34: Thoracic Outlet Syndrome: What You Didn’t Know
Episode Transcript
Summary: Whitney Lowe and Til Luchau share trivia, tips, tests, and techniques for working with thoracic outlet syndrome (TOS), including some cool self-care methods for you and your clients. Find out why TOS is “one of the most controversial topics in musculoskeletal medicine,” and how Til and Whitney actually work with TOS symptoms in practice. Download the handout with detailed episode notes, techniques and tests fromhttp://a-t.tv/ttp-tos/
Get the handout or get the full transcript atTil orWhitney’s sites!
Resources and references discussed in this episode:
- Download the handout for full references etc.: http://a-t.tv/ttp-tos/
- Whitney Lowe’s site: AcademyOfClinicalMassage.com
- Til Luchau’s site: Advanced-Trainings.com
Til Luchau:
Welcome to The Thinking Practitioner.
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Whitney Lowe:
Very well, sir. Good to talk to you again, we’ve been off for a few weeks as we dealt with various different things in different parts of the world here. So it’s good to be back on stage with you again here.
Til Luchau:
Likewise.
Whitney Lowe:
[crosstalk 00:01:30]well, good to see you again.
Til Luchau:
It’s good to be here with you and getting back in the groove here. What are we going to talk about today?
Whitney Lowe:
Today we’re talking about the confusing and often fascinating world of thoracic outlet syndrome actually.
Til Luchau:
Oh, confusion, fascination and thoracic outlet, I love it.
Whitney Lowe:
Yeah.
Til Luchau:
And is there… Sorry, is there a handout?
Whitney Lowe:
Actually, there is a handout that’s going to have some other great resources for you on this, and you will find that on our Thinking Practitioner website, as wells as also on the Advanced-Trainings website as well [crosstalk 00:02:08]
Til Luchau:
We’ll put that URL… Yeah, I’ll put the URL in the notices that we send out too, so we’ll make sure you got that.
Whitney Lowe:
Yes. Perfectly, so got some notes and some other resources there that we wanted to make sure you have access to for our discussion today. So, thoracic outlet syndrome, anyway, we’re going to take a jump dive into this and see what we can explore about this. It is a term that lots of manual therapists hear, a good deal, and it is interesting if you look at a lot of the literature that is written about thoracic outlet syndrome. They’ll frequently say things like it’s either one of the most underdiagnosed things that there is out there, or it’s something that doesn’t even exist. It really runs the gamut, which is interesting when you see that in a lot of the medical literature and that just illustrates some of the confusion around what this actually is.
Til Luchau:
No, that’s really interesting. So there’s either it exists everywhere and we’re misdiagnosing, or it doesn’t even exist at all.
Whitney Lowe:
Yeah. And that’s part of the problem is because it is so ill-defined, it makes it hard to nail down when is it really there, and how do you really identify it. We’re going to look at some of those dilemmas today. One of the things that I found interesting about this looking at some of the history of this term, and the concepts around it, is having to do with anatomically where the term even comes from. Originally thoracic outlet syndrome was seen predominantly as a vascular problem, and so there was a lot of emphasis on looking at especially the subclavian artery as it exits the thoracic rib cage, and makes its way over the top and then starts coming down the arm. And this is the region known as the thoracic outlet, and so that’s where the condition got its name.
The vascular component, and we’re going to talk about this a little bit more down the road here, but the vascular component we’ve now learned is really very small in comparison to the neurological components of this particular condition. Which seem to be a lot more affected by places where neural structures are exiting the cervical region. And some arteries [crosstalk 00:04:10].
Til Luchau:
Sorry, or to say the vascular component is small or it’s less common.
Whitney Lowe:
Yeah, less common. Say, yes, small is probably not a good word. So less common, thank you for that clarification.
Til Luchau:
So, you’re saying the vasculature is a problem, and far fewer people than the other stuff turns out?
Whitney Lowe:
Right, yeah and so I have even seen a couple authors advocating the neurological components of this be more accurately referred to as cervical outlet syndrome instead of thoracic because it really has to do with the nerve roots coming out of the cervical region. So I don’t think we’ll see that anytime soon in terms of a change in terminology, but it is good to understand a little bit more about some of the anatomical features here to see a new word that’s come from.
Til Luchau:
No kidding that changes things if I plugged it into my thinking cap from being a way out of the thorax to being a cervical route possibility, yeah.
Whitney Lowe:
Yeah, and this also helps illustrate some of the different variations and terminology problems associated with this just because the thoracic outlet is kind of an ambiguous region. I even saw somebody talking about this one time saying, “Well, if you are a vascular surgeon or somebody that is looking at the vascular system, the area at the top of the ribcage is the thoracic outlet. But if you are, for example, a respiratory physician, somebody who’s focusing on the airway coming down in there, and that’s the thoracic inlet.” So, again, some of those other confusion, anatomical terms are a bit confusing for us in terms of defining that. We’ll try to do our best to adopt the most common facets of terminology there.
Til Luchau:
That’s great. That’s helpful.
Whitney Lowe:
Yeah, so as we look at this, one of the things that strikes me as being important in terms of clarification or the divisions of what the term is, or the condition we’ll call it, is sort of divided. You will often see references to three different types of thoracic outlet syndrome, or sometimes it’s divided into two vascular versus neurological. And then the vascular may be divided into venous or arterial. So there’s varying different statistics about this but the neurological components of this condition tend to make up about 90% of the cases. Whereas the vascular is much smaller, some around 5% of those with more being associated with venous problems and even fewer with arterial problems. Which I find really interesting, since thoracic outlet was originally viewed as a vascular disorder. Now we’re really seeing it’s much more neurological [crosstalk 00:06:52].
Til Luchau:
Shows you that maybe nine cases out of 10, there’s primarily a neurological component?
Whitney Lowe:
Yeah.
Til Luchau:
I think just from memory, I don’t trust my memory as much as yours but I’m remembering 80%. But still the vast majority are pretty wide agreement that, that’s neurological as opposed to like cutting off the blood flow in most cases.
Whitney Lowe:
Yeah and I think another important thing to consider is that it’s quite likely in many situations that both of these things are going on. So it’s not really appropriate to divide them up and say, it’s just neurological with no vascular component. So that’s why the number [crosstalk 00:07:24].
Til Luchau:
Maybe this is less dividing too, but even the neurological ones you could argue could be microvascular arterial issues where the nerve is possibly distress because it’s not getting the hydration and the blood flow it needs.
Whitney Lowe:
Absolutely. So then is that neurological or is that vascular? Neurological disorder caused by lack of blood flow ischemia to the nerve structure itself. Is that a vascular issue, or is a neurological issue, or is it both? So just know that there are those components and that we may be seeing any of them all the time. And for us, I just encourage people to just treat them as if they’re all involved but know that we may see some different types of things occurring from different types of those different variations. We’ll talk about those in just another minute as well.
Til Luchau:
In other words, maybe it doesn’t affect treatment as much as it might, so that in some ways, we can just treat them and see how that works out too.
Whitney Lowe:
Yeah, that’s interesting. So the other thing that I want to emphasize here, and this is interesting if you look at the literature on thoracic outlet syndrome, It does not go into as much detail on some of the variations of the neurological forms as it often does. Just make those distinctions about vascular and neurological or arterial, venous and neurological. But we have several different variations on the neurological components that do that, or have some important anatomical distinctions.
Til Luchau:
Tell me about them.
Whitney Lowe:
Yeah, there’s essentially four of these variations that we usually ascribe to, sometimes the first two are considered similar together. But the first of those variations has to do with an anatomical anomaly called a cervical rib. It’s really important to remember that there are all kinds of anatomical variations from person to person with lots of stuff that we don’t see in the anatomy books that are still moderately common. And a cervical rib, I believe last time, I would have looked and saw statistics on how this happens in roughly, I think it was one to 3% of the population or something like that.
Til Luchau:
I looked at the stats a couple years ago, what I found, said one in 200, so half a percent that [crosstalk 00:09:39].
Whitney Lowe:
One in 200? Yeah, so a small number but if you kind of think about that out of every 100 to 200 clients you see, one of them might have a cervical rib. So after a while, it’s not as uncommon as you might think. But what is the question?
Til Luchau:
Well, hey, wait a minute, our last episode had like 2000 downloads. So that means there’s like 10 people listening to this podcast may have cervical ribs, you could be one of them.
Whitney Lowe:
About [inaudible 00:10:04] you go. Okay, could be one… I remember when I first learned about the presence of cervical ribs, I was thinking about the number of people that I had worked on previously that seemed to have these rock-hard scalene muscles right in their anterior neck region. And I could not get them to relax no matter what I did, there was rubbing the crap out of them, and they just wouldn’t relax. And I got thinking that’s why, “Hey, I was probably rubbing on the cervical rib.”
So anyway, back to what is it? The cervical rib is an anatomical anomaly that is an extension of the C7 transverse process. And it sort of curls around on the side of the neck and comes down, and has a fibrous attachment usually to the first rib. So it makes an extra sort of curved rib around the top of there and then when it is present, the brachial plexus and the neurological structures are draped across the top of that extra bony structure there. And that they can kind of get both strong across the top of that cervical rib, in this variation of thoracic outlet syndrome. And that’s what usually sets off those symptoms for individuals.
Til Luchau:
Can I make a little distinction there? [crosstalk 00:11:16] I’m sorry to be like your editor to jump [inaudible 00:11:19]. Just because there is a higher incidence of brachial and cervical plexus symptoms and people with cervical ribs but just because you have one, doesn’t mean you necessarily are going to have problems too.
Whitney Lowe:
Very important distinction, yeah. And I would also comment, just because you have a cervical rib, and you have neurological symptoms, doesn’t mean you have to have that rib taken out. Because that is a frequent treatment – surgical removal of the cervical rib. But you’ve had it your whole life and you’ve been able to get along without having the surgery for a long time. So maybe there’s other strategies ways to do that. [crosstalk 00:12:06].
Til Luchau:
Most cervical ribs are asymptomatic too.
Whitney Lowe:
Yeah, so just know it could be a factor that is a possibility. And if it’s there, we’ll try to work with it in a variety of different ways that we can, so that is the first variation of the neurological group. The second one being compression of the brachial plexus or neurological structures between the anterior middle scalene muscles. And this was, I know described by a number of different people it was listed, I remember seeing it in Janet Travell’s book many years ago as their Latin term, scalene as anticus syndrome or the anterior scalene syndrome. So a compression of those neural structures between the anterior middle scalene muscles in the cervical region.
And this would be the area that we refer to as the cervical outlet. So that would make sense for those two variations to be the neurological cervical outlet variations. But again we probably won’t hear that term mentioned that way for a while. So if you cause a little bit farther down the pathway of those major nerve trunks of the brachial plexus, the third variation is the costoclavicular, what’s called costoclavicular syndrome. In many instances, this is compression of those structures between the clavicle and the first rib. So that is right near the true thoracic outlet but it actually isn’t the nerves coming out of the thoracic outlet. It’s just nearby there’s compression of those between clavicle and first rib.
Til Luchau:
Wait a minute, it’s not the neurovascular bundle, you’re saying getting compressed?
Whitney Lowe:
No, it is the neurovascular bundle, it’s not coming out of the thoracic rib cage.
Til Luchau:
Right, it’s already the bundles are out of the quote. Inlet or outlet it’s already out of the periphery of the body a little bit far enough is the clavicle and that’s where you might get caught up.
Whitney Lowe:
Yeah, exactly. And then our fourth of those neurological variations, often referred to as pectoralis minor syndrome. This is compression of that group of structures underneath the pectoralis minor muscle against the upper rib cage. And this is frequently referred to as pectoralis minor syndrome. So those are the four neurological variations and then we have the vascular variations as well.
Til Luchau:
Yeah, now, just a little footnote on the vascular stuff a lot of PTs are taught. Well, there’s a pretty good body of evidence that physical interventions can help a neurogenic kind, either exercise or stretching or manual therapies. There’s a bunch of massage therapy research it is even, but a lot of PTs are taught because there isn’t much evidence of success around truly the vascular ones. That there are a lot of PTs that won’t refer to surgery, if it’s vascular. No, I don’t know if I’d be that fatalistic about it but we can do a whole lot around all four of those neurogenic variations you described, Whitney.
Whitney Lowe:
Yeah, I think so, I think there’s a lot of possibilities there. The more you understand those different possibilities, and we’re going to talk about this a little bit more as we look at how to evaluate some of these things. But it’s not always easy to figure out which one of those is really the primary problem or if there is just one, or might there be more than one, which is frequently the case.
Til Luchau:
I know you and I are kind of layering in our different ideas here. What do you think about me giving a movement example for each one of those? Is that too early in our discussion?
Whitney Lowe:
No, let’s do that. Since that’ll be fresh in our mind, we just talked about these variations.
Til Luchau:
Okay, so like as a little review, the cervical rib, I think you have that noted there, Whitney, is the true neurogenic?
Whitney Lowe:
Yeah.
Til Luchau:
Skeleton is the way to describe it. For a cervical rib, well, I actually don’t have a really good test for that but brachial plexus might be a side flexion of the neck, perhaps. What do you think, Witney? Will that be a movement? [inaudible 00:15:51]
Whitney Lowe:
That would be most likely. Now, again, that’s going to do that more if your arm is out to the side with the rest of the major part of the neural structures down the upper extremity or are already pulled taut from their lower end. And then you pull them taut from the upper end across there.
Til Luchau:
Thank you, Whitney, maybe we could see me do that on our camera. But that is part of that one that say, stretch your arm out and tilt your head away from that, if that makes your hand go numb, or gets some of those tingling symptoms and stuff. Maybe it’s neurogenic, maybe cervical ribs, cervical nerve root. Again, these are not diagnostics, I should just put in that huge disclaimer too. These are working hypotheses for where you might start your work. These are good guesses for bodyworkers. For the second type anterior scalene syndrome, that one’s probably going to light up the most with head rotation, that head neck rotation looking away because of the scissoring effect of that anterior medial scalenes. Where there just kind of a little triangle there that closes around those nerves when you turn your head. And again, it’s going to be much more sensitized, if you stretch your arm out on the side that you turn away from. Would you agree?
Whitney Lowe:
I would, and I want to just point out here to the importance in what you’re describing and illustrating there is a really important valuable lesson for people about understanding, the term is often referred to as neurodynamics. Which is the sort of biomechanics of the nerves in different positions of the body or the extremities, or whatever. And you can take a standard movement procedure that should stress a certain area, like you were talking about for the anterior scalene muscles. Turning your head slightly and possibly even a little bit of lateral flexion, if your arm is in neutral, you may not feel anything but if your arm is pulled out to the side, as we were talking about, now, you’re stretching the whole neural structures in there. And that makes that particular evaluation process more sensitive.
And that’s actually a really important clinical tool because you can use that to determine sometimes a level of severity. Like you start in a really neutral position that wouldn’t really flare something up, and then you have them bring that arm out to the side and pull it a little bit more. And if that really lights the symptoms up, you know okay this one’s pretty sensitive here to those just a little bit of extra movements.
Til Luchau:
That’s good. No, thank you. And I’m suddenly very aware that I’m kind of mucking about in your domain of expertise here. And that there’s so many very specific orthopedic tests that are done in precise ways to try to ensure their sensitivity, or at least up their sensitivity and specificity. I’m talking about really rough, quick movement guesses that you might do as a bodyworker.
Whitney Lowe:
Yeah, and to be quite honest, I think those are often more valuable than some of the orthopedic tests that have been written about and published in all the books a lot of times because everybody is an individual. And when we can tweak those little movement patterns a little and see what is it for you then really what’s the movement for you? Because the other thing to remember, everybody’s structure of their whole skeletal and muscular skeletal system can vary quite a bit. In terms of, is that a wide open pathway in that particular area? Maybe they got a really narrow area between the scalene muscles, but a really wide space between the clavicle and first rib and somebody else’s got the reverse. And so just the application of those tests in a vacuum without considering all those other things. Oftentimes, I think, where people get led astray and in putting way too much emphasis on some of them.
Til Luchau:
That’s great. So we had a side bending the head for neurogenic. We had turning, laterally flexing, stretching the arm for interscalene. For the costoclavicular your third type, the classic test there’s like weight carrying, carrying a heavy suitcase, if you can imagine that. That would pull the clavicle down onto the first rib there and might irritate the neurovascular bundle there. Or it’s forced inhalation, a really big inhalation could below the rib out from underneath the neurovascular space and compress it that way. There’s a lot of overlap here because scalenes are also activated in forced inhalation. So these are precise anatomical diagnostics as much as, again a way to [inaudible 00:20:07] working hypothesis.
Whitney Lowe:
Yeah and lastly.
Til Luchau:
Yeah, lastly. For pectoralis minor involvement, there could be a number of things there. And in our longer thoracic outlet class we teach it as anything in that region, especially anything that attaches to the coracoid process there with pec minor being a prime suspect. But there’s also coracobrachialis, there’s also a short head of biceps, anything in there could be part of what is essentially crowding or binding to that neurovascular bundle. That kind of loops around the pulley of the coracoid process. So the coracoid process is a little beak bony projection that comes forward from the scapula to the front of your body. Pec minor attaches there, so anything that actually activates pec minor, if that reproduces the symptoms, it’s a good clue that you got a zone sensitivity.
Whitney Lowe:
Yeah, and an interesting one about that particular one with the pectoralis minor and some other neurological involvements. That shows the importance of understanding some things about neurodynamics is if you can envision… There are some really good illustrations and again, I remember one in particular that really just made such an impression on me when I first saw this. It was also in Janet Travell’s Myofascial Pain and Dysfunction book, an anatomical image of the arm held in the abduction. And you see how those nerves [crosstalk 00:21:32]
So arm all the way, shoulder all the way out to the side is if you’re putting your hand up on top of your head. And that brachial plexus goes down, loops under the pectoralis minor and then has to come back up almost at 180° turn, to come back up in there. And that’s often when you have a pectoralis minor syndrome, lifting that arm up over your head is the kind of thing that will exacerbate those symptoms. Now, the interesting thing about this from a neurodynamic perspective when we’re trying to discriminate between different types of symptoms. That very same manoeuvre is often used to evaluate the likelihood of cervical nerve root involvement.
Because if you have symptoms down your upper extremity that are neurological in nature, and you do that movement and those symptoms get better. Meaning they dissipate, that’s often indicative of some type of nerve root involvement or something. Because if you don’t have problems in the thoracic outlet region, under the pec minor, you are bringing that whole upper extremity neural structure closer to the neck. So you’re really slackening the whole thing. [crosstalk 00:22:41]. Exactly, so it’s fascinating, it makes it worse in one situation, it makes it better in another situation. [crosstalk 00:22:53] some of those distinctions.
Til Luchau:
No, that is super important. And the other thing to keep in mind for any of these is that if you can reproduce the symptoms with palpation, with gentle pressure with your hands, that’s a really clear sign you’re under something. So if you can gently press around the coracoid process, and someone feels tingling on their arm, bingo, you got a place where the nerves are sensitized. Somewhere around the scalene zone too.
Whitney Lowe:
And that’ll be a really important one when we talk a little bit about treatment methods too because it is really important when treating neurological problems to not do things that make it worse. So then we got to remember there are a couple places here in this thoracic outlet region, especially the area between the scalene muscles. Where those nerves are really superficial, and they’re close to the surface. So it can be easy to irritate them with your palpatory explorations or your treatment as well.
Til Luchau:
Well, and then there are the questions like, isn’t everybody sensitive? In your scalene if you go digging around in there you’re going to get some numbness on all of us. I guess, it’s a question, I don’t know, you got an answer for that one Whitney before I try mine?
Whitney Lowe:
No, I’m saying you go ahead and tell me what you’re going to…
Til Luchau:
I was going to say, keep that in mind that just because you can provoke symptoms doesn’t mean there’s a pathology also. But for sure, it’s level of sensitivity. And is it just like what they always feel? That’s a pretty good clue you’re under something relevant and how much pressure all that kind of stuff is. Just really a little bit of touch, a little bit pressure, yep, that’s pretty sensitive.
Whitney Lowe:
Yeah, just something came to mind here, when I was a kid, I don’t know, probably eight or nine years old or something like that. I used to wrestle with my dad all the time, and I remember I had seen some kind of wrestling show or something like that. Where some guy grabbed this other guy right over the top of the clavicle and just really held on to it really firmly. And the guy passed out or something like that. And so I just thought I was going to imitate this whole thing and grabbed my dad’s shoulder and I can just dag my fingers in and he was laughing because we were playing a lot. But then I made his arm go numb for like two weeks, I learned how to figure it out later on. Well, I probably did some intermittent damage to that brachial plexus [crosstalk 00:25:12].
Til Luchau:
Brachial plexus area.
Whitney Lowe:
That’s not a treatment I advocate any longer.
Til Luchau:
Okay, good.
Whitney Lowe:
Yeah.
Til Luchau:
Good deal, well, and then there’s the double crush idea. [crosstalk 00:25:26] Well, we going to talk about controversies, but the idea is that in a number of people you have more than one spot, more than one place where that nerve track is unhappy. And according to Joe Gibson, who knows a whole lot about this stuff, she says that somewhere between two thirds and three quarters of scalene treatments also have pectoralis minor compression. So you end up with multiple spots along the pathway.
Whitney Lowe:
Yeah, and this is another good reason to sort of… It may sound a little glib, perhaps. But I always tell everybody to treat this person as if they all exist. Because most of the time there is a likelihood for multiple locations of neural entrapment or something like that. And treat them as if all of those things are there and address all of them because they could all be a potential factor. And there aren’t really definitive methods to exclusively say, this one is here, but this one’s not. So there’s not that degree of exclusivity that we have for our evaluation procedures. It is helpful to be able to identify some things differently if we can, just know we can’t be, it’s not rocket science.
Til Luchau:
Well, so we’ve been talking about a whole bunch, is it time to ask the question, is it even a thing?
Whitney Lowe:
Well, let’s do, yeah so we talked about what we think it is for those people. I think there’s a lot more of it than there is talked about that. What about it not being a thing?
Til Luchau:
Oh, I assume it’s a thing. That was my softball to you. I think it is a thing.
Whitney Lowe:
Here’s why I think that comes about in terms of the literature saying like, they don’t even think it’s a thing. It’s because it’s so poorly defined. And people have such a difficult time identifying what’s going on with them. And this is where I’m going to make a real… I’ll just put a caveat out here blatantly by a statement that I think a lot of the practitioners who treat musculoskeletal disorders are not thorough in their musculoskeletal evaluation process. And that’s why they don’t find it, so that’s why I think there’s some dilemma about how accurate that is. And that doesn’t mean necessarily not just their physical examination process.
A lot of it is even delving into a history deep enough to really identify movements that irritate, movements that aggravate, movements that relieve, all those kinds of things. Those are important key factors to help us identify things that I think so many of our practitioners are so pinched for time with each patient. They don’t go into the level of detail to pull that kind of stuff out. So you’re going to miss some of those, you’re going to miss a lot of them actually.
Til Luchau:
And it’s for time I like that, or unclear about their domain or their focus. “Do I need to give this client a full body session? Are they wanting to relax? Or am I giving extra attention to this numbness and tingling in their hand they just told me about?”
Whitney Lowe:
Yeah.
Til Luchau:
Those kinds of questions. [inaudible 00:28:36] a bigger question there, it’s about what makes something a thing? That I’m not trying [inaudible 00:28:41]. In terms of it being a precise diagnosis, no, I can totally go there on the questioning that. Is it a therapeutic narrative that can give some usefully strategic pointers? Yeah, in that case, it’s a thing for me.
Whitney Lowe:
Yeah, absolutely. And another important thing that I want to just touch on here, anatomically, that often doesn’t get addressed as much but is a valuable one. When people come in and say, “I’ve got pins and needles or tingling in my hand.” Lots of individuals immediately their mind just jumps to, “Okay, this is a carpal tunnel issue or something like that.” Which because it’s the popular one that everybody hears lots about, but an important distinction with thoracic outlet syndrome is the vast majority and not all of them, certainly. The vast majority of those cases do tend to involve the ulnar nerve distribution much more so than the other major nerves on the extremity. Either median or radial nerve distributions, and that’s because the nerve roots that come off the lower portion of brachial plexus.
Til Luchau:
Wait a minute, don’t tell us. Let’s make sure that I know what that means. Then you’re talking about numbness that would be in my little and ring finger say, as opposed to thumb and pointer finger?
Whitney Lowe:
Yes, thank you for the clarification there. So outside the edge of your hand, last two fingers, pinky finger and ring finger [crosstalk 00:30:10] is this sensory distribution of the ulnar nerve, yeah. And so across the rest of the palm, the other two fingers and the thumb on the palm side are predominantly the median nerve distribution. And then it wraps a little bit around the thumb and the radial nerve is on the backside of the hand.
Til Luchau:
And just to diverge further, I diverged further from what you’re saying, the median nerve is responsible for a lot of what people call carpal tunnel syndrome, or at least it’s thought to be. And so those tend to focus more or less, thumb and forefinger, but now you’re saying somebody that comes into my practice tingling in my hand, and when I ask or investigate it’s little finger and ring finger? Aha, fair enough.
Whitney Lowe:
Yeah, right, not carpal tunnel syndrome. So and it could be… There’s a number of different potential locations of ulnar nerve entrapment throughout the upper extremity, which is a great topic for us to tackle one day and I’ll probably get back to. But the neurological thoracic outlet variations tend to have a lot more symptoms in ulnar nerve distribution than in the other two. And that mainly has to do with the architecture of the brachial plexus.
Til Luchau:
Okay because the median nerve also arises from the same roots, right?
Whitney Lowe:
It does, more fibres to the ulnar nerve from the lower portions of the brachial plexus, or the lower nerve roots.
Til Luchau:
And so that’s why if it’s ulnar nervous, it’s more likely to be thoracic outlet because it’s typically those lower segments that involve more?
Whitney Lowe:
Yes because others lower segments, if you think about it, the lower those segments that are coming off the last cervical vertebra, are the ones that are going to be most inferior in the group, or the bundle of nerves that make up that plexus. And so they’re going to be the ones that are going to be dragged across that cervical rib the most. They’re also going to be the ones dragged across the upper rib the most, pinched between the clavicle and first rib. And they tend to lie against the upper rib cage with more pressure than the rest of the brachial plexus. So it does tend to get those variations of the lower brachial plexus more involved.
Til Luchau:
Fascinating, that’s really cool. So they’re starting lower, they might have to do a sharper bend to get around those things in the thoracic outlet?
Whitney Lowe:
Exactly.
Til Luchau:
And then if I just put my arm up to the side with my thumb up yeah, like dermatomal position. I don’t know if it’s a factor or not but then I raised my hand over my head, it’s like running around the track. The outer lane has to go further, I don’t know if that’s why those axons get irritated more, perhaps?
Whitney Lowe:
Yeah.
Til Luchau:
But they’re, even in the axilla, even in the pec minor, there’s theoretically a slightly longer pathway they have to take.
Whitney Lowe:
Right, and then if you think about that position, where you’re frequently reaching up like you just did when people can’t see on your camera, you were reaching up towards your head as if you’re scratching your head. Your elbow is flexed at that point, and there’s a lot of tension on the ulnar nerve as it goes through the cubital tunnel. And the cubital tunnel shrinks and gets smaller in elbow flexion as well. So all of this is back to your double crush point, you’ve got multiple locations along there, where you might be potentially irritating that ulnar nerve more significantly.
Til Luchau:
That’s so cool.
Whitney Lowe:
So, yeah that’s why it’s important for us to really zero in, I think on a lot of the symptoms from what our clients are telling us and experiencing because it really helps us narrow down where we want to try to focus I think.
Til Luchau:
Well, I got a couple miscellaneous trivia points.
Whitney Lowe:
Let’s hit them.
Til Luchau:
And then maybe we’ll do the stretches too, I’m going to put some hands-on techniques in the handout. There’ll be an outline of what Whitney and I have talked about and I realized what the URL will be. So I’m going to announce it at the end, the URL is going to be a-t.tv/ttp-tos, you got that right? -a-t.tv/ttp-tos. It’s going to be in the notes, don’t worry.
Whitney Lowe:
I like Morse code. [crosstalk 00:34:06]
Til Luchau:
Forget it, go to the show notes you’ll get it there, but anyway, the trivia points 71% of cases tend to be female of a thoracic outlet. Actually, the average number of physicians visited for what turns out to be a thoracic outlet problem is six, people seek out a lot of treatment before they forget to figure it out. Go ahead, Whitney.
Whitney Lowe:
Can I back up a moment here? Do you have any input or rational ideas on why they are a very skewed percentage toward female instances with this?
Til Luchau:
It’s such a good question. And it’s so true for so many conditions, isn’t it? I don’t, in some conditions there’s clear anatomical differences between the gender sexes, but I don’t know the rationale for this in females and why it’s [inaudible 00:35:00] females. So yeah, a lot of visits to doctors average length of time before it gets diagnosed is five years. So that’s the idea that a lot of people can’t get it figured out, which leads people to even wonder, is it a useful medical diagnosis? Because a lot of those people end up with symptoms in their head like headaches or chest pains or chest tightness, shoulder issues.
And there are stories of lots of unsuccessful surgeries, that eventually, the issue gets resolved when they got their thoracic outlet symptoms addressed. So it can be a challenging problem for someone to have. And just a lot of understanding and sympathy as well as a big open mind or on that too because it’s really hard sometimes to pin it down as this is that. It’s really a case of what activities in the patient’s part or client’s part, what treatments we do tend to seem to help.
Whitney Lowe:
Yeah.
Til Luchau:
In most… Sorry, go ahead, Whitney.
Whitney Lowe:
No, go ahead and finish that point because I want to come back to something. Because I was just realizing in our discussion, we have emphasized and talked a lot about symptoms from the neurological variants. And I want to make sure we just at least touch base on a few of the things to watch for in those other vascular ones as well. So go ahead and finish what [crosstalk 00:36:21]
Til Luchau:
We have to use it, even that’s such a good lead in, let’s hear what that would be.
Whitney Lowe:
So yeah, just keep in mind with the vascular variants, that we’re likely to see a lot of those types of things that are relatively common with other vascular problems. For example, in an arterial involved one, you might see ischemia because there’s lack of blood flow down the upper extremities. So there’s going to be possibly some ischemia associated with that, there may be-
Til Luchau:
What I see that as a practitioner, how would I know?
Whitney Lowe:
So a person’s limb, maybe looking at the comparison of their hands, one hand to each other, one looks a lot wider than the other, more pale than the other yeah, so color evaluation. And then that also goes over to the venous side as well because if there is a venous blockage and that means there’s a blockage of return, we may see more edema. Or possibly a little bit darker coloration to their limbs because of the lack of venous return there, so you’re getting an accumulation of blockage of venous flow on the upper extremity. So those could be certain indicators of vascular problems there. There’s pain that may result just simply from lack of appropriate vascular supply to muscles that can be a factor there.
Other types of vasomotor indications with the… Sometimes, things having to do with the little hairs on your skin that are not acting the same on side to side, those are kinds of little things that could be factors. So these are some of the other things to-
Til Luchau:
Pair some of them at the same side to side, I hit that?
Whitney Lowe:
I know, yeah get it to behave correctly.
Til Luchau:
[inaudible 00:38:06] you get goosebumps on one side, but not the other? That’s really-
Whitney Lowe:
Yeah, they’re pseudo motor responses there. And so if clients express things like sensation of fullness or thickness, or some kind of ambiguous descriptions of them just don’t feel the same on each side. That might be indicative of improper vascular movements in there. So those are some other things we just want to make sure we don’t forget to look at when we’re talking about those different variations.
Til Luchau:
Sausage fingers, I got my sausage.
Whitney Lowe:
Yes, right.
Til Luchau:
That can be some other stuff too, but that can be a vascular thing, for sure.
Whitney Lowe:
Right, yeah.
Til Luchau:
Okay, great. That’s helpful. And then so, I got a bunch of trivia there but I don’t really… Let’s trivial that stuff. Should we do a movement or two for ourselves?
Whitney Lowe:
Let’s do, yeah let’s talk about movements in what we do about these kinds of stuff. So those movement things inside treatment.[crosstalk 00:39:05]
Til Luchau:
The treatment stuff I’m not going to try to explain over the podcast, I’m just going to put a picture in the handout, and refer you to some of Whitney’s great stuff in our courses as well. But I’ll put some specific techniques for the scalenes in the handout, but something you could do for yourself, or you can help your clients with escape side stretches, just take a hold of the bottom of your chair on one side. Let’s say it’s the affected side, hold on to the underside of the chair, yeah and then tilt your head away from that side. So you’re going to laterally flex the neck away from that side, move your head backwards, so reach for the back of the room with the back of your head and then look up.
So that’s going to be stretching a lot of stuff, including your scalenes, excluding the scalenes right around the zone where that thoracic outlet goes through. So being nice to yourself is making my voice a little bit hoarse, be nice to yourself and breathe and relax and then it’s about to come out of that too.
Whitney Lowe:
Do you have an advocation for length of time on holding these versus doing shorter duration stretches? And we got into discussion on another thing about this recently, what’s your sort of go-to on stretching durations for those kinds of things?
Til Luchau:
[inaudible 00:40:15] I get asked that all the time and that is the art, it’s like… There probably in the classical parameter that’s defined as one of the three sets of 10 or whatever, they pick some parameter. They guess it is probably good for the research, do the research, and then everyone adopts that as the treatment standard. The real answer is you want to desensitize things, I’m doing just enough that gets the brain’s attention, but not so much that it upsets my brain. So it might be just a couple seconds, or even more than duration, perhaps at that level is how intensely I do it. So let’s go ahead and do the other side.
So you can hold on to your chair, tilt your head now to the other side, helping out the other hand, tilting away the other side, move your head backwards, look up, breathe, and you get to come out of it when you’ve had enough. But you also get to decide how much intensity, so you’re getting just enough intensity to get your brain’s attention, but not so much to make your brain upset. And then about you come out of it and you’re going to repeat that and yeah, I think it’s valuable to repeat and I think it’s valuable to repeat it a couple times a day. Yeah, but if you want to… It’s more important to teach people how not to overdo it.
And if you have, let’s say, thoracic outlet symptoms of that tingling or numbness down that side of your hand, you could definitely do that in a way that kind of feels good. And you think, oh, the more I stretch it the better, no. It’s more like, the more your brain gets used to it, the more your brain relaxes around it, or perhaps the more hydration you stimulate in there, who knows, then better. So it’s like a gentle tickling more than of an aggressive stretching of that-
Whitney Lowe:
Yeah, so sort of physiologically want to keep in mind when you’re doing these kinds of things that you’re trying to encourage them to increase stretch tolerance to those contractile elements in there, but you’re not trying to stretch the nerves. And that’s sort of the important thing, the nerves don’t really like to be stretched. And so we’re trying to get mobility in those tissues that need some enhanced mobility and freedom of movement. But not do those things that increase neural irritability because another important factor to remember with nerve injuries is they are notoriously slow to heal. So if you’ve had this for a long time, it might take quite a while to get some restoration of good movement and decrease of symptoms there.
Til Luchau:
Oh, those are important points. And I can’t help and quibble a little bit, but you tell, you said nerves don’t like to be stretched. That’s such an important point to tell our students who are used to stretching things like a big joint stretch or something. But I would wonder if you would agree with me, if I be fine to say that nerves like to be stretched within a certain amount of a normal range. Like the sciatic nerve turns out of the length in five inches just along its normal because of range. Actually, I love that, but if it’s asked to be stretched more than it’s used to, that makes it pretty unhappy.
Whitney Lowe:
Yep, I’d say that’s an important clarification. I’d also make the clarification if we can between stretching them and mobilizing them in some instances too. It’s really important to make sure nerves are mobile, and sometimes that might involve applying tensile load to them to make sure that they are fully mobile. But yes, as long as… When we talk about stretch, stretching within their safe parameters, that’s a good distinction so thanks for that.
Til Luchau:
My best metaphor for myself, and please forgive me for this is when I was a kid, our backyard, we would irrigate it with floodwater and all the earthworms would come crawling up out of their holes. Alright, so there’s a bunch of earthworms kind of gasping for breath and are half out of their holes. And we would go gather them up because they were so cool, I’m talking like five years old. If you pull the earthworm too quickly, they’re unhappy, bad things can happen, but if you go really slow with those worms, you actually have a pet, you have a new friend. So it’s like that with nerves, nerves like to be coaxed, to glide and move if you’re just tugging on them, uh-uh (negative), don’t do that.
Whitney Lowe:
Yes, yeah a good distinction there, yep.
Til Luchau:
All right, so pec minor? Should we talk about that?
Whitney Lowe:
Yeah, for sure.
Til Luchau:
If there’s some pec minor symptoms like raising the hand over the head, the abduction evokes the symptoms. There’s some interesting research Whitney, and in fact, the reference I had in my handwritten notes there’s low et al., 2011 that [inaudible 00:44:45]. Low et al., 2011 apparently did some work around the efficacy of different physical treatments. And they found that the doorframe stretched, like putting your hands on a door frame and leading into it, made the biggest change in length to the pectoralis minor out of all the different physical therapy treatments they were studying.
But a lot of people find that almost too much and that you can get a backlash by over stretching it that way too. So some PTs are teaching more of a corner stretch, where you walk into the corner, put your hands on the two opposing walls at about shoulder distance, and gently lean into the corner. That’s a very gentle kind of pec minor stretch.
Whitney Lowe:
Yeah, and I would also call attention to the fact that many of these stretch positions and movements that we’re advocating are very similar to many of the positions that are used in a lot of our evaluation procedures. And what we’re trying to do is we’re trying to move that point farther down the road of what you can do in the direction of what is it that causes some degree of irritability. So, especially with neuro problems, a lot of times what we call a muscular stretch, you can tell somebody, “Oh, go ahead and stretch and stretch into this.” Like you can say, “Oh, yeah just breathe when you feel that discomfort, go ahead and breathe into the discomfort of the stretch.” And this is the point at which that nerve may not be so happy about pushing that degree of the envelope somewhat. But we are going in that direction to move it more gradually increase that capability for it to move into those directions.
Til Luchau:
Capability for to move, and then also the capability of the brain to tolerate that or even enjoy it.
Whitney Lowe:
Yes.
Til Luchau:
Like David Butler saying like, “Tell the joke there, get them to position and tell them a joke.” Just recontextualize their neurological experience.
Whitney Lowe:
I like that.
Til Luchau:
Yeah, go ahead.
Whitney Lowe:
I’m terrible at remembering jokes, my clients are probably like, “You already told me that joke, that was a foot joke.”
Til Luchau:
All right, you’re like-
Whitney Lowe:
[inaudible 00:46:42] from brachial plexus.
Til Luchau:
You need your brachial plexus specific jokes, pec minor jokes something like that?
Whitney Lowe:
Yeah, right.
Til Luchau:
So we got the leaning into the corner, now here’s an interesting point… You said it can be like the hands-on assessments on the table of a fairly thick roll towel or a small round bolster or something under somebody’s spine? So your client is supine with their face up on the table, there’s a bolster, or rolled up towel under their spine, that allows the shoulders to fall back onto the table. Picture that? That’s a great position to essentially load the pectoralis minors and again, if it provokes symptoms, go easy around it. But if it just starts to light them up a little bit, have someone breathe and relax a little bit, to get them just to start mobilize and reset the reactions to those kinds of sensations.
Whitney Lowe:
Yeah, and I would also call attention to this. What you’re describing there is a really good one because I know I’ve had a number of people who have these types of symptoms as an upper extremity shoulder/cervical region, brachial plexus problem. Who says once you put them over in a position supine on a flat massage table like that, start getting symptoms down their arm. And all it takes is a little rolled towel and you’re moving it, just a little bit to try to find what is the position that’s going to slack in that brachial plexus a little bit. So that’s a nice little trick that can help decrease those symptoms for all kinds of things in different positions.
Til Luchau:
Yes, that’s important, you’re talking about actually relieving the symptom, or helping someone be more comfortable on the table, that’s an important skill too. I was talking about provoking the symptom very gently with a towel draping around the table. Again, you don’t want to leave someone there too much, just like you don’t want to be doing that leaning into the corner stretch too long, too. If I forgot to tell you to stop, stop that and come back to your podcast. Okay, so then, one important distinction along these lines is… It was Rosa et al., 2017, they studied this pec minor stretching really carefully, and said, “After an intensive regimen of six weeks of stretching, there was actually no change in its length.”
So, probably the effects we’re getting this fits with a lot of things we’re learning about, well, stretching and biomechanics in general is that, the effects might not come from safe physical or measurable changes in say, the length of the structures involved. But they do have an effect on pain and maybe it’s the tolerance of the stretch, maybe it’s getting used to those movements. Maybe it’s reminding your brain that those are okay, maybe it’s hydration, descending modulation. There’s lots of ways we’re explaining the effects, but I really invite you to tease out that point of view in your mind that says, I got to physically stretch this like a bunch of taffy and hold it until it’s going to stay there. That’s probably not what’s happening and there’s probably even more useful therapeutic narratives you could be imagining do work.
Whitney Lowe:
Yeah, and pectoralis minor is one of a few muscles in the body. I always found this to be interesting when we talked about this in our stretching episode, which I can’t remember the number of, but it was some time ago. When we get into talking about what is really happening with stretching tissues but when we talk about stretching muscles in different parts of the body, pec minor is one that’s very difficult to do that at all. It’s not surprising to me in this particular study, you mentioned that they didn’t find any change in the resting length of pec minor. Because it’s actually really hard to pull the coracoid process away from the ribs far enough to really cause a significant length change in that muscle. And to me, I think that’s one of the reasons why we see so much chronic hyper-tonicity in that pec minors because you just don’t have the available range of motion to do that.
And I would also make note to people to pay attention again here to anatomical things because I see people doing things where they’re advocating pectoralis minor stretching all the time. Where they’ve got their clients arm, raised up over their head and they’re abducting, they’re bringing their arm up all around and everything-
Til Luchau:
That’s the one where you [inaudible 00:50:48].
Whitney Lowe:
What’s that?
Til Luchau:
That’s one where you stand on the client’s elbow?
Whitney Lowe:
Yeah, that could be but remembering that the pectoralis minor does not attach to the humerus at all. So, you’re not really extending the length of that pectoralis minor, maybe a little bit with scapular movement but not much. You’re really going to get a way better stretch on that pec minor by lifting your shoulder up towards your ear and elevating the whole shoulder girdle because that’s what will pull the coracoid process away from the ribs more significantly. [crosstalk 00:51:23]
Til Luchau:
No, nice, and then we can think about the pec minor as being the un shrugged muscle. So when you pull your shoulders down out of the ears.
Whitney Lowe:
Yeah.
Til Luchau:
So that might be just a great little pec minor wake up, is like shrug and unshrug, pull your shoulders down that’s pec minor being both eccentrically and concentrically engaged. And I’ll put up some hands-on techniques, they do not involve standing on your client’s elbow or whatever, that was a joke. Please, [inaudible 00:51:52] of that.
Whitney Lowe:
I hope everybody understands that.
Til Luchau:
But I will put some gentle techniques, we are working with pec minor. In our narrative, at least leverage, say golgi tendon responses. So they’re looking at the neurological control over the resting tone of that pec minor as opposed to trying to say, physiologically lengthened is a connective tissue where neurologically relaxing its resting tone, at least in that point of view.
Whitney Lowe:
Yeah, good. Well, we hit on a lot of stuff. So we’ll put some treatment things in that handout to carry this on to the next little bit here. So anything else you want to wrap up with in summary here about [inaudible 00:52:34]?
Til Luchau:
Well, we covered a lot, so yeah let’s wrap it up. I think for the one point, if I was going to pull it up for summary is the provocation piece. That’s how we know we’re on track, if we can do a movement or find a place to work, or have an inclined position that gently being the big key, provokes some of that sensation, bingo, we found something relevant. And then we work with softening around that, not getting more aggressive, not trying to ratchet up to the next level of intensity, but actually ratchet it back to a level when someone can actually physically autonomically relax around it. So what about you, that was my summary point, provoked but yeah, wisely sensitively and the point there is to change the reaction around what you’re provoking will give you ideas to work on. What about you? How would you summarize, Whitney?
Whitney Lowe:
Yeah, so one of the things that I just wanted to kind of make sure everybody kind of thinks about is when we’re talking about these thoracic outlet syndromes, they are often highly complex and highly variable, and lots of different pieces of the puzzle going on. So make sure to really look at this whole big picture, put a lot of emphasis on history taking, asking really good thorough questions with people really delving into this. And avoid the temptation to really zero in on these special orthopedic tests that are oftentimes designed that a lot of people say, “Well, here’s how you find out if the person’s got thoracic outlet, you do the Adson Maneuver or the right abduction test.” And I think we tend to get off track by zeroing in too specifically on some of those kinds of things and missing the bigger picture. Like a lot of movements, Til, that you talked about, in the beginning of getting people to go through these various different movements, find out what irritates it, what makes it better, that kind of thing. Those are real key factors for us.
Til Luchau:
Awesome, thank you.
Whitney Lowe:
Yeah.
Til Luchau:
Look at that big picture and you’re not getting so detail-focused that you lose that big picture and joint. You’re just making me think, I’m sorry, I know I’ve already a summary, but this makes me think to the other issues in the body, like classically rotator cuff sensitivity can coincide with thoracic outlet symptoms. As you protect the different movements that can set up your scapula to be in a position or movement pattern where it gets irritated too. Keep that picture in mind as well.
Whitney Lowe:
Yeah, great. So lots of interesting and fascinating things to dive into with the thoracic outlet syndrome. And we’ll explore some of these things, maybe we’ll venture down the upper extremity look at some of these other neural entrapment problems that we talked about another areas too. As we look at a lot of other potential problems that may also… And this is one of the things we didn’t get into that can frequently be misunderstood to be or misidentified as a thoracic outlet syndrome when it’s all kinds of other things.
Til Luchau:
Or hypermobility, that whole question hypermobility?
Whitney Lowe:
Yeah.
Til Luchau:
Like a rabbit hole because there is some evidence that there’s like, I think it’s like 25%, there’s a crossover with people that have some, perhaps, some sort of hypermobility something going on.
Whitney Lowe:
Yes.
Til Luchau:
And it’s always a puzzle and manual therapists work with somebody who’s quote, hypermobility, is that really a thing?
Whitney Lowe:
Yeah, good. We would like to thank our closing sponsor today, which is ABMP. And ABMP is proud to sponsor the Thinking Practitioner podcast. So all massage therapists and bodyworkers can access free ABMP resources and information on the coronavirus and massage profession. abmp.com/COVID-19, including sample release forms, PPE guides, and a special issue of massage and bodywork magazine, where Till and I are frequent contributors. So for more information, do check out the ABMP podcast, which is a great one to listen to. Also, that’s available at abmp.com/podcasts, or wherever you prefer to listen there. So thanks again to the sponsors. And you can, as we mentioned earlier stop by our sites for the handout that we’ve got on this thoracic outlet show today. Other show notes, transcripts and extras that are over there as well. So we can have links to that you can find them off of my site at academyofclinicalmassage.com and Til where can they find that stuff from you as well?
Til Luchau:
Our site is advanced-trainings.com right at the top I think it says blog or podcast is right there. And then if you have questions, or things you want to hear us talk about, email us at [email protected], or look for us on social media under our names. Mine is my name, Til Luchau, how about yours Whitney?
Whitney Lowe:
Yeah, and mine is also the same, that’s Whitney Lowe there on social media. And if you will follow us on Spotify, rate us on Apple Podcast or wherever else you happen to listen, if it’s a conch shell you pick up off the beach and hear your podcast from there, we’ll be there as well. So thank you so much for joining us today, it will be great to be back with you again. And thank you all to listeners for hanging out with us again on this discussion and we will see you again here in two weeks.
Til Luchau:
See you later.
