area and patients sometimes complain of chest pain in the upper thorax area. They also may complain of difficulty breathing. They talk about stiffness, and labored breathing and don’t realize it until you bring it to their attention. “Have you noticed lately that your chest feels tight and you have not been able to breathe as well?” And they will answer, “Yes, as a matter of fact I did.” It wasn’t something they were thinking about because they don’t understand the connection.

Why do patients with TOS have shortness of breath?

The reason the patient has a shortness of breath is because when the first rib subluxates in superiorly the intercostals muscles which connects the ribs actually allow not only for the first rib to subluxate superiorly, but the first rib takes the second, third, fourth and fifth ribs with it, because they’re connected. So what you are going to see is superior subluxation of the ribs of the upper thoracic spine and not just the first and second.

Why do so many patients with TOS have headaches too?

The other common symptom patients have with TOS is recurring headaches. The reason why is that they are in a reclining position watching television. Their neck in this position for so long that when they get up, their neck is more in a straightened, military or retrolisthesis position. If they leave their head in this position, they will not be able to see where they are going.

It may seem silly, but postural reflexes kick in and an extension of the C0, C1, and C2 vertebra occurs to compensate for the tucking mechanism caused by the spastic scalenes. This hyperextension at level skull C1, C2, plus axis complex will actually cause compression of the first and second nerve of the spine and radiating headache pain as a result of this compression of the nerves and suboccipital regions.

What is the tingling or numbness in the fingertips? Artery or nerve?

As I mentioned to you, there is tingling in the fingertips. Sometimes the tingling is only seen after conducting provocative tests such as Adsons and Wrights tests, which means the symptoms are sub clinical. If the patients fingertips or a portion of the upper extremity is numb or tingling without testing then it is a full blown TOS.

The tingling usually happens more in the morning. The reason why it is seen mostly in the morning is because the position of the clavicle is not changing while sleeping. The position of the clavicle changes during the day. When the patient is reaching for a broom, or reaching for something out of a cupboard or waving to a friend, this elevation of the clavicle allows for blood supply to seep through into the arm and allows for the arm to be supplied with spurts of blood because the compression is relieved.

Why are the tingling symptoms more common in the morning with TOS?

When the patient is sleeping, there is an aesthetic posture and there is not a lot of movement to stimulate the blood flow, which is why the patient has the tingling in the fingertips in the morning. The other reason is they commonly read in bed at night further compromising the thoracic outlet causing more compression of the vascular structures in the sleeping hours.

Why do the hands swell in the morning with TOS?

The patient has the highest degree of swelling in the hands in the morning with TOS. The swelling sensation called “glove sign”: in the morning, the patient feels the need to shake their hands out. Sometimes, the hand shaking method actually does bring blood supply down into the extremities, because they are elevating the clavicle and moving the extremity causing the need for additional blood to the region. The shaking of the hands actually allows the blood to come in and they are shaking the blood down into the extremities.

This is something that the patient understands, based on instinct, when in fact they are actually correcting their problem temporarily. The problem is never corrected until you actually remove the compression of the vascular structures by manipulating the first rib inferiorly.

How long will Thoracic Outlet Syndrome take to get better?

Read Chapter IX - Case Histories of Patients with TOS

Chapter IX


Case History Of Patients With Thoracic Outlet Syndrome

Here are some interesting ways I determined the cause of a patients recurring tos from their habits

1.  The Music Legend – Sonny Burke

I was working for Steely Dan backstage one night when one of the musicians brought his friend to me and asked for my help.

He said he suspected his friend had a serious problem when he couldn’t get a grip on or lift the top of the miso soup bowl off. I didn’t know who he was but later found out I was working with a music legend. Sonny Burke played piano for Smokey Robinson for 34 years. As a top studio musician he had over 200 record albums and 1000 musical assignments including the entire ‘Saturday night fever’ album, Jackson 5 ‘Dancin Machine’, and other Grammy award-winning artists.

Yet when I met him that day backstage, Sonny couldn’t play at all….his arms and hands were completely numb and too weak play. He couldn’t even button his shirt, open a door or take the top off the miso soup.

“It had been going on for four years. I couldn’t even make a fist,” he said. “I went to five top doctors. First they told me I had ulnar nerve entrapment. I had surgery for that and it did nothing. Then they diagnosed me with diabetic neuropathy. They said nothing could be done about that. I had to live with it.

I had given up hope for a cure for my numbness and severe weakness after seeing 5 top doctors who operated on me and did every test and treatment they knew including surgery. They finally told me there was nothing that could be done so I had to retire from music.

“When he told me he had diabetic neuropathy I didn’t think I could help him, My only hope was that he was misdiagnosed.

When he told me he watched TV in bed…then I knew it could be TOS,”

He told me that the numbness came on in his left hand 4th and 5th fingers first and in the forearm where your funny bone shocks you.  At first, he said the doctors said he had ulnar nerve entrapment because this is the distribution of the nerve.  So they did an operation to remove the ulnar nerve from the elbow.  That left a 7 inch scar yet still no improvement.  While he was recovering from the surgery he noticed the numbness went into the entire hand on the left and into the entire arm and shoulder next.  After 3 more weeks it progressed rapidly into the right side starting from the same 4th and 5th digit then through the hand and up the arm.

A month later his hands started to swell and they got cold.  That is when he could not make a fist anymore, button his shirt or unlock the door to his house.  Thats when he went to 5 neurologists looking for answers.  Unfortunately, all of them misdiagnosed his condition.

If you know diabetic neuropathy you know it effects circulation and nerves.  So it almost always starts distally in the toes and works its way up the feet and legs.  It doesnt start in the hands first.  If it did it would start in the finger tips (distal to proximal) and work its way up the arm. This numbness started in the bottom of the neck on the left.  As the rib was elevated more and more by scalene muscle tension it encroached on nerves higher into the brachial plexus.

When he was recovering he was now leaning back 10-12 hours a day resting per doctors orders in the bed.  Thats when the TOS took off.  As the tension in the scalenes got more and more intense they lifted the first rib even higher and got more swollen and choked off the blood flow out of the arms at the outlet.  That is when the blood could not escape his arms and his hands got swollen from the back up of blood.

When he started using his laptop in bed and the remote the pec minor spasmed and pulled the shoulder girdle down with the collar bone meeting the elevated 1st ribs and that squeezed the artery blood flow into the arm. That is when the hands got very cold.

After examining him I found out indeed it was TOS. Apparently the doctors did not ask about the leaning back in the bed for 3-5 hours a day or check him thoroughly.

So imagine this… After hes been checked by the top 5 neurologists in the country he is told he has diabetic neuropathy.  He completely retires from playing as one of the top studio musicians int the world and touring with Smokey Robinson, one of the legends in the music industry.  Then this chiropractor he doesnt know does a 7 minute history and a 6 minute examination backstage at a Steely Dan concert and tells him that without a doubt he has been misdiagnosed by every top neurologist he has consulted with previously.

I looked at him and said “I bet you dont believe me.”

He said, “Well… no, not exactly.”

I said, I understand.  “Now do you want me to prove it?”

He said, “Yes, can you?”

I said, “I think I can prove it to you in about 15 minutes. Hows that?”

He said, “What do I have to lose”  Do your worst

So I asked him to lay on his side looking horizontal to the ground and relax. I put a pillow under his head so his neck was straight.  Then I got a towel, folded it in half and put it on his neck.  Then I tool a 4 inch circumference rubber headed clinical strength vibrational massage machine, placed the head of the massager at 5400 RPMs on his scalenes, muscles of his neck and shoulders (floor 1 compression) and then on the pec minor, latissimus dorsi (floor 2 compression) and observed his facial expressions.

I was waiting for his eyes to light up and they did.  Then he starts screaming “My arm is on fire!!!!!”  “I knew he would say that”  Remember the machine is loud so he is screaming over the machine noise into the theater “MY ARM IS ON FIRE”   The first rule of being in an old theatre like the Chicago Theatre is you never scream out that anything is on fire when its not literally on fire.  It could cause a stampede of people running out of the building!!!

Also I could just imagine what production managers, tour managers and other support were thinking as this older man was screaming his arm was on fire while this man had this machine into his neck.

I calmly turned off the vibration machine, looked down at him and said, “Sonny, do you remember as a kid waking up with a numb arm from sleeping on it?


“Well do you know why your arm feels like its on fire?”


“Its because the blood is finally flowing back into the arm after being drained for 5 years.  Now make a fist!” He looked down and squeezed his hand into a fist, amazed.

“Could you do that before you came here tonight?


“Did the doctors say diabetic neuropathy would improve drastically in 10-12 minutes of treatment?”

“no, they said it was a permanent condition”  

“Do you still think you have diabetic neuropathy?”


So it was 8:00 p.m. when I started and by 8:30 p.m. I stopped and said, “I think you realize that your condition was misdiagnosed.  You have thoracic outlet syndrome. We may be able to reverse this 100% so you can play piano again.  How does that sound?”


“Ok, so here is my card.  Call me on Monday and lets get started on this first thing. I will treat you as a VIP and we will treat it 3-4 hours a day until we have reached maximum medical improvement. Now, lets go upstairs and watch Steely Dan. They are one of my favorites and we have backstage passes so we should be able to get up close”

He said “Watch Steely Dan!?. I can watch Steely Dan anytime I want!  I need you to do more treatment now!”

UGH!  So I obliged and worked on him another 1.5 hours.  There was enough time to hear one song of Steely Dan.   I was approached by the production manager that night who said “not everyone got treated. Can you work more at our hotel?”  So I went to their hotel at 11 p.m. and worked from then all night, through the next morning, the whole next day until 6:00 p.m. till the last person on the tour was treated.  I went home, got a shower and went on a date.  It was our first date so I asked her “So what did you do last night?”   She said, “I got to see Steely Dan! Have you ever seen Steely Dan or know any of their songs?”

I took the next day off.  I think I deserved it after working 33 hours straight.

I worked on Sonny with deep tissue in floor 1, floor 2 compression spasms and in his arms too for about 30 hours to reverse his TOS to maximum medical improvement.  That is what it took and that is what it takes to reverse an engrained TOS complex.  I cant tell you how many doctors have done 10 minutes of electric stimulation, 10 minutes of ultrasound, (both innefective for toe), some stretches of the neck (makes TOS worse) then an adjustment 3 days a week thinking that will reverse a very severe TOS.  My clinical opinion after seeing some of the worse cases is that this is not possible.  That is my opinion and Im entitled to my opinion.

Watch TV in bed, even with a pillow, and those muscles are constantly contracted for hours at a time. It’s similar to holding a ten pound weight at arm’s length. What happens? Your scalenes go into constant spasm.”

When that happens, the scalenes lift their attached first rib. That compresses the nerves and vessels against the overlying collarbone, and causes the symptoms of TOS. Besides weakness, those symptoms can include tingling, neck pain, shoulder problems, and headaches.  The spasms in the forearms and arm muscles came from playing piano for 50 years for 6-8 hours a day without some tune up deep tissue of these muscles.

I have worked many of the top guitar players in the world and I go right to the finger, hand, forearm and arm muscles working the deep tissue. I ask them if they have ever had this done and they all say no.  Shocking!  They love it so do it.

When the shoulder girdle is compressed down it can cause the collar bone to compress the artery, vein and nerves as they pass underneath. If the pectoralis minor is swollen it can compress the artery, vein and nerves as it passes underneath or both.

Sonny was on disability from playing professional piano as a studio musician and touring with Smokey Robinson for five years because of his problem being misdiagnosed. He had access to the best of the best in the world and still was misdiagnosed.

Just because you have a doctor or two tell you , you have carpal tunnel, pinched nerve, tos and need an operation…  If you think you have TOS and think you need a second opinion, get it!

2.  The Day Trader TOS Patient – a patient came to me suffering from TOS for 6 years with symptoms getting progressively worse. He had gone to 7 neurologists, 5 orthopedic surgeons, 9 chiropractors, 12 massage therapists and 5 physical therapists. He had all about given up until he read this article.

He came to me and said that after his treatment he felt better. Then he went home, turned on the TV to watch the stock news, grabbed his coffee and lap top, sat down in the lazy boy chair leaned back with is lap top resting on his lap and watched TV and traded for 3-5 hours.

His head was dangling by his constantly contracting scalenes compressing floor I and his arms were working the computer in an outstretched position contracting the pec minor and lats for hours contracting floor II.

When he promised to never ever do that again we worked 15 hours in 5 days releasing floor one and two. He was happy about his progress but still felt it wasnt right. He was anxious and agitated about it so I asked him to show me his sitting posture he was so proud of. His perpendicular sitting posture was a 15 degree lean backwards that we noted when we took a photo of him sitting. That ended the argument about what was bringing his symptoms back. After he made the final adjustments on what is truely the perpendicular posture for sitting his TOS corrected with 10 more hours of deep tissue and adjustments. He is working out 3 days a week now after realizing that even though he was thin and looked fit his neck muscles could not move 5 pounds in forward neck bending, side bending right and left and back bending. How can your muscles support a 9 pound head when they cannot resist 5 pounds on the neck machine. Also even though you can do the neck machine for 10 pounds not even Ed Coan (22 inch neck) can hold a 9 pound weight for more than a few minutes in a sustained contraction without causing a compressive force spasm on the spring

3. The 19-Year Old Lacrosse Player – A man contacted me after reading this article. He said his 19 year old scholarship lacrosse playing son had TOS for 5 years. The pain was constant and effecting his personal and professional life. He had been to 4 – 5 neurologists and orthopedic specialists, a few chiropractors and a few physios.

He fractured his collar bone in a game at age 14. He had had symptoms of TOS ever since. What we determined was the fracture of the collar bone was not the cause as it healed up nicely. The rest on the couch leaning back watching TV is what caused the strain on the floor I and floor II muscles to compress the thoracic outlet structures leading to the TOS. After that I learned he would lean back when studying in bed, lean back and to the side when playing playstation xbox and lean back when in the bus on the way to games, lean back when kissing his girlfriend for hours. He would also wear a back pack that would cause compression on his neck and shoulder as well.

However the most compression was coming from his pectoralis minor spasm. His pectoralis minor pulled his shoulder girdle down. This rotated the collar bone down at the end. That caused strain on the clavicular head of the SCM and that was the main source of the pain that drove him nuts. We figured out that holding the xbox, cell phone and mouse was causing this pec minor-scm-scalene chain reaction.

4. The Overnight Bag Mom – A lady came to me with a severe tos on the left. After discussing all the possible ways she could strain the neck and shoulder muscles by reading or watching TV in bed, sitting back in the car, sitting back on the couch we couldn’t find out what it was.

That is when I noticed her purse. It was more like a travel bag. It felt like it weighed 20 pounds. I know when I travel 22 hours to southeast asia with my computer laptop bag I feel a tos coming on.

This can happen with bowling bags, travel bags, back packs, musical instrument bags etc

Below are the rules to a bag or purse:

When the purse is held on the right, the head must lean to the left to counterbalance the weight of the purse and vice versa. You may think that the pressure is on the side of the purse and it is. It would be in level 2 on that side and one and level one on the opposite counter balanced side.

5. The Semi Pro Tennis Player – this man was referred by a vip client. He was told by 3 neuro surgeons he had a herniated disc on the right that was causing the pain shooting 10/10 down his right arm and hand for 3 weeks.

He did have a herniated disc on the MRI but it did not specificially say it was compressing the nerve root. I looked at the MRI  report and it said there was osteophytes which means the disc was an old injury and not likely the cause of his 3 year pain and there was no trauma He said it came on gradually. Herniated discs do not come on gradually. That is how you rule them out.

The one thing that ruled out herniated disc on the nerve root was that his hand was swelling in the morning as he could not get his ring off so easy and his hand felt colder on the left than the right. Both are signs of the vein compressed not letting the blood out so it swelled with blood and the compression of the artery not allowing blood in causing the cold feeling.

So when I did the tests we found out he had tos.

The cause? I asked him all the common bad habits and he had only one which was how his seat was in the car. However he did not drive a lot and did not drive a lot more in the last few weeks so it had to be something else.

What I finally found out was that he got a tennis ball thowing machine to help his clients practice. The problem is that it was not on wheels so he had to grab it with the right hand, lean left with his body and his head and neck straining to the left as he dragged this machine loaded with balls on and off the court many times a day between each lesson.

I suggested he put the tennis ball throwing machine on a flat dolly he got for $20 and push it which he did and after a few days of treatment he no longer needed surgery and was back on the court.

 Read Chapter X – Self Help Treatment for Thoracic Outlet Syndrome

Chapter X


       The Human Spring Approach to Treatment and Prevention

This chapter includes the self-help tips, which incorporate diet, exercises, and tips to avoid the cause. This is included in the complete e-book, “The Human Spring Breakthrough Solution To Thoracic Outlet Syndrome”.

All of the keys to proper examination, treatment, and prevention of Thoracic Outlet Syndrome are found in Dr. Stoxen’s upcoming book, Neck Pain?  Shoulder Pain?  Upper Back Pain? Could It Be Thoracic Outlet Syndrome. 


About Dr James Stoxen DC (281 Posts)

Dr. James Stoxen, D.C., owns and operates Team Doctors Treatment and Training Center. and Team Doctors Sports Medicine and Anti-aging Products. He has been the meet and team chiropractor at many national and world championships. He has been inducted into the prestigious National Hall of Fame, the Personal Trainers Hall of Fame and appointed to serve on the prestigious, Global Advisory Board of The International Sports Hall of Fame. He is also a member of the Advisory Board for the American Board of Anti-Aging Health Practitioners. Dr. Stoxen is a sought after speaker, internationally having organized and /or given over 1000 live presentations around the world.(full bio)Google



  1. Masud Kabir Hero says:

    nice post. need a strong patience for reading this. but its helpful.

  2. Dear Masud, Thank you for taking the time to read this article. This has been written to best educate patients and doctors how to approach thoracic outlet syndrome.

    As you can see it is not a teaser article but more like a book. For those who suffer with this condition they will tell you that it is often misdiagnosed by one, two, three, and some 15 or 20 different health care providers. Some patients have been to 20 doctors, therapists, guru healers, massage therapists etc with no results. Some get the surgery and they feel worse. I love tough cases and have not had any challenges resolving TOS conditions without surgery. The more complex the better for me. Bring me your worst case.

    For these patients this article provides the answers that allow them to make the right decisions that are life changers. Those readers dont mind taking more time to digest the material.

    Many patients who read the article have called from around the world flew into Chicago to visit me at Team Doctors and had their TOS resolved in a matter of days with our 8-12 hour/day round the clock treatments.

    Because of this I plan on adding to it.

    Thank you very much for your comments.

    Dr James Stoxen DC
    President, Team Doctors Treatment and Training Center of Champions

  3. Sean Daniels says:

    Dr Stoxen, Thank you for such an extensive research and information available on thoracic outlet. I have a history of weight training and sports and in have suffered nerve tingling for years and referred pain from my scalenes in the areas around my scapula and arm and upper chest region. about 6 months ago i started having noticeable atrophy throughout these referred regions-particularly in my hands with pain that sharply originated in my palm of hand which is where it started to depress. I had to stop working out and was diagnosed with overuse injury and told to rest and then was told carpal tunnel and being sent for more tests. Being a nursing student and the emotional toll of watching my body fade away on both arms, hands and upper back, i delved into research, looking into my symptoms and i realised early on that i had thoracic outlet syndrome- my chiro agreed. But then throughout this process i have been laughed at by a neurologist who said it wasn’t TOS after a nerve study and been through several specialists. I have nearly lost my livelihood with this condition- i have missed so many days off work, i had to stop studying because i couldn’t type for too long. I’ve stopped being able to lift weights or put body pressure on my hands-it’s a depressing state. It feels like no one is listening to me while my body is wasting. Two weeks ago i saw a sports therapist who worked on my scalenes which were incredibly tight with massage- suddenly the results started with my hand starting to get blood flow to it and the nerves were firing. I feel vindicated but i know i still have a way to go- After all the specialists i have seen i couldn’t believe the lack of understanding of this condition. I have had to fight to get an answer. Thank heavens for specialists like yourself who understand this and know how to treat this. Unfortunately i live in Australia otherwise i would love to be treated by yourself- so much more needs to be done so specialists, doctors are better informed in relation to conditions such as these.

    kind regards,
    Sean Daniels , Brisbane, Australia

    • Great story! Have your chiropractor email and text me so I can talk on the phone or Skype with him to give him some pointers on how to get the best results and fast! Thanks

    • Hi Sean

      Thank you for your very detailed comment on the post. Your story is actually typical of hundreds of patients I have treated over the years.

      Misdiagnosis is Common! – There are so many nuances to this condition that have to be addressed in the examination that very few health care providers will even make the diagnosis of Thoracic Outlet Syndrome.

      The Skill Set Required to Reverse the Cause of the Internal Compressive Forces on the Outlet are rare. What most doctors and patients dont understand is… It is so easy to let our bodies angle outside of the perpendicular position with respect to gravity in our daily routines some of you are actually in a state of muscular stress that is creating internal compressive forces on the thoracic outlet almost every waking moment of the day. This constant strain on the muscles locks in that tonic protective reflex into the brain so deep that it takes hours of work for days to release it.

      26 hours vs 36 hours – It took me 26 hours to reverse a thoracic outlet syndrome that the doctors recommended neck surgery on a top football player this week. I told his dad it would be about 3 days of 10 hours a day but leave the two weekend days open just in case I didnt have it all out due to some unforeseen complications. We had all the internal compressive forces out by about the 24th hour and the last two I trained him hard in my gym. The signs and symptoms did not return during training so we sent him home early. He was excited but his father was really happy.

      I remember his dad calling me back after we got everything logistically set up for his flight in and lodging. He said, “Dont take this the wrong way Dr Stoxen because I respect you. I just wanted to ask you, what if this doesnt get better? Then what? I thought about it and said “You know I cannot answer that” He said, why? Because so far, that has never happened. :) I think he got a vote of confidence with that one.

      With a thoracic outlet engrained in your body as bad as yours it will probably take work on the scalenes, pec minor, rotator cuff, latissimus dorsi, subclavius etc and many adjustments of the first and second ribs. I am going to put my exact hands on treatment approach for what I do to releive the pressure on the outlet via the muscles in my book so get set up with the updates with your email and Ill send you details on this.

      By the way, my last VIP client flew in from Melbourne for 3 days of intense treatment She told her chiropractor she was going to get 10 hours of treatment that day. He thought that was impossible. We did 27 hours of treatment in three days. I released her pain free for the first time in 10 years.

      You can fly into Chicago and stay a week for your treatment with us or I can talk to your doctor and tell him what will work best to get you better, Have your doctor call me or email me at 312 375 7303 team

      Thank you again for your insight and taking the time to write such a thoughtful comment! Here is a picture of Anthony Field and I in his boat adjacent to the Sydney Opera House.

      Dr James Stoxen DC

  4. I just left a long message and it must have been erased. Wondering if I have this syndrome. Symptoms are thoracic pain, left shoulder blade pain and aches, left arm, hand tingly weak. Have had several MRI, x-rays but not of thoracic area. Drs. think it is from my neck. But when the thoracic area is adjusted I feel better but it doesn’t last. My joints then ache, shoulder blade aches and feel awful all over. Sometimes my whole left side feels awful, tense, feel like cringing. Tonight my left hand got extremely weak, hard to grip even and then I raise my shoulders and the thoracic area made a cracking sound and my hand suddenly got stronger. I do get the weakness and tingling on my right side but not often and not as severe. I also get tremors in hand mostly on left but not as bad lately, mostly just weak and numb.
    Wondering if this could be TOS or what? If you have any ideas I would appreciate your sharing them.
    Thank you, sharon

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