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 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?

I know they would have never recovered 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’s 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 with 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 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 are not going to 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 reeducation 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 need to 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.





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