FREE BOOK THORACIC OUTLET SYNDROME – Chapter VIII – Frequently Asked Questions

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

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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?





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