Thoracic Outlet Syndrome
In this episode of the Unreal Results podcast, Anna reviews the relevant anatomy involved with thoracic outlet syndrome. Understanding the anatomy, especially of the spaces the neurovascular structures transverse, help to argue that the traditional standard protocol for TOS treatment and exercise prescription doesn't just not make sense but is the opposite of what would be best.
Anna shares the red flags to look for in assessing vascular TOS vs. neural, as well as provides insight on assisting a neurosurgeon and thoracic surgeon in diagnosing a unique case involving the phrenic nerve and diaphragm paralysis.
To quickly treat the subclavius muscle as a key spot in creating more costoclavicular space check out the Erb's point videos mentioned in the podcast on YouTube or Instagram.
To watch the visual demo of the boney anatomy of the thoracic outlet, be sure to check out this episode on YouTube.
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[00:00:00] Hey there, and welcome. I'm Anna Hartman and this is Unreal Results, a podcast where I help you get better outcomes and gain the confidence that you can help anyone. Even the most complex cases. Join me as I teach about the influence of the visceral organs and the nervous system on movement, pain and injuries, all while shifting the paradigm of what whole body assessment and treatment really looks like.
[00:00:26] I'm glad you're here. Let's dive in.
[00:00:31] hey there. Welcome to another episode of the Unreal Results Podcast. Today we're talking about thoracic outlet syndrome. Thoracic outlet syndrome is one of those things that, um, I feel like actually is underdiagnosed. Um, yes, I feel like it's underdiagnosed, especially positional, um, thoracic outlet syndrome.
[00:00:57] That can be really challenging. [00:01:00] Uh, for people that diagnosed, cuz you can't see it on, um, any diagnostic imagery because it only happens in certain positions. So, um, thoracic outlet syndrome. The most common locations for neurovascular entrapment can be in the inter-scalene triangle of the neck, behind the clavicle.
[00:01:23] So retro clavicular space, also called the costo clavicular space. So the space between the first and second rib and the clavicle. And then also another common spot is behind the peck minor. So, um, . You know, the majority of cases I'd say are probably, , neural more than vascular. But you can have vascular cases.
[00:01:49] It is common, like it's not uncommon. , I think in athletics I just tend to see a lot more neural problems than, um, vascular though, , a common. [00:02:00] Thing in active people, people who do repetitive, you know, flexion extension types of exercises is Paget-Schrotter syndrome. And that is when, , basically from the repetitive movement.
[00:02:18] In the entrapment, you get a, um, blood clot or thrombosis in the, uh, subclavian vein. So that obviously can't be life-threatening, right? Any, any, any blood clot could lead to pulmonary embolism and, and death. So it's like a big deal, right? So understanding vascular symptoms is important. So things like, , discoloration of the arm, , tingling, change in temperature, changing color of the arm.
[00:02:49] Swelling, right? Like, uh, blood flow, not being able to get like return, right? Cuz it's a usually vein, uh, compression. And so, so you end up with a pretty swollen. [00:03:00] Veins that could pop out. Obviously pain is often part of it. Uh, sometimes, um, both vascular and neuro entrapment people will complain of kind of like a dead arm feeling.
[00:03:12] Um, so. . So that's, so, you know, so that's one like big red flag, differential diagnosis sort of thing to pay attention to. Um, the rest of them that tends to be neural. These are, , ones that, like I said, don't get diagnosed very often. Oftentimes they're positional. What I wanna talk about today is, not just the anatomy.
[00:03:34] We're gonna take a quick look at the anatomy, but I also want to talk about, um, the implications for treatment because, . Once you understand the anatomy and once you understand what's happening on the entrapment, it's sort of, , mind boggling what the common treatment options are. So if you were to go to YouTube and you would Google [00:04:00] or search on YouTube, thoracic outlet syndrome exercises.
[00:04:05] The majority of what you would see is, neck stretches and scapular stability exercises. Specifically kind of like old school scapula stability. Well, old school, depending on. , depending for me, old school scapula stability being a lot of like posterior scapular work, like scapular retraction, like Ys Ts, LS, Ws, those things.
[00:04:43] And it, it just kind of makes me laugh because. I don't think understanding what's going on. Is that hard to understand. Right. So the nerves, they come out of the nerves and the vascular structures. So let's just [00:05:00] talk about the nerves first, since they're kind of on a different path a little bit. So the nerves come out of your neck from C 4, 5, 6, 7, 8, and they.
[00:05:16] form the Brachial plexus. As they travel down out of the neck, they come through the scalenes between the scalenes, that's that first entrapment site, the inter scalene triangle.
[00:05:28] So this is a super common spot. To get some entrapment because our scalenes often are pretty tight from, um, being sort of shallow breathers from just carrying tension in our necks. I'm sure in many episodes we'll talk about, um, the nervous system and just it's, you know, it's no wonder that people.
[00:05:52] especially as we age, we tend to have more like neck and shoulder pain, and that's just because a lot of neck and shoulder pain [00:06:00] is actually more from our nervous system and more from, um, our visceral organs than anything else. So that's a talk for another day. But, , all that, all that input just reflexively the muscles of the neck start to stiffen up.
[00:06:14] Plus, as we age, you know, the joints of our neck get. You know, start to move towards arthritis and we have limited mobility, so that alters all of those deep, stabilizing muscles too. And then add on all the, you know, poor posture we have looking at our devices all day long. Those kind of things, right?
[00:06:36] So we know the many reasons why the scalenes might be short or tight or not so, responsive to eccentric and concentric, balance, right? So when that happens, sometimes those nerves get, , sort of strangled as they come through that, right? So they have a entrapment site there and that can, [00:07:00] um, cause a lot of symptoms cuz that's pretty high up in the brachial plexus.
[00:07:03] So it's gonna affect many of, of the nerves. . So then as it travels out of the inter scalene triangle, it has to go behind the , clavicle and under the clavicle as it goes. Then under the pec minor, this is through the clavicular pectoral fascia, , into the upper extremity. And so those are the other two sites.
[00:07:32] around that same area. So, top of the thorax, the thoracic inlet or the thoracic outlet. Right? What, what, what it's called, . The, uh, blood vessels come out of the heart. A couple go up the neck right into our, um, neck and head, and then they come out and curve around. And then at that point, when they curve around, they're like, subclavius artery vein.
[00:07:59] And then as [00:08:00] they go past the clavicle area, they become our axillary artery vein, and then into our arm, our brachial artery vein. So the area of entrapment that often we look at when it is more of a vascular thing is, more. Standard costoclavicular space. ,
[00:08:26] Now there's other, in that sort of inter scalene triangle area, it's sort of is similar to just the. Supraclavicular Triangle, which also contains our vagus nerve. It contains our phrenic nerve, which is a cranial nerve and a cervical plexus and brachial plexus nerve.
[00:08:47] And then, our carotid artery, our jugular vein, right? So there's some other important structures. Our thoracic duct, especially on the left side there, you got the thoracic [00:09:00] duct. On the right side, you just have sort of regular lymph structures. So that supraclavicular space is a space where there's a lot happening as well.
[00:09:12] So you. With that said, a little bit later I'm gonna share a unique thoracic outlet type case I had that has more to do with that super clavicular space than the traditional inters scalene triangle or, , retro clavicular space or peck minor. So the other anatomy we could talk about, so if we look at the muscle pec minor
[00:09:37] Its role. , it depresses the scapula and it tilts it forward. So anterior tilt and depression of the scapula. And that also, you know, it attaches the rib so it can be involved in accessory breathing as well. It gets a, it's one of those muscles that gets a bad rap [00:10:00] because it's associated with quote unquote bad posture.
[00:10:03] The retro clavicular space is interesting that people don't, clavicle kind of reminds me in the fibula, like a lot of people sleep on the fibula. A lot of people sleep on the clavicle. Thinking is like not that important. A little wild to me because the clavicle, I, I think, is almost one of the most important bones of the upper extremity because it is the bone that is the only bony articulation of the upper extremity, right?
[00:10:28] So that is the only actual joint holding our upper extremity to our axial skeleton is our sternoclavicular joint. So the, the clavicle, the collarbone, um, though we're quick to say it's no big deal when we have a clavicle fracture or no big deal when we put a plate in it or no big deal when we sprain our AC joint.
[00:10:53] Right? The other end of it, the acromial clavicular joint. Um, it's, it's always interesting to me because the [00:11:00] clavicle moves. It has two joints, it moves a lot. It needs to move in order to have full range of motion overhead as well. it's position. is so important for our neurovascular structures, right?
[00:11:16] And so this is this changed lens of view. Then when we view the body from an the realization that the organs, the neurovascular structures are the most important thing to the body, now we realize the clavicle plays a really important role of protecting those neurovascular structures. So the retro clavicular space, the muscle that.
[00:11:38] There too is called the subclavius muscle. Um, up until I, I started learning the osteopathic, visceral and neural manipulation. You know, the only time, the only people I ever heard talk about subclavius muscle were massage therapists. And so the subclavius muscle is this little tiny muscle that, um, [00:12:00] seems like it doesn't really do anything
[00:12:03] but you know, plays a role, is there for a reason and is another thing that's in that space that could lead to adding into this neurovascular entrapment. So the subclavius, it is like a little bit more medial. on the clavicle and it basically, uh, connects it basically sub right, right below the clavicle.
[00:12:29] And the, the subclavius muscle, it goes from the first rib and the, costo cartilage, the first rib and cartilage, and it, inserts on the subclavian groove of the clavicle.
[00:12:41] So, which is inferior service of the middle one, third of the clavicle. So yes, so I said it was the medial side of the clavicle. So it goes from that basically like medial part by the SC joint to about halfway it action is [00:13:00]depression of the clavicle and elevation of the first rib. So it, it does play a role.
[00:13:07] Fun fact about the subclavius muscle as well is the nerve that innervates, the subclavius muscle comes from the cervical plexus and. Exits out of Erb's Point. So Erb's point is a point, an area of the neck that I, , focus on for treatment because there's a lot of powerful nerves that come out of that area in one of them being the nerve to the subclavius.
[00:13:33] And, oftentimes when muscles are tight, not responding well to both eccentric and concentric. ranges of motion, right? It's kind of like stuck. It's because they're not getting very good information from the nerve that's communicating to them. And so if we take things one step back instead of just.
[00:13:56] Smashing the heck outta Subclavius to get it to relax, to [00:14:00] create more space in between the clavicle and the rib. If we actually go and treat the area where the nerve is right, we free that nerve and let it communicate it subclavius. Then the subclavius sort of lets go and creates more space under the clavicle.
[00:14:18] So Erb's Point, I have quite a few videos on, YouTube that I'll link in the show notes. And then also, on Instagram, if you search the hashtag #movementrevneural or #movementrevnerves, you'll come up with all the videos. That would include the Erb's Point videos. So, because it comes from the cervical plexus, it also shares, some of the input from the other nerves of the cervical plexus.
[00:14:47] Um, one of them being the phrenic nerve. So the phrenic nerve, our nerve that is most famous for innervated, the diaphragm, it's, it's less famous for, being a sensory nerve to the thorax [00:15:00] organs of the thorax and the organs of the upper part of the abdomen. So the, the peritoneum.
[00:15:05] So sometimes, the subclavius muscle will be tight because of irritation in the visceral organs, and sometimes meaning all the time. In fact, the Barral Institute refers the subclavius muscle as a witness to a visceral restriction. Okay, so. I wanna talk about actually this retro clavicular space because, um, sometimes it's nice to see a visual and obviously if you're listening on the podcast, you don't have a visual.
[00:15:40] But know, I'll be sharing a visual on my social media. And. , the podcasts are all on YouTube to video, so you'll see it. But basically if, if you take a model of the scapula and a model of the clavicle and you put that joint [00:16:00] articulation together, you'll notice that you know the, the medial part of the clavicle.
[00:16:06] Comes out anteriorly. So that's kind of the roundness we feel of our clavicle. And then it dives in towards the posterior as it articulates with the lateral side of the scapula being, um, at that AC joint. And this makes sense too, like if we look at it from the. Side, we would see a big V shape. And that V shape is because obviously the clavicle is on the front side of our thorax and the scapula is on the posterior side of orth thorax, and the thorax is round, right?
[00:16:40] So we've got some, some width of our body. that separates those two bones, right? So it's not that the clavicle is like directly on top of the scapula as they think a lot of people think about it. It's more of this like V shape.
[00:16:56] So,[00:17:00]
[00:17:00] once we are put that together, now you can see that space in between even the scapula and the clavicle from a height standpoint is not very big. So that's also, you know, another space that we can look to for problems. Not necessarily thoracic outlet, but um, can sometimes mimic. You know, is even, um, sub the subacromial space.
[00:17:25] So the space under the acromium, right under the acromioclavicular joint, that space is not very big. And in the, front here under the clavicle, we have to remember that we also have a rib. , a first rib and a second rib that live right underneath that medial half of the clavicle. So there's actually not that much space for those neurovascular structures to go from the, thorax into the upper [00:18:00] extremity.
[00:18:00] We can feel this. It's the groove. Basically, if you bring your shoulder blade forward, it's the groove, right? It's this like line. This diagonal line that makes our armpit right, it's the line that leads us to our armpit. Basically, that is the line that your neurovascular structures go down through. So, um, freeing up that space is important.
[00:18:24] So, n now, now that means we gotta talk about, and this is what I talked about in the beginning, saying that the, um, treatment exercises that are often given to people for thoracic outlet, why it doesn't make any sense.
[00:18:41] We don't need exercises to bring us into thoracic extension and bring us into scapular retraction and depression, because that actually creates less space in the retro clavicular space [00:19:00] that narrows it even more. Not to mention that it takes the pec minor. also stretches it out, which theoretically, maybe it is a good thing if the pec minor is tight, but I don't know about you.
[00:19:16] If something is tight, going to stretch it, especially if there's a space behind it is just going to make that space even smaller and compress what's underneath even more. , right? So you have to not think about only what's happening with the muscles. You need to think about what's happening with the neurovascular structures.
[00:19:38] So when we do scapular retraction and downward rotation, when we're doing our scapular stability classics, , we're actually exacerbating the entrapment and the compression and the overstretching of the nerves. [00:20:00] And the vascular structures. And so what needs to happen is we need the opposite. We need to get the shoulder blade to move forward on a round ribcage.
[00:20:10] On a round thorax. So we need to restore the thoracic curve, right? So restore our curve, especially when you think about thoracic outlet syndrome in an active person, right? In athletes, this is who I deal with mostly. So many times people are stuck actually in thoracic extension, people in a swayback posture, which is really common for, I feel like almost everybody, but definitely the lay person.
[00:20:40] People who are in a swayback. You think they have. Thoracic kyphosis, but when you get them out of their sway back, what you see is they're kind of flat in a thoracic spine. And so restoring the thoracic curve is so important. You know, the, [00:21:00] the scapula lives on a curve. The scapula loves a curve. The scapula is more stable when it has a curve to move on and move into upward rotation and protraction with..
[00:21:13] So, and that's, that's what we need to restore and. oftentimes too, when we restore that flexion and when we restore the mobility of the, scapula, we improve breathing mechanics, and then therefore, the scalenes also often relax and cause less entrapment at that first space too. So instead of doing.
[00:21:46] Things like Ts and Ws, and prone As or prone swimmers even. I would do closed chain [00:22:00] scap pushups. I would do sideline scapula stretches into upward rotation. I would direct manual therapy to the rhomboids, to the leavator scapula, to the mid trap. area, I would facilitate function of the upper trap because if we look at our clavicle mobility, we want the clavicle to be elevated and protracted to give more space in that cost clavicular or retro clavicular space.
[00:22:33] And so I like to start people just. , getting to know their clavicle and then learning how it moves. Usually guided by what's happening at the SC joint, and that usually often frees up the scapula. Sometimes people's scapula are so glued to their back though because of, um, they've done so many posterior exercises that we need to take a step back and free things up from the back.
[00:22:59] So I might [00:23:00] do cupping back there. I might have them roll on. Yoga tuneup, therapy balls. I might do, um, all the stretches, right? All the like protraction rounding stretches. So when you understand the anatomy of the thoracic outlet and the in possible areas of entrapment, now you see how you need to actually restore.
[00:23:30] a more, anterior tilt and a more protracted position, right? So, um, the scapula is funny. Again, like I said, the pec minor gets a bad rap. , um, because people felt like forward shoulders was bad posture. And I'm sure once upon a time for people it was, or, or there are some people, it is the problem, but you have to sort of look at the shoulder blade in a bigger picture of how is it sitting on you and knowing that, that what is the [00:24:00] normal position when someone has curve a.
[00:24:03] For the shoulder blade to live on is actually 10 degrees of anterior tilt. So oftentimes when somebody's having the entrapment side of the, uh, thoracic outlet at the pec minor it's not because they have too much anterior tilt, it's because they're actually too posteriorly tilted. Right. The scapula is like, Totally flat.
[00:24:24] If I place my hands on their scapula, on their back, do my hands, do I see that 10 degree tilt forward in my hands, or are my hands like basically vertical? If they're basically vertical, everything under that pec minor is getting strangled. No wonder they're having neurovascular symptoms in their upper extremity.
[00:24:43] So again, you have to look at things relative to the person in front of you and also understanding the anatomy. So that entrapment site is often from a pec minor being over lengthened. [00:25:00] And this is why I don't like labeling things as tight because this is something tight. Or is it feel, it's giving a sensation that is tight when you're stretching it.
[00:25:10] And that is not a reliable, um, quality to, you know, Bet on, so you have to look at the bones, where are they and what's happening? And how is pain provoked? How is pain eliminated? Can you get rid of their pain within the session? So, um, yeah, let's stop doing posterior. Work for people with thoracic outlet.
[00:25:39] Let's add in some pushing. Let's add in some scapular mobility. Let's restore a normal position of the scapula, which if you look at the clavicle should be the AC joint, about 10 to 15 degrees higher than the SC joint or about an inch to an inch and a half higher than the SC joint. [00:26:00] How many people do you look at and their clavicles are like horizontal to the ground.
[00:26:05] I say this for the pelvis a lot, and I'll say it for the clavicle and the shoulder blade. Neutral is not horizontal. Neutral is not vertical. Neutral is neutral. Neutral has to do with the curves of the ribs, the curves of the spine. We live on curves. Curves is what gives us support and absorption, ability to absorb shock.
[00:26:30] All right, so. Hopefully the next thoracic outlet syndrome person, you'll see one, you'll know the differential diagnosis to make sure it's not a life-threatening thing like Paget Schroetter, syndrome the, uh, thrombosis. And then second, instead of doing, the old standard protocol.
[00:26:53] You're going to restore this space under the clavicle, [00:27:00] addressing any tone in the subclavius, addressing any rib mobility things, and restoring the position of the clavicle and the mobility of the scapula that will more than likely get rid of the person's neurovascular. entrapment symptoms.
[00:27:19] So I promised you too a story about another type of thoracic outlet.
[00:27:23] I'll touch on quickly cuz I know I'm like running long on this podcast. Um, but anyways, I had this patient who came to me with half of his diaphragm, um, paralyzed and nobody could figure it out. And after a couple sessions, basically I was able to follow his locator test assessment protocol to the area of his super clavicular, like super clavicular area, which is right where the [00:28:00] phrenic nerve is.
[00:28:00] So that makes sense, right? Because his phrenic nerve wasn't working and I was, I was palpating along the phrenic nerve and I was right at this spot. And I was treating here and I actually, in order to get to this spot better, I wanted to bring his, um, shoulder blade. I wanted to create more space, right, more space in that area so I could allow my fingers to get in a little bit deeper.
[00:28:26] So I took this shoulder blade and I brought in in Protraction, and I used a towel roll and I propped him up. So he is laying on his back and I used a towel roll to prop his shoulder in protraction. and a little bit of elevation so I could get in that area where the phrenic nerve is. And when I did that, all of a sudden his breathing started to come back, like the function of his diaphragm came back.
[00:28:49] And I was like, what? And he was like, what? And so then what I decided to do was exactly what I just said to you is I was like, okay, like [00:29:00] something is, you're having like a thoracic outlet type syndrome, but it's entrapping your phrenic nerve. . I was like, I've never heard of that, but I don't see why it's not possible.
[00:29:08] It's in an area where things, anything can get entrapped anywhere. And so we focused our treatment on freeing up his scapula cuz his was like glued back there. And, um, it helped his breathing quite a bit, gave him some relief. But more importantly, it had me looking in the literature for, has anybody ever seen this before?
[00:29:32] And I was like thoracic outlet syndrome, but phrenic nerve. And I found this random case study from some doctors, I think at ucla, and they described something called Red Cross Syndrome. And basically there is one of these, um, branches from an artery that grows can grow across, right? It goes, um, I can't remember what artery it comes off of.
[00:29:56] If it's coming off one of the carotids or it's coming off the [00:30:00] subclavian artery. But either way, the artery is going, um, lateral to medial towards the neck, and it's like horizontal. So it was going across the. Phrenic nerve perpendicularly, and it had just grown over the phrenic nerve and started compressing it and over time completely kind of shut off the communication throughout that nerve, which caused paralysis of his diaphragm on the right side.
[00:30:27] And so , I told him what I thought. I sent him the article and he gave it to his, neuro doc and then she was like, oh my gosh, I think your therapist figured it out and sent them to a thoracic, uh, vascular surgeon. And he was like, I've never heard of that. I don't think you're right. But I'm happy to do surgery and go in there and figure out what's going on.
[00:30:50] And sure enough, he went in and that is exactly what happened. And the doctor was like, oh, look how smart I am. I just figured this out. Which of course made [00:31:00] me laugh cuz I was like, yeah, great job doctor. , but he had a double red Cross syndrome. He had two arteries going across the phrenic nerve and compressing it.
[00:31:11] So they ablated those arteries and, uh, stented the nerve and, um, gave it a little bit more space to let it bounce back and, and he's on the road to recovery. So, again, though, I only found that. Two ways. One, the, the, the locator test assessment protocol like led me to that spot, , so that was his body leading me to the spot, but then also understanding that with thoracic outlet and to create more space in the area, I need to bring the shoulder blade into protraction and elevation.
[00:31:44] That is when I happened to see the response in his body and was like, whoa, this is positional thoracic outlet.
[00:31:54] this is wild. I've never seen this before. And then that led me on the hunt. So,[00:32:00] when in doubt, never, never doubt going back to the anatomy and really thinking it through and not believing the standard treatment protocol because the standard treatment protocol does not work sometimes because it's not correct.
[00:32:15] When you look at the anatomy, it just doesn't make sense. And now we're looking at anatomy, not from a musculoskeletal standpoint, but from a neurovascular standpoint. So I hope this was helpful for you. Be sure to let me know and, uh, check out the show notes for all the resources I talked about. And, uh, if you wanna see the visual of the anatomy model, head to YouTube.
[00:32:43] Thanks for being here. See you next week.
[00:32:47]
