Thoracic Outlet Syndrome: A Love Story

You guys, I am so into thoracic outlet syndrome right now.

Thoracic outlet syndrome (TOS) is when muscles and other anatomical structures surrounding the brachial plexus nerve push on the nerve and cause pain in the areas that that nerve innervates. Simply put: a primary nerve that branches throughout your upper chest cavity, shoulder, and arms is pushed on and it causes a lot of muscular pain. Blood vessels in the same area can also be compromised, causing less blood flow and nutrients to reach those areas. For those of you out there with sciatica, sciatica is a similar condition but in the lower body, where the sciatic nerve is pinched (commonly by that pesky piriformis!), causing pain down the back of one’s leg.

Unanswered questions so far:

1. Where exactly is the brachial plexus? Upper body isn’t really that specific, Liz.

2. What are these anatomical structures of which you speak?

3. Why are you so into it Liz?

4. Why should I give a [insert phrase of choice]?

1. The brachial plexus is actually a complex network of nerves that share common “roots” at four of the neck vertebrae (C4 - T1 for those who are counting). It is a big tree trunk with many smaller nerve branches. What matters to TOS is not where the brachial plexus ends, but where it travels THROUGH.

The brachial plexus travels from the vertebrae, UNDER your collarbone, and DOWN through your shoulder into your arm. UNDER and DOWN are where it is most vulnerable to being compressed or pinched.

In the case of TOS, under the collarbone river and through the shoulder woods to Grandma’s house we...stop and cry due to debilitating pain.

You have two brachial plexii, one extending on each side of your body.

2. Three major anatomical structures that surround the brachial plexus nerve are the muscles of your neck and upper shoulder, namely: scalenes (group of three neck muscles that help you turn your head to the opposite side), pectoralis minor (smaller of the two large chest muscles that help you do push-ups and generally hold your arms forward), and the coracobrachialis (long thin arm/shoulder muscle that extends from the collarbone to the lower bicep. Helps you move your arm to the other side of your body, like saying the Pledge of Allegiance), and fascia. SO MUCH FASCIA.

A note about fascia. Fascia is the body’s shrink wrap. It surrounds and coats every muscle, tendon, and ligament. Simply put, it is the saran wrap to your brie wheel. The neoprene to your wetsuit. It keeps things so nicely held together and temperature controlled. But when one piece of it gets bunched up or wrinkled, all bets are off.

Clearly these are all very important and highly used muscles. However, all muscles need time off from the heavy lifting. And in our world of crouched necks and forward held arms for hours on end (see: typing, texting, driving, biking), they get a little cranky. They get inflamed. They get cramped in an amount of space that wasn’t meant for that much continuous strain and wrinkled fascia. They eschew the brachial plexus nerve needing “personal space.” Therefore, our brachial plexus goes ALL CAPS. And it is going to tell the upper shoulder, length of your arm, and pinky finger ALL ABOUT IT. (Methods used include searing pain, numbness, tingling, weak grip, and inability to give high-fives.)

3. I am into it because I had a client who was experiencing symptoms and couldn’t sleep through the night due to the pain. It was time that those muscles had a talking to. My A team massage techniques were helping but not getting it done! Research ensued. Marathon reading and YouTube video watching of physical therapy techniques, massage therapists’ recommendations, and myofascial experts’ explanations commenced. I learned about lifting these angry, vulnerable muscles away from each other and how to gently re-stretch and glide fascia back into place.

TOS and other nerve compressions are interesting because the exact things that make it worse are what our body decides to do first. Something hurts - clamp down. Something is inflamed - push harder. Additionally, the pain itself is misleading. The body areas that are screaming (upper shoulder, arm, hand) are the ones that are affected by the nerve, not the muscles that are chronically cramped and causing the compression itself (pectoralis minor, scalenes, coracobrachialis). So I have to approach it from a different angle. In the case of TOS, through the axilla (armpit). Providing additional space by not only moving and soothing muscles, but also re-educating the tissue to relax when it ISN’T being used. I’m really enjoying using these techniques on other areas of the body, too!

4. TOS affects you because it is easy to develop and manifest as something that it isn’t - general muscle pain or other serious problems like carpal tunnel syndrome or frozen shoulder. More importantly, it is easy to manage by using preventative self-care. Ice ice, baby! Tennis ball time! Rest and digest! Stretch out your pecs like the pec stretching door frame hanger-outer you are. (Given that a surgical intervention for TOS is removing the first rib, using a tennis ball a couple times a week doesn’t sound so bad.*) I often say that working on a muscle group when it doesn’t hurt is like talking to a rational human being about a problem as opposed talking to someone who is COMMUNICATING LIKE THIS.

So, breathe into it. Know that we are happy and here to help with your nerve and muscle injuries as they occur, and are even happier when you are able to take the reins and guide your body to heal on its own.

Next time...hip injuries! Or migraines! I can’t decide! (Or are they related...hmmmmm…)

*When the thoracic outlet cavity (space between collarbone and ribs) is compromised for a different reason (hereditary, birth defect, etc.) stronger interventions may be necessary. However, I strongly contend that drug and surgical interventions are not necessarily our best line of defense in many circumstances; and are not mutually exclusive from using massage/acupuncture/other less invasive techniques as treatment strategies. That’s a blog post in and of itself.

Another great resource: http://physicaltherapydatabase.blogspot.com/2011/04/thoracic-outlet-

syndrome-tos-part-i.html