You are reading Chapter IV – History, Cause and Patient Presentations
THORACIC OUTLET SYNDROME
by Dr James Stoxen DC
History, Cause and Patient Presentations
Table of Contents
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
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 is not going to be too keen on this surgery. They are going to be 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.
- Traumatic injury and
- 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
- Neck Pain
- Herniated Disc in the Neck
- Pinched Nerve In the Neck
- Upper Back Pain
- Mid Back Pain
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 must 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!
Most 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 dont do enough deep tissue work to release the constant painful contractions of these muscles you will still have some compression 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 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 forceing 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 such as whiplash is seen in sports or car accidents can cause TOS.
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