Chapter 7: How Do They Diagnose It?

It is by doubting that we come to investigate, and by investigating that we recognize the truth.

—Peter Abelard

The Most Important Purpose of the Examination

In this chapter, I inform you what examination components are essential to a thorough physical exam.

This will allow you to check your doctor’s work to ensure there is sufficient information to lead to the correct diagnosis. In the next chapter, you will learn that this is not such an easy task. That is because there are about 30 different conditions that can cause symptoms similar to thoracic outlet syndrome. So, your doctor has to be a “Sherlock Holmes” detective of medicine to determine which of the 30 it is, sometimes in a matter of minutes.

The most important purpose of the examination is for you and your doctor to get a complete understanding what is causing this condition, so you can remove the underlying cause to reach maximum medical benefit.

What makes examining patients with a possible TOS more challenging is that you could have two, three, four, and even five of these different diagnoses at the same time, overlapping one another. This is called double, triple, quadruple, and quintuple crush syndrome.

Also, as you learned in Chapter 1, there are many different names for the same diagnosis of thoracic outlet syndrome. Confused enough? So are most doctors!

Thoracic outlet syndrome is one of the most commonly misdiagnosed, mistreated conditions in medicine. This confusion about thoracic outlet syndrome is why many of you are not finding relief from chronic suffering.

The Case History and Examination

The history and examination is a process by which your medical professional investigates your symptoms, together with the medical history, the physical examination, and diagnostic tests, if necessary, to make the correct diagnosis and devise a treatment plan.

Step One, The Medical History—

This is the back-and-forth conversation with your doctor. After your first visit, a good doctor will write a detailed accounting of the events that have possibly contributed to or caused your current condition. A lot of diagnosis comes from the history.

The Symptoms

A symptom is subjective evidence of disease that you feel but cannot see or examine. One important component is to determine the symptoms that you have. However, thoracic outlet syndrome is a little trickier. Symptoms of TOS can range from mild pain and sensory changes to limb and/or life- threatening complications (1).

Ten most common symptoms reported in patients with TOS include the following (2).

1. Numbness, burning pain, or tingling in the upper limb (98 percent)
2. Neck pain (88 percent)
3. Trapezius pain (92 percent)
4. Shoulder and/or arm pain (88 percent)
5. Collarbone pain (76 percent)
6. Chest pain (72 percent)
7. Headache at the base of the skull (76 percent)
8. Numbness, burning pain, or tingling in all five fingers (58 percent)
9. Numbness, burning pain, or tingling only in the fourth and fifth fingers (26 percent)
10. Numbness, burning pain, or tingling in the third finger (14 percent)

Auto Accident or Work Related

The timing of the symptoms is important (3). The first thing I always ask a patient is if they’ve had any traumas, such as a sports injury, an auto accident, or other acute trauma to the neck, back, or shoulder.

One of the key questions the doctor should discuss is what type of work you do. Usually the patients who have strenuous jobs, where they have to hold their arms overhead for long stretches or hold their heads in awkward positions, might develop spasms for thoracic outlet. Some of the occupations that have higher-than-normal incidence of TOS are dentists, electricians, hairdressers, and barbers.

Patients with thoracic outlet syndrome usually don’t do something strenuous to cause the injury or condition, but just the opposite. If the individuals read or watch TV in bed, have their chair leaning back at work or at home, work at the computer all day, or sit leaning back in the car while driving— these are histories that suggest the patient might have thoracic outlet syndrome.

These are the most common activities of daily life that cause strain on the suspension muscles that protect the thoracic outlet.

• Sitting for long periods of time at work in static positions at a table or desk.
• Sitting or lying in static positions with awkward postures when they’re at home, when working at the computer, or when watching TV.
• Leaning back in the bed, propped up with the pillows.
• Sitting in a recliner, watching television, or reading a book.
• Driving long distances with the seat leaned back.
• Doing work overhead, forcing the arms up for a long period of time.
• Carrying heavy luggage, book bags, purses, bags, backpacks, musical instrument, or all the above.

Any long-term leaning of the body to one side or straight back can lead to muscle contractions that can become chronic, muscle-spasm patterns, compressing the outlet.

Almost 100 percent of the time, I can predict exactly what side of the couch the people sit on when they watch TV from their symptoms. I’m usually about 99 percent accurate, which does startle them a bit, thinking that I’m looking through the window while they are watching TV. I don’t have to do that, as the compression related to thoracic outlet syndrome is predictable, based on the laws of gravity, physics, and nature. Science makes diagnosis predictable.

Symptoms on One Side or Both Sides Is an Important Clue

One key component of the history is whether the symptoms are on one side or both sides. Sometimes a patient will describe numbness or tingling pain shooting into the arm on one side and milder symptoms on the opposite side. When I hear this, my usual thoughts are that the patient has thoracic outlet syndrome. Herniated discs don’t compress both sides, only in extremely rare instances. I have only seen a handful in my 30 years of practice, and those were wide central (herniated up the middle), as opposed to on one side or another. Also, there is always a major traumatic force that herniates the disc up the center. If there is no recent trauma, I’m leaning toward a diagnosis of TOS.

Physical Examination

The examination is where doctors find the signs of your problem. A sign is objective evidence of disease that the doctor can see, feel, or detect with diagnostic tests.

The doctor should check for lumps, asymmetry, swelling, discoloration (like bruising), or evidence of trauma. The doctor should check the lymph nodes, reflexes, and cranial nerves. We are not going to review every assessment of a physical. We are going to review the most important things to look for, to determine if you have thoracic outlet syndrome.

What to Look for if You Suspect TOS

Physical Examination

Skin Color

If the veins are compressed, the doctor might see a light blue discoloration of the skin resulting from poor circulation or inadequate oxygenation of the blood, in the arm.

If the artery is compressed, your doctor might see pallor, which is a paleness, pallidness, lack of color, an ashen hue, pastiness, or a gray tone to your skin.

Examination for Swelling, Inflammation and/or Edema (Pitting Edema)

Next your doctor might do an examination of your skin, muscles, and bones for any swelling or inflammation. What the doctor is likely to see with TOS is swelling. Swelling can occur anywhere in the neck, shoulders, arms, or fingers. There are two types of swelling found with patients that have thoracic outlet syndrome, inflammation swelling and edema swelling.

The doctor might also see swollen veins in the arms, shoulder, or chest.

Inflammation Swelling

Inflammation swelling is swelling of injured or strained tissues, such as strained muscles, ligaments, and joints. It might be either acute, from a recent car accident, or chronic, from constant strain of the neck, chest, and shoulder area doing activities of your daily life.

I can usually see obvious signs of swelling that the patients and their immediate friends and family cannot. That is because this disorder, oftentimes, comes on during weeks, months, and even years that the onset of swelling seen by the naked eye of friends and family is not noticed.

The best way to notice this is to find someone who is healthy and ask them to stand next to a mirror with you, with the upper chest and neck exposed. Compare the difference. You should see a bold outline of the collarbone and neck muscles though the skin and a space called the supraclavicular fossa. If you cannot see the outlines of these structures under the skin, you might have “inflammation swelling” of the neck, upper chest, and shoulder.

Edema Swelling

Edema swelling is an abnormal accumulation of fluid in the interstitial space between the skin and muscles. In a patient with thoracic outlet syndrome, you might notice swelling of the fingers, arm, or entire upper extremity. This swelling occurs because there is a compression of the veins that drain the blood and fluids from the arm.

The first visible sign is swollen fingers, especially in the morning when putting on rings. I get a more detailed, exact account of the hand swelling by taking a photo of the hands with my camera and evaluating the photo.

The visible fi rst sign is swollen fi ngers, especially in the morning when putting on the wedding ring.

Another, more advanced, sign of swelling is pitting edema. This is a sign I have seen seven times in 28 years. Normally, doctors only see it in calves of the lower leg with poor circulation, but this can also happen in the arms. The doctor will push his or her thumb deep into the calf or forearm and notice an indentation, or pit, where indented area persists.

The purpose of this treatment was to relax muscle spasms that were pulling his collarbone down on the subclavian vein. I felt a large amount of fluid between the skin and muscles, which was there because the subclavian vein was extremely narrowed, limiting the escape of blood and fluids from his arm.

The next Monday, he came in panicked. “What did you do to me?” he exclaimed. I looked down and saw a hand typical of someone who had starved for years, with skin and bones showing. I wasn’t alarmed, because it was impossible for the muscles to atrophy like that in two days. This skin-and- bones appearance was only visible now because there was no longer a layer of fluid over them. When I opened the thoracic outlet and tunnel, I focused on relieving the pressure on the vein. When the outlet opened, the fluid drained completely. This revealed a skin-and-bones look of the fingers and hand. This was a result of severe atrophy from a lack of exercise and a reduction of blood supplying oxygen and nutrients. He couldn’t exercise because he had a severe weakness in grip strength because there wasn’t enough blood in the arm to allow muscle contraction.

I looked down and said, “Well, that is what your hand should look like when it has had almost no blood

flow or exercise for five years.”

“What am I going to do to fix it?” he asked.

I had the perfect answer. “You are going to exercise it, playing the piano again.” You should have seen the look on his face!

Posture Evaluation

The first step in examining yourself for these shifts in body parts involves an examination of your posture. We talked about posture extensively in Chapter 4, “The Control of Tension on Your Human Spring.”

These are the two most important things that can cause a shift in the structures to compress the outlet or change the posture.

1. Muscle Weakness (Muscle Imbalance)—Weakness in the muscles that suspend the shoulder over the outlet, such as the upper trapezius muscle and levator scapulae muscle, can happen either from muscle fatigue from constant contraction or spasm or general weakness.
2. Muscle Spasms or Muscle Tension—A trigger point, super contraction, can cause direct or indirect compression of the outlet. Ribs can elevate into the outlet by a super contraction of the scalene muscles, and the shoulder can get pulled or dragged down into the outlet by super contraction of the pectoralis minor muscle, the subclavius muscle, the coracobrachialis muscle, the biceps short head muscle and the anterior (front) neck muscles.

These are the postural changes that might suggest muscle contractions are compressing the outlet or weakness in the muscles that suspend the shoulder over the outlet to maintain the outlet tunnel. A lot of doctors look for the “high” shoulder. I look for the low shoulder. The low shoulder is usually the shoulder that is pulled down by muscle spasms.

• Your head is tilted down.
• Your head leans to the side of the symptoms.
• Your shoulders droop forward and down on the side of the symptoms.
• Your hands are rotated inward on the side of the symptoms (only the thumb and the knuckle of one finger should be showing in the mirror). That is because the muscles are pulling the head down and pulling the shoulder down and into the thoracic outlet tunnel, narrowing it. These postures tend to increase the compression on the brachial plexus nerves, and the subclavian artery and vein.

Range of Motion of the Neck Range, Shoulder, Elbow, and Hand Range

Patients with thoracic outlet syndrome are usually capable of bending their neck forward, backwards, and rotating, or turning, the neck to the right and left. They almost always have difficulty laterally bending to the side. The reason is because the scalene muscles are contracting, not allowing the neck to bend to the side.

If the scalenes are in a spasm, they will lift the first and second ribs and the top of the neck toward the shoulder. The muscles can swell with the constant tension, causing a thickening, which can also narrow the opening for the artery and nerves.

The exact ranges of motion of the shoulder, elbow, and hand are a little complex to go over in this book. If your range of motion is reduced you usually can tell.

1. Jaw Examination (Examination for TMJ Syndrome)

This is a problem with the muscles and joints of your jaw. The jaw can develop a form of arthritis and pain just like any other joint.

The problem with patients who have TMJ syndrome is that the pain and muscle tension can spread into the neck and other areas. So, if a doctor wants to give you the best chance of reversing your TOS 100 percent they must have a strategy to address your TMJ at the same time.

I take out my phone and videotape your mouth opening and closing. Then I play the video back in slow motion and we review what we see.

If we see the jaw deviate to one side during opening, it usually means signifies you have TMJ on both sides. It is important to look and feel for any dislocation of the jaw joints by watching and placing a light contact over the jaw just anterior (forward) and inferior (down from) the ear. If you see, feel, or hear the jaw pop out, then you might have a misaligned jaw.

2. Neurologic Evaluation

Reflexes—Do you have damage to your brain or spinal cord, what and where?

The first test a doctor must do is check your reflexes in your elbow, wrist, and forearm. With this test, the doctor is trying to determine if you have something wrong with your brain, spinal cord, or nerves.

The doctor should check your cranial nerves too.

The Sensory Exam—Are Your Nerves Pinched and Where?

The sensory exam includes testing for pain sensation (pinprick) and light touch sensation, which is performed with a light brush motion across strategic areas of the skin around your neck and upper extremities.

The doctor will touch you with the pin or brush and ask you to tell him if it is “sharp” or “dull.” The levels of the nerves of your spine supply feeling to specific areas of your shoulders, arms, and fingers.

The nerve level corresponds to a specific area to be tested with the brush and pin:

The most common symptoms associated with a pinched nerve are either pain, numbness, tingling, weakness, or all the above. The level of the spinal nerve that could be pinched is on the left and the symptom is on the right.

• C2—the back of the head and headaches
• C3—the back of the head and behind the eye and ear
• C4—the base of neck and the upper shoulder
• C5—the area around the upper arm and shoulder
• C6—the thumb, and half the index finger and half the middle finger
• C7—the middle finger
• C8—the ring finger and little finger
• T1—the little finger and the inner side of forearm

3. Palpation

Deep Muscle Palpation—Muscle Tension and Inflammation Examination

The most important examination is to check for painful muscle spasms.

These muscle spasms, also known as trigger points or super contractions, can be painful or nonpainful.

The question is, how do you find them? You stick your thumb into them.

There are two ways to find the muscle compressive spasms.

1. There are 10 muscles that when contracted constantly can compress the thoracic outlet. You can determine which muscles are involved by the pain and pattern of pain radiation.
2. They are painful if you press on them. Palpation (pushing your thumb deep into the muscle)

is a reliable way to examine for trigger point, super contractions. Muscles that are not in spasm do not hurt.

Refer to Chapter 13, “What Works and Why?” for the location of these muscles. You are going to examine yourself and treat yourself at the same time.

Muscles when contracted compress the thoracic outlet and tunnel.

You push the pad of your thumb into the muscle to check for a ropy-like, hard muscle that hurts more the deeper you push.

Here is a list of all 10 muscles that either directly compress or contribute to the compression of the outlet and tunnel.

1. Anterior scalene muscle—(compression of the interscalene triangle)
2. Middle scalene muscles—(compression of the interscalene triangle)
3. Posterior scalene muscle—(compression of the interscalene triangle)
4. Anterior neck muscles (compression of the neck)
5. Pec minor muscle—(compression of the costoclavicular and subpectoral space)
6. Coracobrachialis—(compression of the costoclavicular and subpectoral space)
7. Biceps short head muscle—(compression of the costoclavicular and subpectoral space)
8. Latissimus dorsi muscle—(compression of the costoclavicular and subpectoral space)
9. Lower Trapezius—(compression of the costoclavicular and subpectoral space)
10. Subclavius muscle—(compression of the interscalene triangle, the costoclavicular, and the subpectoral space)

The subclavius muscle is the only muscle that compresses the interscalene triangle, the costoclavicular, and the subpectoral space so it must be treated in every case of thoracic outlet syndrome. In my 30 years experience of treating nonsurgical cases that failed, I have never heard of one patient who told me their previous doctor or doctors treated the subclavius muscle.

You never hear of doctors talking about the posterior scalene when treating thoracic outlet syndrome. Don’t they understand that if this muscle is in a spasm, it will lift the second rib, and because the second rib is connected to the same spine as the first rib, it will lift the entire rib cage up on that patient?

You never hear of doctors talking about the lower trapezius or latissimus dorsi. Don’t doctors realize that these two muscles depress the shoulder into the outlet when in a chronic spasm?

You never hear of the coracobrachialis or biceps short head with thoracic outlet treatment. Don’t doctors know that these muscles are primarily used in shoulder flexion (holding the mouse, smartphone, tablet, and typing on the computer with outstretched arms. These two muscles attach at the same coracoid process as the pectoralis minor and their function can be to depress the shoulder.

The vision of the big picture of thoracic outlet syndrome is primarily tunnel vision to the muscles the doctors like to surgically resect. This tunnel vision of TOS is a HUGE irresponsible misunderstanding of human anatomy and human engineering.

If the doctor does not check for all 10 of these painful, compressive, muscles spasms (super contractions), then you are most likely wasting your time. What is acceptable about doctors not examining and treating muscles they are paid to know the function of? If they don’t do the deep tissue treatment on these 10 muscles, you are DEFINITELY wasting your time. It’s time to find a doctor who will.

There are photos illustrating where to press on the body to check for pain in each muscle in Chapter

13, “What Works and Why.”

Motor Examination

Manual Muscle Strength Testing

Manual muscle testing, looking for weakness, can help in pinpointing the muscles that are involved in your thoracic outlet syndrome. The muscles are weak because they are contracting 24 hours a day, seven days a week.

Spine, First and Second Rib Examination

The spinal examination I do is a motion palpation examination.

Motion palpation is technique I use to locate stiffness or locking of the joint “spring” within the spinal column and extremities.

It is a technique developed by Henri Gillet, a Belgian chiropractor, in which the practitioner’s hands are used to feel the motion of specific segments of the spine while the patient moves. The purpose is evaluation of the dynamic movement of the extravertebral joints and vertebrae to assess dysfunction between the joints.

The Cervical Rotation Lateral Flexion Orthopedic Test

During this test I’m looking for is stiffness or locking of the joint play or joint spring in the lower neck and upper ribs. More specifically I’m looking for an elevation and/or locking of the first and second rib. In the examination I check the joint play or joint spring of all twelve of the ribs. I’m also looking for a reduction in joint spring or joint play in the joints of the collarbone and the rest of the shoulder girdle.

I have been feeling the motion of the spinal column for subtle discrepancies of motion for 30 years.

After more than one million segments, 12 hours per day, 6+ days per week for 31 years, I know when the movement is not right.

A doctor would use his or her hands to put play into the joints, checking their motion for stiffness or locking at the end of the movement. It takes time to develop this skill set. Some chiropractors are very skilled and others have a variable skill level. Some don’t even bother to check joint play or do hands on adjustments of the spine, ribs, and extremities and instead just give up and only use therapies.

Examination of the Shoulder

The key to examining the shoulder is muscle testing. However, with a strong athlete, construction worker, or former athlete, an inexperienced doctor can miss a muscle weakness in the shoulder with a routine muscle testing.

Doctors and therapists MUST follow-up negative or positive muscle testing with a deep tissue palpation of the 10 muscles most commonly involved with thoracic outlet syndrome.

The structure of the shoulder that most commonly drops into the thoracic outlet and tunnel is the collarbone. The position of the collarbone is determined by the tension of the muscles that pull the shoulder down into the outlet and the fatigue or weakness of the muscles that suspend or lift the shoulder off the thoracic outlet or tunnel. When the motion of the collarbone is restricted, it can narrow the space between the collarbone and the chest narrowing the outlet tunnel (13). You and your doctor can check the motion of the collarbone by placing your opposite hand on the collarbone, while lifting your arm on that side, up and back. You are checking for clicking, restricted movement, pain, numbness, and tingling during motion.

Examination for Other Areas of Compression

• Headaches—base of the skull
• Herniated discs—neck and upper back
• Hyperabduction syndrome—shoulder
• Cubital tunnel compression—elbow
• Median nerve compression—forearm
• Carpal tunnel syndrome—wrist
• Guyon’s canal—wrist I also do an examination for other compression syndromes of the shoulder, arm, and wrist. I check for rib misalignments, pinched nerves, and herniated discs of the spine and thorax. I check for hyperabduction syndrome, shoulder subluxation, and rotator cuff syndrome of the shoulder. Farther down the body, I check for cubital tunnel syndrome of the elbow and median nerve compression in the forearm and wrist, called carpal tunnel syndrome. I also check for impingement of the tunnel of Guyon’s canal in the hand.

If you have thoracic outlet syndrome and another compression syndrome, it’s called double crush.

If you have two additional compression syndromes, it’s called triple crush and so on. You would be surprised to know that I have found many patients have multiple areas of compression. If the doctor fails to examine for multiple areas of compression, you cannot put much faith in the treatment.

This type of misdiagnosis is called underdiagnosis or not diagnosed. The reason I check for everything is because I want to treat everything at the same time, so at the end of treatment, you are as close to perfect as humanly possible. This also reduces the possibility of misdiagnosis.

I don’t want to say to you at visit 10, “At first I thought it was thoracic outlet syndrome, but after 10 treatments I found out it is thoracic outlet syndrome and carpal tunnel syndrome.”

If we were treating thoracic outlet syndrome and carpal tunnel syndrome from the first visit, we could’ve had both reversed by the last visit. To see videos of how muscle tests are performed, go to www.thoracicoutletsyndrome.org.

Orthopedic Tests for Thoracic Outlet Syndrome

Tests Doctors Do to Determine a Diagnosis of Thoracic Outlet Syndrome

There are tests that doctors do to determine if you have thoracic outlet syndrome. But if you look at these tests the way I do, you can learn more than if you have compression of the outlet.

The reason why doctors don’t learn as much from the tests as they should is because they have these specific stringent protocols for the “exact” way to do an orthopedic test. This stringent protocol is only for the textbook doctors who are hung up on naming the condition. You only get “the diagnosis” that way.

They argue about the validity of the tests with terms like false positives and false negatives. A false positive is where there have been other patients without thoracic outlet syndrome that the test is positive. With this attitude, they become even more confused and that might have them end up doing nothing.

All findings give you better insight into what is causing the signs and symptoms. I never look at an orthopedic test as a positive or a negative. Examination of the human body with the hands is an art form. That is the best way to describe it. Any and all information you can get from tests helps to form your approach to treatment of that specific condition.

It’s like asking someone to make a clay structure of a human or draw something. With one artist, you know what he or she is drawing or sculpting, but with someone who has the art, it’s an entirely different level. When you have someone really skilled, you will feel it right away.

Tests for Compression at the Interscalene Triangle

There are specific orthopedic tests for compression at the interscalene triangle from scalene spasms that cause elevated ribs, and the pectoralis minor muscle and subclavius muscle compressing the collarbone onto the ribs.

Why is it so important to do these orthopedic tests and check the muscles that are attached to the ribs?

A swelling above the collarbone around the neck most commonly means a problem with the movement of the first and second ribs. This swelling could represent inflammation swelling related to an abnormally raised rib (12).

Morley’s sign (tenderness in the supraclavicular fossa) might have a diagnostic value when it is clearly on one side and especially when it triggers the symptoms of pain or numbness in your arm (16).

This finding should be followed by an examination of the first rib springiness, joint play, and position with the cervical rotation lateral flexion test, Adson’s test, and costoclavicular maneuver. When the first rib locks in the elevated position, there is pain where the rib attaches to the sternum.

There might also be pain between the shoulder blades, because the ribs attach to the spine in the back. So, the pain between the shoulder blades could be related to this elevated rib.

Remember, you cannot have an isolated first rib elevation. When one rib elevates, it takes all the ribs that attach to it, with it. The intercostal muscles interconnect all 12 ribs.

The intercostal muscles are several groups of muscles that run between the ribs and help form and move the chest wall. The intercostal muscles are mainly involved in the mechanical aspect of breathing.

These muscles help expand and shrink the size of the chest cavity to facilitate breathing.

Compression of the Costoclavicular Space and Subpectoral Space

Difficulty Breathing, Shortness of Breath, and Chest Tightness

The other muscle that attaches to the ribs is the pectoralis minor muscle. When the pectoralis minor spasms, it abnormally lifts and locks the third, fourth, and fifth ribs at the spine in the back and the breastbone in the front. This rib tightness can cause difficulty with deep breaths or shortness of breath when walking long distances, running, or performing sports.

Heart Attack False Alarm

Shoulder and rib lock can cause upper back pain and stiffness or pain between the shoulder blades. In severe rib misalignment, it can also cause chest pain, chest tightness, difficulty getting a full breath of air, shortness of breath, and radiating pain into the arm, which has made many of my patients think they were having a heart attack.

Orthopedic Tests for Scalene Spasms Causing First Rib Elevation Signs

Adson’s Test—Scalenes and First Rib Elevation

Adson’s test more specifically addresses compromise to the plexus through the scalene triangles.

Here is what I do during this test.

I stand behind the patient. I have one hand on the shoulder on the involved side and the other hand is taking the pulse. I take the pulse to feel the blood pulsating against my fingertips. Then I press down on the shoulder and check the pulse. Then I move the arm behind the back and rotate it in adduction extension and external rotation and take the pulse.

I stop there and move the arm and shoulder in different positions for a few seconds, while I’m feeling the pulse. If there is a specific position that causes a decrease in the pulse, then I know it is most likely a compression spasm of the muscles that compress the outlet around the shoulder.

Then I ask the patient to rotate his or her head to the involved side, which twists the scalene muscles further, narrowing the interscalene triangle, while I feel for changes in the pulse. If I feel the pulse decrease at this point, I know at least some of the compression is coming from the scalene muscles.

Then I ask the patient to inhale deeply and hold his or her breath. This causes the rib cage, including the first and second ribs, to rise. If the pulse decreases here, then I have determined the ribs are most likely lifted into the thoracic outlet/tunnel by spasms in the thoracic outlet.

Doctors think that this is not a reliable test, because there are too many false positives. This is a rookie mistake made by doctors. We don’t have to have full-on compression of the thoracic outlet, nerves, artery, and vein to determine there is a medical necessity for treatment. In this case, we have narrowing of the outlet, but not enough to cause compression of the bundle of blood vessels and nerves.

It’s the beginning stages of thoracic outlet syndrome, which should be treated so it doesn’t end up being full-blown thoracic outlet syndrome in the future.

I could just imagine if one of my professional boxers had a subclinical thoracic outlet syndrome that wasn’t treated that got to be a full-blown thoracic outlet syndrome in the ring on round six of an important fight. We don’t allow these conditions to linger.

• I take the pulse to feel the blood pulsating against my fi ngertips. Then I move your arm behind your back and rotate it in adduction extension and external rotation.
• I stop there and move the arm and shoulder in different positions for a few seconds while I’m feeling the pulse. If there is a specifi c position that causes a decrease in the pulse then I know it is most likely a compression spasm of the muscles that compress the outlet around the shoulder.
• Then I ask you to rotate your head to the involved side, which twists the scalene muscles further, narrowing the inter- scalene triangle.
• If I feel the pulse decrease at this point I know the majority of the compression is coming from the scalene muscles.
• Then I ask you to inhale deeply and hold your breath. This causes your rib cage including the fi rst and second ribs to rise.
• Positive Test: If the pulse decreases here then I have determined the ribs are most likely pulled by spasms into the thoracic outlet.

First Rib Motion Palpation Test

The subluxation, or a slight misalignment, of the first rib, along where it attaches at the spine is associated with malfunction of the first rib.

The purpose of this test is to check for elevation of the first and second ribs. The rib can be pulled up and back into the outlet, causing compression of the nerves, artery, or vein. The scalene muscles are what pull the ribs out of position. If they are elevated in an abnormal position for too long, the joint can become locked in that position by tension in the ligaments.

• You are seated.
• I place my thumb on the base of your fi rst rib and concentrate on how the rib moves or doesn’t move during the test.
• I rotate your head to the opposite side of the pain.
• Then I side bend your head and neck to the painful side.
• While I am doing this I am also using my opposite hand to feel the movement of your ribs on the effected side.
• I usually feel the ribs roll down away from my touch.
• A positive test for me is when I feel an abrupt stop to the movement of the ribs with my opposite hand at the same time as I feel an abrupt stop to the side bending of your neck.
• If I feel the rib is locked or elevated during this test then it needs to be adjusted down out of the outlet and tunnel. In this test, I rotate the head away from the painful side until it cannot move any farther. While maintaining that position, I bend the neck to the side as far down as possible If I cannot get full rotation and side-bending position, then the test is considered positive. Again, doing this test in the most stringent way to get the true positive or negative finding is not useful to help reverse the conditions a patient might have. It’s just what doctors who are hung up on naming your condition focus on.

I am moving the head and neck in many directions, and at the same time I put my hand on the first rib on the opposite side to feel how it moves. That is because I want to see if it’s elevated, what direction it is elevated, where the joint play or joint spring is locked, and how bad the rib is locked up. That is because we need to reduce the spasms that are elevating it, and then adjust it out of its locked state, so it moves and drifts to its normal position.

One scientific study found that more than 90 percent of patients who had a positive cervical rotation lateral flexion test also had a malfunction of the first rib (18).

Some say that the most objective way to check the movement of the first and second rib is this cineradiographic examination. While this is interesting and more objective, it is over-the-top unnecessary and only useful for doctors who cannot close their eyes and visualize what’s going on inside the body because of experience and they don’t have good hands or a sense of touch. In a study done by Lindgren in 1992, it was found that the cervical rotation lateral flexion test was as good as the findings of the highly objective cineradiographic examination (19).

Costoclavicular Maneuver—Compression of the Collarbone on the Rib Cage We will now discuss testing for spasms in the scalenes causing first rib elevation, and the pec minor, and subclavius, compressing the collarbone onto the ribs. Costo means rib and clavicular means collarbone. With this test, we are trying to determine if there is a narrowing of the thoracic outlet between the ribs and the collarbone.

First, I ask the patient to sit, while I feel the pulse. Then I put my other hand on the shoulder. Then with the hand that is checking the pulse, I pull the arm back and push down on the shoulder. I hold it and move it around in different positions for a minute or two, while I’m checking the pulse for any reduced pulse or inability to note the pulse. If there are any changes in the pulse or weird feelings, such as pain, numbness, or tingling in the arm, then this is a positive test.

What I get from this test is different from other doctors. I now know that there are compression spasms of the pec minor, subclavius, and latissimus dorsi muscles. Again, now I know what muscle spasms are causing the compressive force, so I can more accurately treat you.

Costal Clavicular Maneuver (Military Brace Test)

• You would be standing or sitting.
• I stand behind you, grasp your wrist and use my fi ngers to feel your radial pulse.
• Then you would push your chest out and shoulders back.
• Positive test: If the costoclavicular space is already narrowed then there will be a reduction in the pulse from a compression of the subclavian artery as it passes through the area of the thoracic tunnel under the collarbone or clavicle. You should feel numbness or tingling in the arm and hand at about three to ten seconds after the arm is extended.

This is how I do it:

• I stand behind you, grasp your wrist and use my fi ngers to feel your radial pulse.
• Then you would push your chest out and shoulders back.
• I depress and retract the scapula or shoulder blade backward with the other hand. This will pull the collarbone back and down closer to the ribs, which essentially narrows the thoracic tunnel.
• If I am doing the depressing and backwards rotation I can get a more exact feel for the position of the shoulder Hyperabduction Maneuver—Wright’s Test In this test, I am feeling the pulse to get the pulse rhythm and intensity. Then I ask the patient to lift his or her arm overhead and extend it back behind the body. If the muscles are free from compression spasms, then the patient won’t feel any pain.

If there is a feel of reduction of the pulse, or if there is complete loss of the pulse, then the test is positive. The patient will also feel tingling, then numbness, if I hold it there long enough. The doctor will then determine that you have thoracic outlet syndrome and write the plus sign (+) on your file.

What I determined from this test is that it is positive and it means the patient has a compression spasm of either the pectoralis minor muscle, subclavius muscle, or latissimus dorsi muscle, or, more likely, all the above, causing compression of the pec minor or collarbone on the bundle of nerves, artery, and vein.

I immediately determine what bad habits cause this particular pattern of spasms. Then I know where to work to reverse it.

A pulse oximeter is a safe, convenient, noninvasive, and inexpensive method for measuring oxygen saturation in the blood passing into the arm and the pulse rate of the heart at the fingers. I put it on the patient’s finger, then do the tests, observing the pulse rate. If the oximeter shows no pulse during a motion or position, I know the compression is there. The price varies from $20 to $400, but a $30 pulse oximeter is probably good enough for your use. You can get one and check when you lose your pulse and where. This will help you to diagnose the cause of your TOS with or without a doctor.

Wrights Test or Hyperabduction Maneuver

• You are seated.
• I take the pulse.
• Then starting with the arm at the side, raise the arm to a position above the head as you are feeling for the pulse.
• If I feel a reduction, interruption or suspension of your pulse then the test is considered positive.
• The coracobrachialis and biceps short head also attach to this prominence of the shoulder. So while I’m doing the test I am also checking for restrictions of the shoulder movement caused by shortening or super contractions of the biceps short head and corcobrachialis muscles too.
• I am also checking the tension of the anterior deltoid, trapezius and latissimus dorsi muscles when I maneuver the shoulder.

Roos Test (Elevated Arm Stress Test)

Caption: Roos Test, “elevated arm stress test” or the “EAST”

• With this test I ask you to raise your arms in a position like you are under arrest. Your arms are to the side elevated to the sides to shoulder height and your elbows are bent to 90 degrees.
• Then I ask you to open and close your hands slowly for 3 minutes.
• If you are unable to keep your arms in this position for 3 minutes or if you have pain, heaviness, or weakness in the arm or numbness or tingling in the hand during the test then some doctors say this is a positive Roos test. With this test, I ask patients to raise their arms in a position, like they are about to do a military press. Their arms are elevated to the sides to shoulder height with the elbows bent to 90 degrees.

Then I ask the patient to open and close the hands slowly for three minutes. If they are unable to keep their arms in this position for three minutes, or if there is pain, heaviness, or weakness in the arm or numbness or tingling in the hand during the test, then some doctors say this is a positive Roos test.

The problem with this test is that many people are just so weak that they can’t hold their arms in that position for three minutes. A round of boxing is three minutes. Most people are shocked at how hard it is to hold their hands up to guard their face in boxing for three minutes. Even top pro boxers have a tough time holding their arms up. This test is tainted if you had to work all day with your arms up.

What this test tells me is that the patient not only has a positive Roos test, but they most likely have compression spasms and weakness in the deltoid muscles of the shoulder, the trapezius muscles of the shoulder and neck, and possibly the subclavius muscle. Numbness could mean spasms of the pectoralis minor muscle, subclavius muscle, and latissimus dorsi muscle too.

Here again, I am forming my treatment approach to address these compression spasms.

Modified Upper Limb Tension Test Modified upper limb tension test is also known as the brachial plexus tension test or the Elvey test. With this test, the patient is lying down. I put the arm out to the side, parallel to the table. I start by applying gentle pressure to the shoulder to 90 degrees, then rotate the arm and shoulder backward and extend the wrist.

If the patient feels numbness, it could mean there is compression of the nerves from the neck to the arm (22). Doctors like to do this test to name your thoracic outlet as a neurogenic TOS, which we all know is nice for those doctors who are focused on naming your thoracic outlet syndrome.

What I learn from this test is that the patient might have a compression spasm of the pectoralis minor muscle, the subclavius muscle, the biceps short head muscle, the coracobrachialis muscle, and the scalene muscles. The patient might also have a locked collarbone where it attaches to the sternum.

I will work on these muscles and manipulate the collarbone to move better. Also, I have some great exercises that naturally mobilize the collarbone.

Cyriax Release Test This is both a test and a treatment that allows for temporary relief. The patient sits in a chair with the arms pinned down and the elbows bent at 90 degrees. I put some pillows underneath the forearm to elevate the shoulders, so the shoulder girdle is elevated, opening the thoracic outlet tunnel. If the symptoms of nerve, artery, or vein compression diminish, then this is a positive sign of thoracic outlet syndrome.

The symptoms could take hours to decrease. Because the symptoms go away, it is considered a treatment. The treatment is temporary and, in fact, in my opinion offers no permanent relief. This could allow a patient to get 5–10 minutes of relief to fall sleep, but he or she might wake up in the middle of the night with the symptoms back again.

Summary of Orthopedic Tests If your doctor orders diagnostic tests, such as MRI, CT, or EMG, right after this exam, without at least trying a nonsurgical treatment approach, they don’t know how to treat you without surgery.

If they don’t start some form of treatment, it might be time to find someone who is willing to do treatment.

Cyriax Release Test

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

Conclusion

These are key elements of sorting out your symptoms to determine where the compression is. It might be thoracic outlet syndrome, a herniated disc causing a pinched nerve at the neck, hyperabduction syndrome, median nerve compression, cubital tunnel syndrome, compression of the wrist, or carpal tunnel syndrome. You can learn more about how to differentiate these conditions by reading this

All these compressions cause symptoms downstream of the compression. Therefore, this symptom might be one of the above, a few of the above, or all the above.

If your doctor leaves out the deep palpation of the 10 muscles that can pull the shoulder into the thoracic outlet for these super contracted muscles, then you know they won’t be treating these super contracted muscles during the treatment either.

Again, if they leave out this area of the examination, I suggest you get up, thank the doctor, pay for your visit, and walk out and find someone who will do the examination right.

Now spring out of the doctor’s office and examine yourself!