Review this slideshare and for a more comprehensive approach to thoracic outlet syndrome, look for my book, Neck Pain, Upper Back Pain, Shoulder Pain, Could it be thoracic outlet syndrome? on Amazon.com What is Thoracic Outlet Syndrome? It is one of the most underrated, overlooked and misdiagnosed conditions and proves difficult to manage. Medical professionals appreciate that it is probably the most important peripheral nerve compression in the upper extremity. Thoracic outlet syndrome has been called many names Thoracic outlet syndrome bilateral thoracic outlet syndrome thoracic outlet disorder neurogenic TOS arterial TOS arterial thoracic outlet syndrome cervical rib syndrome cervicobrachial neuralgia compressive neuropathy costoclavicular syndrome disputed neurogenic thoracic outlet syndrome effort thrombosis, first rib syndrome hyperabduction syndrome inflammation of the brachial plexus neurogenic pectoralis minor syndrome (NPMS) neurogenic thoracic outlet syndrome (NTOS) neurological thoracic exit syndrome Paget-Schroetter syndrome peripheral nerve compression scalenus anticus syndrome spontaneous subclavian vein ("effort") thrombosis subcoracoid brachial plexus compression superior thoracic outlet syndrome symptomatic thoracic outlet syndrome thoracic outlet compression venous compression syndrome venous thoracic outlet syndrome double crush syndrome triple crush syndrome The Mayo Clinic, Cleveland Clinic and the National Institute of Neurological Disorders And Stroke, plus top 10 ranked hospitals for neurology and neurosurgery all tell us that compression is what leads to thoracic outlet syndrome. Surgery can have poor outcomes including: Chronic lifelong pain Progressive weakness Clot formation Emboli Stroke Limb amputation Failed surgery Spinal stimulators Addiction to painkillers Complications leading to death There were 16 Treatment Approaches for TOS I found in the National Database of Health NIH Medication: Analgesic drug therapy, Antidepressants, Anticonvulsants, others Scalene Injection (Bupivacaine) Nonsteroidal Anti-Inflammatory's NSAIDS Painkillers For Symptom Reduction Scalene Injection (Botox) Gentle Stretching Of The Scalene's And Pectoralis Minor Traction Nerve Gliding Ultrasound & Muscle Stimulation Different Bra For Breast Hypertrophy Breast Reduction - Reduction Mammoplasty Ergonomic Corrections Correction Of The Ergonomics Of The Workstation First Rib Adjustments Alone General Massage Exercise Strengthening None of these treatments by itself addresses the cause of TOS. Review this slideshare and look for my book, Neck Pain, Upper Back Pain, Shoulder Pain, Could it be thoracic outlet syndrome? on Amazon.com

1. THE INTEGRATED SPRING-MASS
MODEL APPROACH TO THORACIC
OUTLET SYNDROME
DR JAMES STOXEN DC (USA)

2. Thoracic Outlet Syndrome

3. Confusion
• The fact is that doctors that work with
musculoskeletal conditions feel thoracic outlet
syndrome is, underdiagnosed, (1) some
doctors that don’t know how to examine for it
say it's overdiagnosed. (2) others say it's
misdiagnosed (3) or not diagnosed. (4) Putting
it bluntly, the majority of doctors are really
confused about thoracic outlet syndrome!

4. My Story

5. What is Thoracic Outlet Syndrome?
• It is one of the most underrated, overlooked
and misdiagnosed conditions and proves
difficult to manage.
• Medical professionals appreciate that it is
probably the most important peripheral nerve
compression in the upper extremity. (1)

6. Incidence
• It affects approximately eight percent of the
population with women about four times
more likely to develop a neurogenic TOS. (206)

7. History
• TOS was first described by Sir Ashley Cooper,
in 1821 (2) and in 1861 Richard Holmes Coote
at St. Bartholomew’s Hospital in London
performed one of first surgical procedures, the
removal (resection) of a cervical rib, for what
came to be termed arterial TOS. (3) (4)

8. Thoracic outlet syndrome has been
called many names
• Thoracic outlet syndrome
• bilateral thoracic outlet syndrome
• thoracic outlet disorder
• neurogenic TOS
• arterial TOS
• arterial thoracic outlet syndrome
• cervical rib syndrome
• cervicobrachial neuralgia
• compressive neuropathy
• costoclavicular syndrome
• disputed neurogenic thoracic outlet
syndrome
• effort thrombosis, first rib syndrome
• hyperabduction syndrome
• inflammation of the brachial plexus
• neurogenic pectoralis minor syndrome
(NPMS)
• neurogenic thoracic outlet syndrome
(NTOS)
• neurological thoracic exit syndrome
• Paget-Schroetter syndrome
• peripheral nerve compression
• scalenus anticus syndrome
• spontaneous subclavian vein ("effort")
thrombosis
• subcoracoid brachial plexus compression
• superior thoracic outlet syndrome
• symptomatic thoracic outlet syndrome
• thoracic outlet compression
• venous compression syndrome
• venous thoracic outlet syndrome
• double crush syndrome
• triple crush syndrome

9. Cause = Compression
• The Mayo Clinic, Cleveland Clinic and the
National Institute of Neurological Disorders
And Stroke, plus top 10 ranked hospitals for
neurology and neurosurgery all tell us that
compression is what leads to thoracic outlet
syndrome. (7) (8)

10. Surgery – Poor Outcomes
• Chronic lifelong pain
• Progressive weakness
• Clot formation
• Emboli
• Stroke
• Limb amputation
• Failed surgery
• Spinal stimulators
• Addiction to painkillers
• Complications leading to death

11. PUb Med / 16 Treatment Approaches
• Medication: Analgesic drug therapy, Antidepressants, Anticonvulsants, others
• Scalene Injection (Bupivacaine)
• Nonsteroidal Anti-Inflammatory's NSAIDS
• Painkillers For Symptom Reduction
• Scalene Injection (Botox)
• Gentle Stretching Of The Scalene's And Pectoralis Minor
• Traction
• Nerve Gliding
• Ultrasound & Muscle Stimulation
• Different Bra For Breast Hypertrophy
• Breast Reduction - Reduction Mammoplasty
• Ergonomic Corrections
• Correction Of The Ergonomics Of The Workstation
• First Rib Adjustments Alone
• General Massage
• Exercise Strengthening

12. Which one by itself reverses
compression?
• None of them

13. What compels many doctors to
recommend surgery for TOS?
• Intractable pain (9)
• Neurologic deficit (9) – Weakness and decreased sensation
• Long term compression
• Limb threatening complications
• Arterial compression
• Completed and successful initial treatment of subclavian vein
thrombosis (9)
• Post subclavian vein thrombosis -- vessel reconstruction
• Paget Schroetter Syndrome (PSS)
• A previous surgery failed leading to another surgery
• Surgery that was performed for all the wrong reasons
• Failure of a carefully supervised physical therapy program (9)

14. Surgery Outcomes
• One study found 66 percent of people who
had surgery for TOS as part of workers’
compensation cases rated their experience as
good to excellent. (10)
•
• But what of the other 34 percent who had
poor results? More surgery? A life on
painkillers?

15. The thoracic outlet is made up of three passageways in
which this neurovascular bundle can be compressed:
• The Scalene Triangle
• The Costoclavicular
Space
• The Subcoracoid Space

16. Four Subtypes Of
Thoracic Outlet Syndrome
• Neurogenic - compression of the nerves in the
bundle
• Venous - compression of the vein of the
bundle
• Arterial - compression of the artery of the
bundle
• Disputed - it is disputed there is a thoracic
outlet syndrome like symptom pattern but the
exact cause cannot be determined.

17. Symptoms of
Thoracic Outlet Syndrome
• As the compression of the neck, upper back, shoulders and chest
lead to narrowing of the thoracic outlet you may initially feel slight
numbness and tingling of the finger tips, then more progressive
numbness, weakness in the hands when gripping things like
opening a jar of food, arms, and you may even start dropping
things.
• In extreme cases you may see wasting of the muscles of the hand
and arm, discoloration of the hand, cold fingers and hands, a lack of
color in the hand and even pain and swelling in the arm and hand,
possibly due to blood clots.
• The symptoms can be in one arm or in both. (17) In fact if the
symptoms are in both arms it’s more likely thoracic outlet
syndrome making it easier to diagnose.

18. First – How Is The Body Designed
• How is it engineered to protect itself from
impacts?
• How is it designed to recycle energy for
maximum efficiency?
• How is it engineered to provide spaces so
bones wont bang or grind?
• By what engineering creates the thoracic
tunnel for the blood vessels and nerves to
pass safely?

19. How The Mechanism Is Controlled
• How are movement patterns stored in the brain?
• How does the nervous system sense and react to
strained positions and movements?
• How does the does the nervous system react to
strained positions or movements?
• Can these abnormal strained moment patterns
be reprogrammed?
• How does the nervous system modulate and
change the tension on the human spring?

20. The top 5 advancements in
musculoskeletal medicine have been:
• Arthroscopic surgery
• The use of nails, screws and plates to stabilize
unstable joints that are damaged or
degenerated
• Joint replacements
• Digital x-rays
• 3-D models from CT and MRI studies

21. These are the models of human
movement we are going to examine:
• The inverted pendulum model, which is 340 years-old and still the
primary source of information for most doctors.
• Resistance exercise and the lever series model - A vision of
exercising the body and human movement propelled with a series
of lever-like connections.
• The spring-mass model, that acknowledges the lower half of the
body in motion operates as a spring mechanism.
• The integrated spring-mass model, which is an advancement of the
spring-mass model theorized by scientists from Harvard that
includes the upper body and head.

22. Inverted Pendulum Model
• In 1685, a renaissance Italian physiologist
physicist and mathematician Giovanni Alfonso
Borelli’s major achievements focus on
explaining human movement or
biomechanics. (1)
• Running according to Borelli was perceived to
be a different process – as a rebounding or
bouncing off compliant or bent legs. (1)

23. Plyometrics
• At age 26, I expanded
on that experience by
organizing a course at
the National Institute of
Physical Culture and
Sports Sciences in
Moscow in 1988 that
featured Yuri
Verkhoshansky and
many other top Russian
sports scientists.

24. Borelli Giovanni Alfonso 1680
Inverted Pendulum & Lever Model
• De Motu Animalium, Pars prima or
On the movement of animals
• In his seventeenth century volume
‘De motu animalium’, Borelli
discussed walking as vaulting over
stiff legs using a pair of compasses
and noted the importance of
rebounding on compliant legs in
running (97).
• From that early account up to the
present, walking and running have
been treated as different mechanical
paradigms, and the two
corresponding models, the inverted
pendulum model for walking (5) (98)

25. Spring-Mass Model
Blickhan 1989; McMahon & Cheng 1990
Harvard University
• The planar spring-mass
model is a simple
mathematical model of
bouncing gaits, such as
running, trotting and
hopping (105)

26. Inverted Pendulum vs Spring-Mass
Geyer H., Seyfarth A., Blickhan R. 2006 (13)
•
• Recent modeling analysis has shown that Inverted Pendulum applies well to walking
• The basic mechanics of human locomotion with the Inverted Pendulum model are associated with vaulting over
stiff legs in walking and rebounding on compliant legs in running.
• However, while rebounding legs well explain the stance dynamics of running, stiff legs cannot reproduce that of
walking.
• With a simple bipedal spring-mass model, we show that not stiff but compliant legs are essential to obtain the
basic walking mechanics
• We argue that not stiff but compliant legs are fundamental to the walking gait.
• In fact, they concluded the spring-mass model was best for describing the walking gait
• With a simple bipedal spring-mass model, we show that not stiff but compliant legs are essential to obtain the
basic walking mechanics; incorporating the double support as an essential part of the walking motion, the model
reproduces the characteristic stance dynamics that result in the observed small vertical oscillation of the body and
the observed out-of-phase changes in forward kinetic and gravitational potential energies.

27. Spring-Mass Model
vs
Integrated Spring Mass Model
• The Spring-Mass Model
embodies that during
walking and running,
the whole leg were a
linear spring. (15)
• The Spring-Mass Model
models the legs as
springs and the torso as
the mass

28. Spring-Mass Model
vs
Integrated Spring Mass Model
• Integrated Spring-Mass
Model suggests the legs are
the combination of a
Progressive Rate Spring and
Torsion Spring
• This new model models the
legs as Progressive Rate
Torsion Springs the body as
a Progressive Rate Spring
and Torsion Spring.
• The head is the only mass

29. Spring-Mass Model
vs
Integrated Spring Mass Model
• Lever Defined:
A simple machine
consisting of a bar that
pivots on a fixed support,
or fulcrum, and is used to
transmit torque. A force
applied by pushing down
on one end of the lever
results in a force pushing
up at the other end.
• Spring Defined:
In classic physics, a spring
can be seen as a device
that stores potential
energy, specifically elastic
potential energy, by
straining the bonds
between the atoms of an
elastic material.

30. Inverted Pendulum Model vs Spring-Mass Model

31. Spring-Mass Model

32. Types of Springs in the Human Body
• Menisci, Cartilage and
Vertebral Discs =
Compression Springs
• Spinal Column = Torsion
Spring
• Lower limb = Torsion
Spring
• Foot Arch = Leaf spring
• Tendons = Extension
Springs
• Human body = Torsion
Spring

33. Spring-Mass
• The head is the mass

34. Springs and tunnels provide a space
for structures to pass safely
• The nerves pass safely
between the vertebra of
the spine.
• The nerves that pass
safely over the rib cage.
• The nerves pass safely
under the shoulder girdle.
• The blood vessels pass
safely over the rib cage.
• The blood vessels pass
safely under the shoulder
girdle.

35. What Are The Only Structures That
Can Compress The Human Spring
Muscles…
That is why the surgical approach to TOS is
to resect the scalenes and pec minor

36. Muscles When Contracted Compress
The Thoracic Outlet & Tunnel
1. Anterior scalene
2. Middle scalene
3. Pectoralis minor
4. Anterior cervical
5. Subclavius
6. Anterior deltoid
7. Biceps short head
8. Coracobrachialis

37. What muscles are addressed with
surgery
• ONLY THREE
1. Anterior scalene
2. Middle scalene
3. Pectoralis minor
4. Anterior cervical
5. Subclavius
6. Anterior deltoid
7. Biceps short head
8. Coracobrachialis

38. Hooke’s Law Of Physics Applied To
Your Human Spring
• Hookes Law of elasticity,
discovered by the English
scientist Robert Hooke in 1660,
states the amount of deformation
of the spring is dependent on the
weight or force of the load. That
means the heavier the load
causes more deforming of the
spring.
• The tension on the spring or
spring stiffness is also a factor. If
your spring is strong and has a
greater degree of stiffness then it
can hold heavier loads during
springing. (walking, running and
impacts from sports)

39. Spring Modification, Tweak, Fine
Tuning or Regulation
• Spring Compliance
• Spring Stiffness
• Muscle Stiffness is not
Spring Stiffness

40. What Determines
Human Spring Strength?
• Overall body stiffness
• Single joint stiffness (i.e. foot stiffness, limb
stiffness, spine stiffness and head neck stiffness)
• Muscle tendon unit stiffness (i.e. medial
gastrocnemius and achilles acting together)
• Individual tissue stiffness (i.e. achilles tendon)
• Individual fiber stiffness (i.e. single muscle fiber)
• Cellular stiffness – Scientists have found that even
cells have stiffness factors

41. A Weak Spring
• Capable of improving spring compliance thus
protecting you from impacts like steps and
accidents
• Capable of increasing the spring stiffness
potential to improve efficiency of movement
• Capable of a strong spring suspension system,
maintaining a wide opening in your thoracic
outlet and tunnel and other openings where
blood vessels and nerves pass.

42. Nervous System Learned Behaviors
and Reflexes
• The nervous system can adjust the stiffness of the muscles and tendons that support the spring to
reduce stiffness to make it more compliant and better able to absorb the forces of impacts of
walking and running on different surfaces. However when the spring is more compliant your body
needs more energy to move.
• The nervous system can also adjust the tension on the spring to make it stiffer so the spring
bounces your body off the ground with more efficiency and speed. The greater the tension on the
spring the less apt it is to protect you from impacts.
• The nervous system can alter the tension on the spring to adjust for the forces of gravity to control
balance, posture and equilibrium while lying down, sitting, standing, lifting and other movements.
• The nervous system tightens the tension on the spring when the sensory system signals that it is in
a stressful or injured state.
• The nervous system can help you by programming every day activities of daily life into programmed
patterns such as walking, talking, eating, etc

43. Key Nervous System Function
• #3 The nervous system can alter the tension
on the spring to adjust for the forces of
gravity to control balance, posture and
equilibrium while lying down, sitting,
standing, lifting and other movements.

44. Reflexes
• In many cases tasks you take for granted are hard
wired in your nervous system called reflexes.
They react faster than learned behavior, which is
a good thing because they protect you from
harm.
• This is called an involuntary task because you did
not volunteer to do it. It happened automatically
without your control.

45. Is posture reflexive or a
learned behavior?
• Sir Charles Sherrington’s made some
significant scientific breakthroughs and it was
his work entitled, The integrative action of the
nervous system published in 1906 is regarded
as the founding text of modern neuroscience
devoted to understanding how reflexes work.
He determined that perfect balanced posture
is actually controlled by reflexes.

46. Posture
• Your posture allows you to maintain upright alignment
of the floors of your integrated spring mechanism.
• It maintains the spaces between your joints and the
openings and tunnels that allow your blood vessels and
nerves to pass safely.
• It permits efficient movement patterns through a
recycling of the energy through a balanced spring
mechanism.
• It allows your joints to be loaded symmetrically which
will decrease loads and strains on your ligaments,
muscles and tendons, cartilage and bones.

47. The two main functional goals of
postural behavior are:
• Postural Orientation - Postural orientation involves the
active control of body alignment (strain free or
strained) of the seven floors of your integrated spring
with respect to gravity, the surface you are lying, sitting
or standing on, and your internal state.
• Postural Equilibrium - The human body is said to be in
equilibrium when all forces or tensions are balanced.
The body should have no strain when it is in the state
of equilibrium.

48. Sensory Receptors
• Skin Pressure Receptors
• Visual Systems (your eyes)
• Somatosensory Systems
• Vestibular System

49. The Somatosensory System
• These special receptor cells include muscle
spindles (2) Golgi tendon reflex cells (3), joint
receptors, (4) skin receptors, (5) visual and
balance control or vestibular receptors (6) (7)
(8) (9) and receptors that control the flow of
blood through your circulatory system and
respiratory system or the control of your rib
cage spring (9)
•

50. Muscle Spindle Cells – What is their
function?
• Strain on the muscle
fibers creates strain on
the filaments of the
spindle cells. The nerves
that attach to the
filaments transmit the
message of how much
strain is on the muscles.
This important
information is relayed to
the brain’s software by
the nerves.

51. The Vestibular System
• provides information
related to movement and
head position related to
your body positions
relative to gravity
• is important for
development of balance,
coordination, eye control,
attention, being secure
with movement

53. Vestibular Reflexes
• Vestibulo-Ocular Reflex
• The vestibulo-ocular reflex generates eye movements that enable
your eyes to remain focused on the target while the head is in
motion.
• Vestibulospinal Reflex
• The vestibulospinal reflex generates tenses the muscles below the
neck to provide compensatory body movements in order to
maintain head and postural stability and thereby prevents falls.
• Vestibulocollic Reflex
• The vestibulocollic reflex takes control of the tone of the neck,
trunk and limb muscles to adjust your head so it remains
perpendicular to gravity so your eyes are horizontal to earth.

54. Righting Reflex Or Labyrinthine
Righting Reflex
• The most important reflex
is called the "righting
reflex". When the
position of the head or
body changes, reflex
movements occur that
return the head or body
to the normal posture of
your head perpendicular
to gravity and your eyes
level with the horizon.

55. The Cause of Compression!
• The optimum management of TOS
requires an understanding of the
underlying cause(s) of the
neurovascular compression or
tension. (1)
• Headaches
• Neck pain
• Upper Back Pain
• Herniated disc in the neck
• Thoracic Outlet Syndrome
• Cubital Tunnel Compression
• Median Nerve Compression Of The
Forearm
• Carpal Tunnel Compression
• Guyon Tunnel Compression 107
• Low back pain
• Herniated disc in the low back
• Degenerated discs
• Degeneration of the knees
• Degeneration of the hips

56. Doctors say the causes of Causes of
Thoracic Outlet Syndrome
• In the 2300 studies that came up in the search of the
National Institute of Health, US National Library of
Medicine, database there a little over a dozen different
ways the thoracic outlet and/or tunnel can become
compressed.
1. Muscle Super Contractions (Spasms) caused by poor
posture,
2. Something grows into the outlet (scar tissue, tumor)
3. Conditions you are born with or anomalies (cervical ribs,
elongated bones)
4. A Traumatic Shift (rib fracture, clavicle fracture, car
accident, work injury, sports injury)
•

57. Muscle Contraction
• Your brain sends an electric signal through nerves that connect to muscles. When
the signal arrives, a chemical, acetylcholine is released into the space between the
nerve and muscle. The acetylcholine docks or binds to the receptors of the
muscles surface. This causes calcium to enter the muscle cell. This starts the
contraction of the muscle.
• During the contraction, the pressure on the capillaries increases temporarily
moving the blood out of the area. When the contraction releases, the pressure
releases blood flows back into the muscle.
• After a healthy contraction, a little bit of lactic acid is released. This makes the
area a little acidic. Under normal circumstances lactic acid is flushed out of
muscles into the bloodstream within 30 minutes after the exercise.
• At about the same time, an enzyme called acetylcholineesterase breaks up the
acetylcholine to prevent the acetylcholine from constantly triggering the muscle
contraction.

58. Abnormal Muscle Contractions
• A single overloading is like a whiplash, sports
injury or work accident.
• A recurring episode of sustained
biomechanical overloading is more than 20
repetitions of muscle contraction with no rest.
• A sustained biomechanical overloading would
be like holding a 9-pound bowling ball in your
arms for 30 minutes or more without rest.

59. Theory #1
• Compression
• Lack of Blood flow
• Aerobic to Anaerobic Metabolism
• Lactic Acid
• PH Below 7
• Acetylcholineesterase cannot breakdown
Acetylcholine

60. Theory #2
• This constant state of muscle contraction damages muscle tissue.
These damaged muscles release inflammation.
• Intertwined between muscle and tissues are other receptors called
nociceptors. According to the International Association for the
Study of Pain, a nociceptor is defined as: “… a high-threshold
sensory receptor of the of the nervous system that is capable of
detecting stressful, harmful and even toxic stimuli. (3)
• They are thin nerve fibers in muscles that sense and send
information about harmful mechanical, temperature and chemical
stimuli in and around muscles. These nerves send this information
to the brain. (7)
• Different tracts of the spinal cord have the ability to transmit
nociceptive information to the central nervous system (spinal cord
and brain). (9)

61. 2. Something grows into the outlet
(growth or tumor) RARE
• When something like a pancoast tumor or other
tumor grows into the thoracic outlet or tunnel
this is usually in the later stages of the tumor
growth. By this time you should already have the
diagnosis of the tumor however sometimes it is
the symptoms of TOS that get you to the doctor
first.
• If you have a pancoast tumor of the lung you are
more concerned with survival than the thoracic
outlet syndrome.

62. 3. Conditions you are born with or congenital
Abnormalities (cervical ribs)
• It is rare for patients with
an extra rib to
spontaneously develop
thoracic outlet syndrome.
One researcher reported
that over a 28-year period
and 1000 surgeries for
thoracic outlet syndrome
there has been an
incidence of less than five
percent for extra or
deformed first ribs. (46)

63. Sleeping Posture and
Sustained Contraction

64. Sitting Posture and
Sustained Contraction

65. Pectoralis Minor Contraction &
“All of the above” Contraction

66. The Rules Of Gravity &
The Righting Reflex
• Body Lean Right Causes
Scalene Contraction On The
Left To Tilt The Head Left
And TOS On The Left
• Body Lean Left Causes
Scalene Contraction On The
Right To Tilt The Head Right
And TOS On The Right
• Body Lean Back Causes
Scalene And Anterior Neck
Muscle Contraction For A
Neck Lean Forward And TOS
On The Left And Right

67. Neck-Upper Extremity Problems -
Workplace Stressors – Causes
• Repetition Strain Injury – Keyboards - You have to hold
the arm in a certain position to get your fingers on the
keyboard, which strains your pectoralis minor muscle,
the coracobrachialis, the long and short head of the
biceps as well as the anterior deltoid muscles.
• Mouse Use Duration - One research study found an
association between use of a mouse device for more
than 20 hours per week and risk of possible carpal
tunnel syndrome rather than actual duration of
keyboard use. (23)
• Monitor position and visual stressors

68. A single overloading strain on muscles, tendons,
ligaments and bone.
• Motor vehicle accidents resulting in whiplash
are the most common causes of neck injuries
with approximately 1,000,000 per year in the
US. (38)

69. Diagnosis – History - The Symptoms
10 most common symptoms reported in patients with TOS include
• Numbness, Burning Pain or Tingling In The Upper Limb (98%)
• Neck Pain (88%)
• Trapezius Pain (92%)
• Shoulder and/or Arm Pain (88%)
• Collarbone Pain (76%)
• Chest Pain (72%)
• Headache at the base of the Skull (76%)
• Numbness, Burning Pain or Tingling In All Five Fingers (58%)
• Numbness, Burning Pain or Tingling In The Fourth & Fifth Fingers
Only (26%)
• Numbness, Burning Pain or Tingling –Third Fingers (14%)

70. Common ADLS associated with TOS
• They sit for long periods of time at work in static positions with a
bad chair or in an awkward posture.
• They are sitting or lying in static positions with awkward postures
when they're at home when on the computer or when watching TV.
• They are leaning back in the bed propped up with the pillows.
• They are sitting on a recliner watching television or reading a book
• They are driving long distances with the seat back.
• They are doing work over head which forces them to hold their
arms up for a long period of time.
• They carry heavy luggage, book bags, purses, bags or backpacks, or
all the above.

71. These are the two causes of
a shift in the structures
• Abnormal Muscle Weakness - Weakness in the
muscles that suspend the shoulder over the outlet such
as the upper trapezius and levator scapula can happen
either from fatigue or general weakness.
• Abnormal Muscle Tension - Trigger point super
contraction can cause direct or indirect compression of
the outlet. Ribs can elevate into the outlet by a super
contraction of the scalenes and the shoulder can get
pulled or dragged down into the outlet by super
contraction of the pectoralis minor, the subclavius
muscle, the coracobrachialis, the biceps short head,
and the anterior deltoid.

72. 8 Muscles that Compress the Outlet
1. The Anterior Neck Muscles – (Compress the neck into the head)
2. The Anterior Scalene muscle – (Compress the neck)
3. The Subclavius Muscle – (Compress the shoulder into the outlet)
4. The Coracobrachialis – (Compress the shoulder into the outlet)
5. The Pec Minor Muscle – (Compress the shoulder into the outlet
from the front)
6. The Latissimus Dorsi Muscle – (Compress the shoulder into the
outlet from the back)
7. The Biceps Short Head Muscle – (Compress the arm into the
shoulder)
8. The Anterior Deltoid Muscle (Compress the arm into the shoulder)

73. Examination
• Manual Muscle Testing
• Orthopedic Tests

74. Orthopedic Tests
• Adsons Test – Scalenes and
First Rib Elevation (Adson’s
test more specifically
address compromise to the
plexus through the scalene
triangles)
• I take the pulse to feel the
blood pulsating against my
fingertips. Then I move
your arm behind your back
and rotate it in adduction
extension and external
rotation. (see image)

75. Orthopedic Tests
• Cervical rotation lateral
flexion test
• Costal Clavicular
Maneuver
• Hyperabduction
Maneuver – Wrights
Test
• Roos Test (elevated
arms stress test)
• Cyriax Release Test

76. Roos Test (elevated arms stress test)
• With this test I ask you to raise
your arms in a position like you
are about to do a military press.
• Then I ask you to open and close
your hands slowly for 3 minutes.
• If you are unable to keep your
arms in this position for 3
minutes or if you have pain,
heaviness, or weakness in the
arm or numbness or tingling in
the hand during the test then
some doctors say this is a positive
Roos test.

77. Hyperabduction Maneuver
Wrights Test
• In this test I am feeling
your pulse to get the
rhythm and intensity.
Then I ask you to lift
your arm over your
head and extend it back
behind you.

78. Cyriax Release Test
• What you do is sit down in a
chair with your arms pain
down elbows bent at 90°. Put
some pillows underneath your
forearm to elevate your
shoulders up so that the
shoulder girdle is elevated
opening the thoracic outlet
tunnel. If the symptoms of
nerve, artery or vein
compression diminish then
this is a positive sign of
thoracic outlet syndrome. (13)
•

79. Diagnostic Tests
• When is diagnostic testing indicated?
• Persistent thoracic outlet syndrome, back or neck pain
with radiating pain, numbness or tingling in the arm
and no improvement after 2 weeks of conservative
therapy? 4 weeks? 6 weeks?
• One doctors recommendation was that diagnostic
testing should start at 12 weeks of conservative
therapy.

80. Diagnostic Tests that Rule out
Thoracic Outlet Syndrome
• X-Rays
• Specialized nerve Tests: EMG, NCV and SSEP Tests
• Venography
• Venous Scintillation Scans (Ct, Mri Or Pet Scans)
• Doppler Ultrasonography
• Plethysmography
• Magnetic Resonance Angiography
• Duplex Scanning
• CT Angiography
• Pulse Oximetry

81. X-Rays
• A Straight Or Reversal Of The Curve in the
Neck (military neck)
• Disc Degeneration and Joint Degeneration In
The Neck
• Calcium Deposits In The Rib Joints
• Extra Ribs In The Neck (Cervical Ribs)

82. Nerve Conduction Velocity Test
• Some doctors think that the nerve conduction
velocity test is their primary objective test for
thoracic outlet, nerve compression. (3)

83. Venography Also Called Phlebography
Or Ascending Phlebography
• Doctors can check to
see if you have a
compressed vein. If a
vein or artery has a clot,
doctors can deliver
medications through
the catheter to dissolve
the clot.

84. Venography
• showed appropriate
flow in left subclavian
artery in adduction of
left upper limb.

85. Pulse Oximetry
• Pulse oximetry monitors
the oxygen in your
blood.
• I have a pulse oximeter
with plethysmogram
that I use when doing
my examinations of
patients.

86. 30 Different Conditions in the
Differential Diagnosis
Neck Trauma
• Trauma - Cervical Disc Injury – 6th nerve root
• Trauma - Cervical Disc Injury – 7th nerve root
• Trauma - Cervical Disc Injury – T1 nerve root
• Cervical Radiculopathy or Brachial Plexus
Injury Brachial Neuritis (5)
• Cervical Spondylosis –
• Neck Trauma
• Thoracic Disc Injuries
Shoulder Diagnosis
• Clavical Injuries - Acromioclavicular Joint
Injury
• Clavical Fracture Malunion
• Inflammatory Conditions of the shoulder
(tendonitis arthritis)
• Shoulder impingement Syndrome
• Rotator Cuff Inflammation
• Intercostal Neuritis (pinched nerve between
the ribs)
Extremity Compression
• Compressive Neuropathy - Cubital Tunnel
Compression
• Compressive Neuropathy - Carpal Tunnel
Syndrome
• Compressive Neuropathy - Guyon's canal
• Compressive Neuropathy - Median Nerve
Entrapment
• Compressive Neuropathy - Double Crush (5)
• Compressive Neuropathy - Triple Crush
• Compressive Neuropathy - Quadruple Crush
Vascular Compression
• Vascular Diseases (atherosclerosis)
• Paget-Schroetter syndrome AKA Effort
Thrombosis
•
Tumors and Others
• Pancoast’s Tumor
• Spinal Cord Tumor or Neoplasm
• Complex Regional Pain Syndrome (reflex
sympathetic dystrophy) (5)
• Degenerative Spinal Cord Disease – MS
• Degenerative Spinal Cord Disease -
Syringomyelia
• Raynauds Phenomenon
• Cervical Ribs and Fibrous Bands (6)
General Musculoskeletal
• Myofascial Pain Syndrome

87. Neck Trauma
• Trauma - Cervical Disc Injury – 6th nerve root
• Trauma - Cervical Disc Injury – 7th nerve root
• Trauma - Cervical Disc Injury – T1 nerve root
• Cervical Radiculopathy or Brachial Plexus
Injury Brachial Neuritis (5)
• Thoracic Disc Injuries
• Cervical Spondylosis –

88. Shoulder Diagnosis
• Clavical Injuries - Acromioclavicular Joint Injury
• Clavical Fracture Malunion
• Inflammatory Conditions of the shoulder
(tendonitis arthritis)
• Shoulder impingement Syndrome
• Rotator Cuff Inflammation
• Intercostal Neuritis (pinched nerve between the
ribs)

89. Extremity Compression
• Compressive Neuropathy - Cubital Tunnel
Compression
• Compressive Neuropathy - Carpal Tunnel
Syndrome
• Compressive Neuropathy - Guyon's canal
• Compressive Neuropathy - Median Nerve
Entrapment
• Compressive Neuropathy - Double Crush (5)
• Compressive Neuropathy - Triple Crush
• Compressive Neuropathy - Quadruple Crush

90. Vascular Compression
• Vascular Diseases (atherosclerosis)
• Paget-Schroetter syndrome AKA Effort
Thrombosis

91. Tumors and Others
• Pancoast’s Tumor
• Spinal Cord Tumor or Neoplasm
• Complex Regional Pain Syndrome (reflex
sympathetic dystrophy) (5)
• Degenerative Spinal Cord Disease – MS
• Degenerative Spinal Cord Disease - Syringomyelia
• Raynauds Phenomenon
• Cervical Ribs and Fibrous Bands (6)

92. What treatment “alone”
doesn’t work and why?
•
• Gentle Stretching and/or Stretching Exercises
• Traction
• Ultrasound, Hot Packs & Muscle Stimulation
• Structural Massage (myofascial, neuromotor techniques)
• Scalene Injection (Bupivacaine)
• Scalene Injection (Botox)
• Nerve Gliding
• Different Bra For Breast Hypertrophy
• Breast Reduction - Reduction Mammoplasty
• First Rib Adjustments Alone
• Nonsteroidal Anti-Inflammatory's NSAIDS
• Medication: Analgesic drug therapy, Antidepressants, Anticonvulsants, others
• Painkillers For Symptom Reduction
• Strengthening with Exercise
• Correction Of The Ergonomics Of The Workstation
• Ergonomic Corrections

93. 1. Gentle Stretching and/or
Stretching Exercises
• Gentle stretching of the
neck from side to side
in my opinion actually
causes of elevation of
the ribs even worse

94. 5. Scalene Injection (Bupivacaine, Etidocaine,
Lidocaine, and corticosteroids)
• The first flaw in this
approach to diagnosis and
treatment is that the
scalene muscle is not the
only muscle that causes the
compression of the nerves
and blood vessels.
• The second flaw in this
approach to diagnosis and
treatment is that these
injections only affect the
muscle itself. The reflex is
stored in the brain.

95. 6. Scalene Injections of
Botulinum toxin or Botox
• Botulinum toxin can also cause prolonged
muscle relaxation through inhibition of
acetylcholine release. (12)
• It causes muscle fibers began to get weaker
on the 4th day and this continued to the 14th
day after being injected. (11)
• It blocks contraction of not only of muscle
contraction, but also of contraction of the
spindle cell fibers too. (395) Atrophy or
weakness will result in the spindle cells
which are the strain gauges that gauge the
tension on the scalenes for balance and
equilibrium.
• Also, after the drug wears off you will end up
with severe atrophy of the muscle, which will
require months of rehabilitation to build the
strength back.

96. Are Botox injections effective? Here
are three studies that say its not.
• 1. One study found that 64% of subjects had a minimum of 50% decrease in pain, numbness and
fatigue for at least month following the injection. (13) We all know that botulism or Botox injections
are a neurotoxin being injected into the body. We also know that Botox only provides temporary
relief to ONLY muscle with spasms that are injected.
• 2. In a double blind, randomized, controlled trial conducted at the University of British Columbia,
Department of Medicine, Division of Physical Medicine and Rehabilitation, British Columbia,
Canada, the effect of botulism toxin type injections to the scalene muscles on patience with
thoracic outlet syndrome's were studied in six week, three months and six months increments. (14)
– The study concluded that Botox injections to the scalene muscles did not result in clinically or statistically
significant improvements in pain, paresthesias, or function in this population of subjects with TOS. (14)
• 3. Additionally, many patients in a study done at Johns Hopkins Hospital in Baltimore report no
relief of symptoms from Botox or scalene injections, which may indicate that the pain does not
stem from the scalene muscle and may not be TOS. Botox can be an effective treatment for
neurogenic TOS.

97. When is surgery medically necessary?
• Failure Of A Carefully Supervised Physical Therapy Program
(8)
• Intractable Pain (8)
• Neurologic Deficit (8) – Weakness and Decreased Sensation
• Long Term Compression
• Limb Threatening Complications
• Arterial Compression
• Completed And Successful Initial Treatment Of Subclavian
Vein Thrombosis (8)
• Post Subclavian Vein Thrombosis - Vessel Reconstruction
• Surgery was performed for all the wrong reasons.
• Paget Schroetter Syndrome (PSS)

98. Failure Of A Carefully Supervised
Physical Therapy Program (8)
• The condition was misdiagnosed from the start.
• The patient was under diagnosed - The patient had thoracic outlet
syndrome and an overlapping condition or two that were not treated.
• The treatment approach did not focus on the 5 requirements to effectively
reverse thoracic outlet syndrome in the long term.
• The health care professional tried the five requirements but did not have
enough experience nor the skill set to do the release of the super
contractions.
• You don’t have the resources (insurance) or you ran out of insurance.

99. Thoracic Outlet Syndrome - Surgery
• Thoracic outlet syndrome
surgery involves surgical
removal of the scalene
muscles and the first rib.
• They may even remove the
pectoralis minor if they feel
the collarbone and shoulder is
compression of your thoracic
tunnel.
• Some do the shot gun
approach because they feel,
when in doubt cut it all out.
• This is the strategy of
surgically removing all three
muscles and the ribs too. (2)

100. Effective TOS Treatment
• The treatment approach must erase the neuromotor pattern in the brain,
which controls the constant super contractions of the eight muscles,
which can either directly or indirectly compress the thoracic outlet
completely.
• The “joint play” must be reestablished in the joints such as the top ribs
(costochondreal and sterno claviular joints), the joints of the collarbone (
the sternoclavicular joint and acromioclavicular joints) as well as the joints
of the vertebral column must be unlocked.
• All inflammatory chemicals must be flushed out of the area to prevent
retriggering of the neuromotor pattern of muscle super contractions.
• The muscles that suspend the shoulder over the thoracic outlet and
tunnel must be trained to open and preserve adequate space in the
thoracic outlet and tunnel.
• Your activities of daily living must not exacerbate the condition.
•

101. Pectoralis minor surgery

102. Why The Pectoralis Minor Surgery
Is An Inadequate Approach To Decompression
• The Pectoralis Minor isnt
the ONLY muscle to
compress the shoulder
girdle to the chest
• The coracobracialis and
biceps short head also
attach at the coracoid and
drag the shoulder into the
outlet

103. Complications of surgery
1. Postoperative Scars
2. Recurrences
3. Winging Scapula - Long Thoracic Nerve?
4. Postoperative Bleeding - Apical Hematomas
5. Pneumothorax
6. Artery Injuries
7. Upper Limb Ischemia
8. Vein Complications
9. Brachial Plexus Injuries
10. Phrenic Nerve Paralysis
11. Scapula Alta
12. Death

104. What are the 5 Key Components to a
Successful Conservative Therapy Approach
1. The treatment approach must erase the neuromotor pattern in the brain, which controls the
constant super contractions of the eight muscles, which can either directly or indirectly compress
the thoracic outlet completely.
2. The “joint play” must be reestablished in the joints such as the top ribs (costochondreal and
sterno claviular joints), the joints of the collarbone ( the sternoclavicular joint and
acromioclavicular joints) as well as the joints of the vertebral column must be unlocked.
3. All inflammatory chemicals must be flushed out of the area to prevent retriggering of the
neuromotor pattern of muscle super contractions.
4. The muscles that suspend the shoulder over the thoracic outlet and tunnel must be trained to
open and preserve adequate space in the thoracic outlet and tunnel.
5. Your activities of daily living must not exacerbate the condition.

105. Paget-Schroetter Syndrome
• Effort thrombosis, or Paget-
Schroetter Syndrome, is a
outcome of venous thoracic
outlet syndrome that got much
worse!
• It is when the compressed vein in
your chest under your collarbone
(axillary-subclavian vein) has a
blood clot (thrombosis).
• This is usually associated with
strenuous and repetitive activity
of the upper extremities.

106. Paget-Schroetter Syndrome
Symptoms
• The primary symptom is arm swelling, frequently
accompanied by cyanosis, pain, and occasionally
paresthesias. (7)
• Cyanosis is a blue discoloration of the skin and mucous
membranes resulting from inadequate oxygenation of
the blood.
• Symptoms can be excruciating deep pain the chest,
shoulder and entire upper extremity, accompanied by a
feeling of heaviness that occurs especially after activity

107. The symptoms of subclavian vein
effort thrombosis are
• Heavy After Activity
• Deep Pain In The Chest
• Cyanotic Discoloration
• Distended Dilated
Collateral Veins – Urschels
Sign
• Edema
• Swelling And Discomfort
• Redness In The Arms
• Cyanosis

108. Paget-Schroetter Syndrome - Cause
• Effort thrombosis usually follows
sporting activities, such as
wrestling, playing ball, gymnastics
and swimming, which involve
vigorous and sustained shoulder
and arm movements. (10)
• A majority of patients report a
discrete precipitating event,
usually sports-related arm
exertion. (10)
• Approximately 60–80% of
patients diagnosed with Paget-
Schroetter Syndrome report a
history of repetitive or vigorous
overhead activity.

109. Diagnose the Vein Obstruction
• Angiography
• MRV Venography For
High Sensitivity
• Compression
Ultrasonography With
Color Doppler
• Contrast Venography
• Magnetic Resonance
Venography

110. Treatment - Surgery
• Limb Elevation
• Local Catheter Directed Thrombolytic (drugs are used in
medicine to dissolve blood clots)
• Fibrinolytic Agent (clot dissolving drug)
• Remove The Extrinsic Compression (thoracic outlet
surgery)
• Remove The Intrinsic Stenosis (cut out part of the vein that
is narrowed)
• Vein Patch Angioplasty (patch that part of the vein)
• Percutaneous Angioplasty (technique of mechanically
widening narrowed or obstructed arteries)
• Subclavian vein narrowing requires balloon angioplasty

111. Rehabilitaiton
• Inpatient physical therapy is started the day after the
operation to maintain range of motion, with
postoperative rehabilitation then overseen by a
physical therapist with expertise in the management of
TOS, and no restrictions placed on upper extremity
activity beyond 12 weeks after surgery. (4)
• Full recovery is typically complete within 3 months of
the operation, and a return to previous levels of
functional activity can usually be expected. (4)

112. Pulmonary Embolism
• When the clot releases into the lung,
this could be a big problem. Doctors
call it a pulmonary embolism. The
key signs and symptoms of a
pulmonary embolism include
dyspnea, chest pain, syncope, low-
grade fever, and Racing heart rate.
(25) (26)
•
• It only happens with 5.6%, which is
rare for Paget–Schroetter syndrome.
However, a pulmonary embolism is a
serious complication related to this
condition that may result in a fatal
outcome, reinforcing the importance
of a proper diagnosis. (25) (26)

113. What works
• Step 1 - Release the compression of your bodies
spring and the compression on your thoracic outlet
and tunnel
• Step 2 - Strengthen your bodies spring suspension
system to suspend the shoulder over the thoracic
outlet and tunnel with resistance exercises
• Step 3 - Spring train the human spring with spring
training drills and plyometric exercises to enhance
and maintain the bodies human spring engineering

114. What makes your deep tissue treatment effective in
decompressing the outlet?
• You must know what muscles and where they are.
• You have to know how to get the super contraction directly under
your thumb
• You must apply the right depth of pressure
• You must know how long to hold the point
• You must know where the super contraction patterns will be.
• You must know the patterns of referred pain
• You must know how the symptomatology progresses through the
application
• You must know what is good pain and what is bad pain
• You need to know when its completely released (MMI)
• You need the ideal therapy to change the biochemistry

115. You need to know how long each
treatment will take
Eight Muscles that Either Directly or Indirectly
Contribute to Compression of the Outlet
1. Subclavian Muscle – 6 cun
2. Supraspinatus Muscle – 4 cun
3. Anterior Scalene Muscle - 6 cun
4. Middle Scalene Muscle – 6 cun
5. Pectoralis Minor Muscle – 6 cun
6. Anterior Deltoid Muscle – 4 cun
7. Biceps Short Head Muscle – 4 cun
8. Coracobrachialis Muscle – 4 cun
Additional Muscles Considered:
1. Latissimus Dorsi Muscles 2 cun
2. Suboccipital Muscles – 2 cun
• Total area to cover is 44 cun.
• So if you have a very chronic severely
compressed upper body it may take 3 or
more minutes per application point.
• If you are that patient it would take an
estimate 132 minutes to treat all the muscles
that directly or indirectly compress the outlet
on one side of the body on the first three
visits.
• It would be 264 minutes if the condition is on
both right and left sides equally. That means
that it could take over 2 hours to cover every
inch of every muscle on one side and up to 4
hours if its on both sides.

116. The Fastest Approach
• Patients are treated in slots of
three hours per day where they
get 30 minutes of vibrational
massage and 2.5 hours of deep
tissue per day.
• This amount of deep tissue allows
me to pass through all of the
effected muscles multiple times
per visit speeding up the
recovery.
• The treatments are minimum
three hours long. This is required
for more difficult to reverse cases
that come from out of town.

117. How I Got My Wiggle Back
Anthony Field / Wiggles

118. Deep Tissue Techniques

119. Neck Muscles

120. Shoulder Muscles

121. First Rib Adjustment

122. Neck Exercises

123. Neck Exercises

124. Torso, Chest and Shoulder Stretch

125. Thank You!