What Works and Why?

When Physical Therapy Does Not Provide Lasting Relief

The tenth reason why a doctor and patient may ultimately decide to proceed with thoracic outlet syndrome (TOS) surgery is the failure of a carefully supervised physical therapy program. While physical therapy, rehabilitation, and conservative treatment help many patients, some individuals continue to experience persistent symptoms despite months or even years of treatment.

When patients come to me for treatment of thoracic outlet syndrome, they typically have severe, chronic TOS that has caused years of pain, numbness, weakness, or disability. Most tell me they view my clinic as their last resort before surgery. Many already have a scheduled thoracic outlet decompression surgery, and in some cases they contact me from another country only days before their operation, hoping there may still be an opportunity to avoid surgery through nonsurgical treatment.

Working to Avoid Surgery Whenever Possible

When you have practiced for more than three decades without recommending a patient for thoracic outlet syndrome surgery, you naturally hope that every new patient can also recover through conservative care. That goal motivates every examination, every treatment plan, and every effort to identify the true causes of the patient's condition.

Over the past twenty years, the cases I have evaluated have become increasingly severe and complex. Patients are often referred only after years of unsuccessful care, making recovery more challenging than ever. Even so, I continue to believe that every patient deserves a thorough evaluation before concluding that surgery is the only remaining option.

Setting Realistic Expectations

One patient once wrote in an online support group that I had guaranteed I could save her from surgery. I never made that statement, and I never will. She misunderstood what I said and unintentionally misquoted me.

No ethical healthcare professional can guarantee that a patient will avoid surgery. Every individual responds differently to treatment, and every case of thoracic outlet syndrome presents unique anatomical and biomechanical challenges. My goal is always to determine whether a patient's condition can improve through a comprehensive nonsurgical treatment program before surgical intervention becomes necessary.

Most Patients Have Already Tried Everything

By the time patients arrive at my office, most have already visited several healthcare providers. They often tell me they sought treatment from physicians or therapists who were considered among the best in their field.

Some patients have seen three or four specialists. Many have consulted more than ten different healthcare professionals, and a surprising number have visited twenty or more experts. Despite these extensive efforts—including physical therapy, chiropractic care, pain management, manual therapy, injections, and other conservative treatments —their symptoms remain largely unchanged.

Why Previous Treatments Often Fail

After evaluating thousands of patients seeking second opinions following unsuccessful conservative treatment or thoracic outlet syndrome surgery, I have found that treatment failure most commonly occurs for four reasons.

1. Inadequate Resources to Reach Maximum Medical Improvement (MMI)

Many patients simply do not have adequate insurance coverage or financial resources to continue treatment long enough to achieve Maximum Medical Improvement (MMI). Recovery from thoracic outlet syndrome often requires a carefully coordinated treatment program over time, and prematurely ending care can prevent lasting improvement.

1. The Original Diagnosis Was Incorrect

Some patients were misdiagnosed from the beginning. If the underlying cause of symptoms is misunderstood, even excellent treatment may fail because it is directed at the wrong condition.

1. The Patient Was Underdiagnosed

Many patients have thoracic outlet syndrome along with one or more overlapping conditions that were never identified or treated. These may include cervical spine disorders, shoulder pathology, peripheral nerve entrapments, myofascial pain syndrome, vascular compression, or other musculoskeletal disorders. Unless every significant contributing condition is addressed, recovery is often incomplete.

1. The Treatment Did Not Address the Six Requirements for Long-Term Recovery

Perhaps the most common reason treatment fails is that the overall approach does not address all six essential requirements needed to achieve lasting recovery from thoracic outlet syndrome. Treating symptoms alone is rarely enough. Successful long-term TOS treatment requires correcting the underlying biomechanical dysfunction, restoring normal movement, reducing inflammation, relieving nerve compression, improving tissue health, and preventing recurrence through a comprehensive rehabilitation strategy.

1. Limited Resources to Reach Maximum Medical Improvement (MMI)

Sometimes patients simply do not have the financial resources or insurance coverage needed to reach maximum medical improvement (MMI) from thoracic outlet syndrome.

Many insurance plans limit the number of chiropractic or physical therapy visits, even when additional treatment is medically necessary to fully reverse thoracic outlet syndrome. In other situations, patients cannot obtain the required referral from their primary care physician or HMO.

Unfortunately, many HMOs focus on reducing short-term costs rather than investing in the conservative treatment that may help patients avoid surgery. When speaking with an insurance administrator, it is reasonable to ask whether they would rather pay several thousand dollars for comprehensive thoracic outlet syndrome treatment or tens of thousands of dollars for thoracic outlet syndrome surgery, hospitalization, rehabilitation, and follow-up care.

Most logical decision-makers recognize that funding effective non-surgical treatment is often the more cost-effective option.

To help patients obtain medically necessary care, we work with financing companies that partner with multiple lending institutions. Some patients also use their Flexible Spending Account (FSA), while others receive support through crowdfunding services such as GoFundMe.

If someone is truly suffering and motivated to recover, I have always been willing to work with them to help make treatment as affordable as possible.

2. Thoracic Outlet Syndrome Was Misdiagnosed

One of the most common reasons patients fail to recover is that their thoracic outlet syndrome diagnosis was incorrect from the very beginning.

Review Chapter 8, "More Tests?", which discusses more than thirty conditions that can mimic thoracic outlet syndrome symptoms, including combinations of multiple disorders.

Many patients are initially diagnosed with conditions such as a cervical disc herniation, even though the disc abnormality seen on MRI may not actually be causing their symptoms.

Over the years I have evaluated countless patients who underwent treatment for the wrong diagnosis before eventually discovering they actually had thoracic outlet syndrome, brachial plexus compression, or another form of nerve compression.

Correct diagnosis is always the first step toward successful thoracic outlet syndrome recovery.

3. Thoracic Outlet Syndrome Was Only Part of the Problem

Another common reason treatment fails is that the patient was underdiagnosed.

Many patients have thoracic outlet syndrome together with one or more additional nerve compression syndromes that were never identified or treated.

Compression may occur simultaneously at multiple locations throughout the upper extremity, including:

• Cervical disc herniation in the neck
• Thoracic outlet compression involving the neck, shoulder, and chest
• Cubital tunnel syndrome at the elbow
• Median nerve compression in the forearm
• Carpal tunnel syndrome at the wrist
• Guyon's canal (5) compression in the hand

After one of my lectures on thoracic outlet syndrome in Bangkok, Thailand, in 2017, a woman approached me and confidently stated,

"I have thoracic outlet syndrome."

As I looked at her arm, I noticed scars on her wrist, elbow, and neck.

I asked,

"Were you first diagnosed with carpal tunnel syndrome, then cubital tunnel syndrome, then a cervical disc herniation, and after all of those surgeries failed, someone finally diagnosed thoracic outlet syndrome?"

She looked surprised and answered,

"Yes."

She ultimately received the correct diagnosis only because it was the only possibility remaining after several unsuccessful surgeries.

It is unfortunate that she had to undergo multiple operations before receiving the proper thoracic outlet syndrome diagnosis.

4. Treatment Did Not Address the Six Requirements for Long-Term Thoracic Outlet Syndrome Recovery

Many thoracic outlet syndrome treatment programs fail because they do not address every component necessary for long-term recovery.

Successful thoracic outlet syndrome rehabilitation requires all six of the following:

1. Treat the body as a spring mechanism, not simply as a lever.
2. Release the protective muscle spasms that compress the thoracic outlet.
3. Restore normal joint play throughout the cervical spine, ribs, clavicle, shoulder, and upper back.
4. Stop the production of new inflammation and lactic acid while removing existing inflammatory chemicals from the tissues.
5. Modify activities of daily living so they no longer aggravate the condition.
6. Strengthen the muscles that suspend the shoulder to preserve adequate space within the thoracic outlet. (See Chapter 14, Spring Training.)

1. Treat the Body as a Spring Mechanism

Throughout this book you have learned that most healthcare professionals view the body primarily as a system of levers.

My research has led me to a different conclusion.

The body creates and preserves the spaces that protect nerves and blood vessels through interconnected spring mechanisms, which form the foundation of the Human Spring Approach.

Even if a treatment completely restored normal lever mechanics, it still would not necessarily restore the openings that allow safe passage of the brachial plexus, arteries, and veins through the thoracic outlet.

That is why successful thoracic outlet syndrome treatment must restore normal spring function, not simply improve lever mechanics.

2. Release the Muscles Compressing the Thoracic Outlet

The protective muscle spasms compressing the thoracic outlet must be released.

Effective thoracic outlet syndrome treatment requires reprogramming the nervous system so these abnormal protective reflexes stop activating the muscles that compress the outlet and rotate the surrounding bones.

Many failed cases never addressed the true cause of the compression.

Patients often received stretching, exercise, or passive therapy but little or no deep tissue therapy, myofascial release, or treatment directed specifically toward the scalene muscles, pectoralis minor, subclavius, coracobrachialis, and other muscles responsible for brachial plexus compression.

Likewise, the elevated first rib dysfunction that contributes to thoracic outlet syndrome frequently remained untreated.

For many years I have estimated treatment time using the traditional Chinese measurement known as the cun, which corresponds approximately to the width of a person's thumb.

By measuring the length of each involved muscle and calculating the total treatment surface, I can estimate how much deep tissue therapy will be required to fully release the involved muscles.

I test several representative points, measure how long each point takes to relax under sustained pressure, and then calculate the total treatment time for the entire region.

This allows me to provide patients with a realistic estimate of both treatment duration and cost.

In many patients, releasing all of the muscles involved in thoracic outlet compression requires treating twelve separate muscles—the ten primary muscles producing compression plus two muscles that develop secondary fatigue spasms.

If each treatment point requires approximately three minutes to release and a muscle contains multiple treatment points, it becomes easy to understand why a typical 15- to 20-minute office visit is often insufficient to fully address thoracic outlet syndrome.

The longest single treatment session I have ever performed lasted approximately three and one-half hours on one side of the body.

That patient had undergone multiple unsuccessful surgeries, including cervical spine surgery, spinal fusion, and pectoralis minor resection, yet her symptoms were actually worse afterward.

Most patients require approximately 30 to 45 minutes per side during the initial visit, or 1½ to 2 hours for the entire upper body.

Typically, it takes around ten complete treatment passes before these muscles consistently maintain relaxation, although severe chronic cases often require considerably more.

Some of the most difficult cases of thoracic outlet syndrome require more than 30 hours of comprehensive deep tissue therapy to fully reverse decades of abnormal protective reflexes.

Patients seeking accelerated recovery often receive six to nine hours of treatment per day for three to six consecutive days, allowing them to achieve improvements in days rather than months.

3. Restore Normal Joint Play

Normal joint play must be restored throughout the cervical spine, thoracic spine, ribs, clavicle, shoulder, and upper extremity.

Many thoracic outlet syndrome treatment programs fail because they restore only a few restricted joints while leaving many others locked.

An elevated first rib dysfunction, restricted clavicle motion, and multiple spinal restrictions continue to reduce the space available for the brachial plexus and blood vessels.

Every restricted joint contributing to thoracic outlet compression should be restored.

Otherwise, surgery may ultimately be recommended simply because the mechanical problem was never fully corrected.

4. Eliminate Inflammation, Lactic Acid and Flush Metabolic Waste

Successful thoracic outlet syndrome recovery requires more than simply reducing pain.

The production of new inflammation, inflammatory chemicals, and lactic acid must be stopped while the existing inflammatory byproducts are thoroughly removed from the tissues.

In my opinion, after more than thirty years of practice, I have rarely seen a treatment program that aggressively addresses the removal of inflammation, metabolic waste products, and accumulated lactic acid throughout the affected tissues.

Reducing muscle inflammation is one of the most overlooked components of successful thoracic outlet syndrome rehabilitation.

5. Daily Activities Must Stop Reinjuring the Thoracic Outlet

Your activities of daily living, work habits, and posture must stop reproducing the forces that caused thoracic outlet syndrome in the first place.

Patients must learn proper posture correction, body mechanics, workstation positioning, sleeping positions, and movement strategies that reduce unnecessary strain on the muscles surrounding the thoracic outlet.

If you ignore these recommendations, even the best thoracic outlet syndrome treatment will have difficulty producing lasting results.

I freely admit that I am a posture fanatic.

If you come into my office and lean back in a chair with poor posture, I will ask you to sit upright every single time.

Long-term thoracic outlet syndrome recovery depends on consistently practicing good posture—not just during treatment, but throughout every day.

6. Strengthen the Muscles That Preserve the Thoracic Outlet

The muscles that suspend the shoulder over the thoracic outlet and thoracic outlet tunnel must be strengthened to open and preserve adequate space in the thoracic outlet and tunnel.

The treatment must include an effective exercise program to strengthen the muscles, which open and preserve adequate space in the thoracic outlet, neurovascular tunnel, and thoracic outlet tunnel. I will give you a complete array of exercises and stretches in Chapter 14, “Spring Training.”

Treat the Body as a Spring Mechanism

Only spring engineering is capable of opening tunnels and spaces for nerves and blood vessels to pass safely.

Finally, the Human Spring Approach!

The Human Spring Approach and Human Spring Model are the only biomechanical models capable of explaining how our bodies perform these three important functions.

The Human Spring Model explains:

1. how the body absorbs impacts,
2. how the body recycles energy, and
3. how the body provides safe passage for blood vessels and nerves.

Only spring engineering is capable of opening tunnels and spaces for nerves and blood vessels to pass safely. Now it’s time for me to teach you how we use the principles of the Human Spring Approach to treatment to open up the thoracic outlet and thoracic outlet tunnel to allow the safe passage of blood vessels and nerves.

Three Steps to Restoring Your Human Spring

Step 1—Release Compression

Release the compression of your body’s spring and the compression on your thoracic outlet and tunnel.

Step 2—Strengthen the Spring Suspension System

Strengthen your body’s spring suspension system to suspend the shoulder over the thoracic outlet and tunnel with resistance exercises.

Step 3—Spring Train the Human Spring

Spring train the Human Spring with spring training drills, plyometric exercises, and functional strengthening exercises to enhance and maintain the body’s spring engineering.

Step 1—Release the Compression of Your Body's Spring and Thoracic Outlet

Goal 1

Release the compression on your thoracic outlet.

Goal 2

Release the compression on your entire Human Spring.

Compression Is the Cause of Thoracic Outlet Syndrome

Everyone agrees... compression is the cause of thoracic outlet syndrome (TOS).

The Mayo Clinic, the Cleveland Clinic, and the National Institute of Neurological Disorders and Stroke, plus the top-10 ranked hospitals for neurology and neurosurgery tell us that compression is what leads to thoracic outlet syndrome (6). I agree. Now we have to determine what the cause of the compression is and treat it with the most effective approach to reverse it and keep it from returning.

Which Treatments Remove Compression of Your Spring?

None of them. (2)

The cause of thoracic outlet syndrome is compression (3). In fact, compression of the Human Spring is the cause of many conditions, such as Morton's neuroma, plantar fasciitis, heel spurs, Achilles tendon strain, Achilles tendon tear, shin splints, chondromalacia patella, knee degeneration, hip pain, lower back pain, lumbar disc herniation, cervical disc herniation, upper back pain, neck pain, cervical degeneration, headaches, and many of the diseases of aging. We are just going to focus on the compression of the thoracic outlet for this book.

The Two Primary Treatment Goals

The two main goals are to:

1. Turn off the super contractions that are lifting the ribs up into the outlet and pulling the shoulder girdle down into the outlet.
2. Adjust the ribs and shoulder, including the collarbone, down out of the thoracic outlet.

The Five Requirements of the Human Spring Approach

These are the five requirements of the Human Spring Approach to thoracic outlet syndrome, that all must be satisfied to effectively reverse it.

1. The spasms in the 10 muscles that are compressing the outlet must be released.
2. The joint play must be reestablished in the joints of the spine and extremities.
3. The inflammation and lactic acid must be completely flushed out of the tissue.
4. Your activities of daily living must not exacerbate the condition.
5. The muscles that maintain a wide thoracic outlet and tunnel must be strengthened.

Numbers 1–4 focus on removing the compression on the thoracic outlet. Number 6 will be covered in Chapter 14, “Spring Training.”

These are the five most important treatment considerations to reverse the compression of the thoracic outlet.

Human Spring Treatment Approach

The only treatment approach that will bring you long-lasting benefit is the approach that reprograms the brain reflex that is maintaining the muscle in a contracted state. These are the reflexes or circuits that keep you suffering every day.

The Optimum Treatment Must

1. Turn off the spindle cell strain/brain reflex circuit.
2. Turn off the inflammation/lactic acid/brain reflex circuit.

You cannot do this with injections, nerve blocks, surgery, stretching, or other ineffective treatments.

You must employ a treatment that affects the tension on the muscle spindle cells to send a message to the brain that the tension on the spindle cell has normalized.

You must employ a treatment or treatments that reduce the level of inflammation and lactic acid that are stimulating the nociceptor nerves, which alarm the brain that there is an injury in the area.

If you don’t do both to near perfection, your brain will maintain a constant compressive tension reflex, maintaining you in a chronic state of compressed and twisted suffering.

The only approach I have found to work long-term is the approach that reverses the pattern by reprogramming it at the source. This self-help treatment approach reverses the cause of compression on your Human Spring mechanism and thoracic outlet, because it focuses on the cause of the trigger points or super contractions.

Thoracic outlet syndrome is a combination of many conditions that are primarily myofascial pain syndromes. The most effective healers in the world have found soft tissue techniques, similar to those of Doctors Janet Travell and David Simons, to be helpful with thoracic outlet syndrome (13).

Breaking the Cycle of Compression and Pain

The key to breaking the cycle of pain and compression is to understand it, then break it down at as many links as possible, with the most targeted and effective treatment. Let’s review the cycle of compression and pain.

1. The abnormal strain is picked up by the strain gauges of the body in the sensory system, primarily the muscle spindle cells, Golgi tendon organs, and mechanoreceptors.
2. This alarm message is transmitted to the brain for processing by the nerves.
3. The brain responds to this alarm message by protecting the area with a trigger point that eventually leads to a super contraction.
4. The muscles contract continuously.
5. The muscles swell, causing compression of the artery and nerves. The muscles pull the bones into the outlet and tunnel.
6. The compressed thoracic outlet and tunnel compress the blood vessels and nerves.

Resetting Muscle Tension by Reprogramming the Brain

This is how therapy reprograms the reflexes to decompress the Human Spring.

When my patients tell their friends that I reversed their thoracic outlet syndrome without surgery, the friends ask, “What do you call what he does?” Then the patient describes the deep tissue bodywork and the friends commonly say, “Oh, my doctor does that and tried it on me,” or “You mean it’s like massage?”

If you make the mistake of thinking you got effective deep tissue therapy and yet you still have thoracic outlet syndrome, you are in for a big surprise. First, there are so many names, approaches, skill sets, hand strengths, and endurance levels that make a huge difference in the outcome.

Here are many names for different brands of deep tissue therapy to confuse you even more. I’ve listed them in alphabetical order: active release, acupressure, anma, bodywork, Bowen technique, connective tissue massage, deep tissue, Dorn method, fascial twist, Grostic technique, lomilomi, kneading, manual therapy, manual lymphatic drainage, massage therapy, muscle energy techniques, muscle manipulation, myofascial release, myofascial therapy, myofascial trigger point therapy, myotherapy, physiotherapy, Rolfing structural integration, seitai, shiatsu, soft tissue manipulation/manipulative therapy, soft tissue mobilization, soft tissue therapy, sotai, sports massage, strain-counterstrain, structural integration, Thai massage, therapeutic massage therapy, trigger point therapy, tui na, Watsu, and zero balancing.

I am not going to put a name on my treatment, because those who treat you will have to do it this precise way. If it doesn’t work, then you will know why.

What Makes You an Effective Self-Treating Patient?

1. You must want to do this.
2. You must have the knowledge.
3. You must have strong hands.
4. You must be thorough.
5. Your hands must have endurance.
6. You must be confident.
7. You must be tenacious.
8. You must stay the course.
9. You must not quit!

The Requirements to Restore the Thoracic Outlet

1. You must know the anatomy of where the 10 muscles are.
2. You have to know how to get the super contraction directly under your thumb.
3. You must apply the right depth of pressure.
4. You must know how long to hold the pressure.
5. You must know where the super contraction patterns will be.
6. You must know the typical patterns of referred pain.
7. You must know what good pain is and what bad pain is.
8. You must increase circulation to normalize the chemistry.
9. You must know how the symptomatology progresses through the application.
10. You need to know how long each treatment will take.
11. You need to know when it is completely released.
12. You must learn how to develop a strong open thoracic outlet and tunnel.

Know the Anatomy of the 10 Muscles

The simple cookbook approach is to determine what muscles compress the thoracic outlet and how to perform soft tissue techniques on these 10 muscles, which will release the compressive forces on your outlet. If you do the self-help to these muscles, are thorough, and work them until they are released, you should have a patent thoracic outlet and tunnel.

So, you’re going to digitally reprogram the scalene muscles, the muscles of cervical flexion, the short head of the biceps, the coracobrachialis muscle, the pectoralis minor muscle, and the subclavius muscle, which is an often-overlooked muscle. You must know the origin, insertion, and where the muscles lie.

The illustrations I provide and the photos of the model treating herself and me treating patients should help you find the 10 muscles that need to be treated.

2. You Have to Know How to Get the Super Contraction Directly under Your Thumb

When you locate this band of tender contracted muscle, muscle knot, trigger point, myofascial trigger point, hyperirritable muscle band, or super contraction, and as you apply pressure, the band might slip out from under your thumb. This happens when you are a rookie. After some experience, you will eventually be able to lock the pressure down without the muscle slipping out from your contact. Developing this skill improves deep tissue therapy, manual therapy, trigger point release, myofascial release, and muscle tension treatment accuracy.

3. You Must Apply the Right Depth of Pressure

Applying Precise Deep Tissue Pressure

I use the flat part of my thumb pad to press into the tissue. I line up the thumb lengthwise to the muscle fibers, muscle fiber alignment, and soft tissue. When I apply the pressure, I press down as deep as possible into the muscle and muscle spindle, spindle cell mass, and neuromuscular tissue to get as many of the superficial and deep spindle cells as I can. I make sure that I visually mark the application area to ensure that on the next point I have a slight overlap of the previous point treated. I think that the results are much better with a thorough application to the entire region. This systematic approach improves trigger point therapy, myofascial treatment, muscle relaxation, soft tissue mobilization, and neuromuscular re-education.

Improving Tissue Chemistry and Circulation

I also am pressing out the inflammation, inflammatory chemicals, and acetylcholine from the tissue into the body’s free space, allowing the opportunity to flush these chemicals out with the vibration massage acting like an inflammatory plow, to plow out the inflammation and draw in healthy blood, containing oxygen, nutrients, circulation, and microcirculation. This process supports blood flow, tissue perfusion, lymphatic drainage, cellular healing, waste removal, and recovery.

Understanding Therapeutic Pain

My brand of deep tissue therapy is not a painless procedure. If you feel pain during the pressure, you are in the right spot. Healthy muscles do not exhibit pain during properly delivered deep tissue treatments, manual therapy, or trigger point release. When healthcare practitioners say they can do this work without pain, then contact me. I’d like to hear about it.

4. You Must Know How Long to Hold the Point

Holding the Pressure Until the Muscle Releases

I apply consistent and persistent pressure for the entire duration of the application. I hold the point of application until the pain is gone. The pressure must be deep and constant until the pain under my point, and any referred pain, radiating pain, or muscle tenderness from this point, drops to zero. I tell the patient, “We must be thorough, so let me know when you only feel the pressure of my thumb and no tenderness whatsoever before I let up my contact.”

Resetting Chronic Muscle Patterns

Some points are more difficult than others, because they have been there for a longer period of time, establishing their cells in the nervous system, neuromuscular system, and pain pathways as a deeply laid pattern. People are always telling me that they have a high tolerance for pain. That has nothing to do with what we are doing. Either you feel it or you don’t.

Managing Resistant Muscles

In some really hard-to-treat patients, I press down on their muscles and all of a sudden I feel them pushing back at me. It’s like they have a mind of their own. In these cases, I have to try every trick I’ve ever learned to get that muscle to calm down. I lightly shake the body part. I reinforce my pressure by laying my other thumb over the top of the other too because I’m bracing for a long hold, so I don’t fatigue before the point is down. Some patients need to be distracted. In one case, we needed to have her husband talk to her and hold her hand to get the points to go down. These techniques help reduce protective muscle guarding, muscle spasm, neuromuscular tension, and reflex muscle contraction.

Do Not Shorten the Treatment Time

Sometimes patients tell me the pain has subsided when it hasn’t. That is either because they are trying to give me a break, or they are trying to give themselves a break. Do not do this! If you don’t let me maintain the pressure constant and deep until the pain is gone, chances are that tomorrow you will be hurting in all those areas you short-changed yourself on application time. Proper treatment time improves muscle recovery, pain relief, soft tissue healing, and trigger point deactivation.

5. You Must Know Where the Super Contraction Patterns Will Be

Predictable Muscle Contraction Patterns

The location of these shortened muscles forms a pattern according to the exact abnormal patterns you have in your daily life. The muscles contract to resist the pull of gravity on your Human Spring, human spring mechanism, biomechanical system, and postural support system. The patterns are predictable, in patient after patient.

Common Muscle Patterns from Daily Activities

If you perform activities in your daily life that involve a lot of sustained contraction of your right shoulder, then the patterns of painful super contractions, trigger points, and muscle spasms will most likely be in the pectoralis minor muscle, coracobrachialis muscle, lower trapezius muscle, biceps short head muscle, latissimus dorsi, and trapezius muscle on that side.

If you lean back a lot to the right while driving, watching television, or reading this book, then the patterns of painful super contractions, myofascial trigger points, and muscle shortening will most likely be in the scalene muscles on the left side.

The Human Spring Model Predicts Muscle Dysfunction

Because the body is modeled as a Human Spring, spring mechanism, and biomechanical model, and the response to the pull of gravity on the spring is predictable, we are now able to predict where these painful muscle spasms, trigger points, contracted muscles, and myofascial pain patterns are, based on the repeated posture, walking, running, sitting, or standing patterns during daily life. So, the Human Spring Model allows you and your doctor to more accurately predict where and why the trigger point, painful muscle contraction, and muscle spasm will be.

6. You Must Know the Typical Patterns of Referred Pain

Understanding Referred Pain Patterns

You can feel the incredible range of referred pain from these muscles. The referred pain caused by pressure on a super contraction, trigger point, or myofascial trigger point is usually dull and aching, often deep. It can shoot all over your body. For example, deep tissue treatment of the infraspinatus muscle in the back of the shoulder blade usually shoots to the front of the shoulder. Sometimes people feel more numbness, tingling, or radiating pain into the shoulder and arm when doing treatment correctly. That is because the area is already compressed, and you have to compress it deeper, only temporarily, to reset the muscle tension, muscle spindle activity, and neuromuscular control.

Temporary Increase in Pain During Treatment

This radiating pain from the point of pressure varies from being severe and even incapacitating on the first pass through the muscles. When a patient tells me that they feel excruciating radiating pain, referred pain, or trigger point pain from under my thumb pressure, I tell them that is good. It means I’m on the right spot. We aren’t going to get anywhere treating the areas that don’t hurt. This treatment isn’t hurting you. It just hurts.

7. You Must Know What Good Pain Is and What Bad Pain Is

Recognizing Therapeutic Pain

Good pain will subside, if you hold the point. Bad pain will not subside or it will get worse eventually. Sometimes patients get nervous, tighten up, and think it is getting worse. Of course, I know when they are tightening up. I can feel it with my hands and see it in their eyes, what they say and do. You should know your body as I do. Understanding the difference between therapeutic pain, protective pain, muscle guarding, muscle tension, and pain response is essential for safe and effective manual therapy.

8. You Must Increase Circulation to Normalize the Chemistry

Restoring Healthy Blood Flow

This is so the flow of fluid and blood will wash away the inflammation, inflammatory chemicals, lactic acid, metabolic waste, and toxins. Improving circulation, blood flow, oxygen delivery, nutrient delivery, and lymphatic drainage helps normalize the chemistry of the tissue and supports muscle recovery, soft tissue healing, and cellular repair.

Vibration Therapy

Why Vibration Therapy Is One of My Most Important Recovery Tools

The best therapy I have ever found to move oxygen, nutrients, and healthy circulation in and move all inflammatory chemicals, lactic acid, metabolic waste, and toxins out is vibration therapy. I have a powerful, handheld, clinically strong vibration therapy device called the Massage Assist that works well to reduce inflammation, muscle tension, muscle soreness, soft tissue stiffness, and myofascial pain. The Massage Assist power vibrational massage is my number one secret tool that helps me speed the healing process incredibly fast by plowing out the inflammation while vacuuming in healthy circulation with healing oxygen, nutrients, and blood flow at the same time.

How Vibration Therapy Works

Vibration therapy, used properly, involves the 4-inch head of the vibrator angled like a plow to move the inflammation, lactic acid, interstitial fluid, metabolic waste, and other fluids through the area. By stimulating circulation to bring oxygen, nutrients, and healthy blood flow to the area, and by moving the lactic acid, inflammation, toxins, and cellular waste out of the area, we can speed up the release of the compressive force on the thoracic outlet, neurovascular tunnel, and surrounding soft tissues. The reason why this is so effective is it treats large sweeping areas of tissue with a large applicator head, promoting lymphatic drainage, microcirculation, tissue recovery, muscle healing, and faster recovery.

What Is the Theory Behind How Vibration Reprograms Muscle Tension?

What is the theory behind how vibration therapy, neuromuscular stimulation, muscle spindle modulation, proprioceptive stimulation, and mechanoreceptor activation reprogram the muscle tension, restore normal muscle tone, improve neuromuscular control, and promote long-term muscle relaxation?

What Is the Theory Behind How Vibration Therapy Reprograms Muscle Tension?

How Vibration Therapy May Help Reprogram Muscle Tension, Muscle Spasm, and Neuromuscular Function

What is the theory behind how vibration therapy, mechanical vibration, therapeutic vibration, and neuromuscular stimulation reprogram muscle tension, muscle tightness, and protective muscle guarding?

The Filament Tension Release Theory

The Filament Tension Release Theory proposes that muscle spindle cells, Golgi tendon organs, and mechanoreceptors react to abnormal muscle tension, mechanical strain, tissue stress, or soft tissue dysfunction in the surrounding tissue, sending warning messages through the sensory nervous system to the brain and central nervous system to react. The brain reacts by creating additional protective muscle tension, muscle guarding, and reflex muscle contraction in the surrounding tissues around the reactive receptors. The vibration therapy confuses or modulates the sensory nervous system, altering the abnormal sensory input. The nervous system then releases its protective lockdown on the region, allowing the muscle fibers, fascia, and connective tissues to relax and restore more normal neuromuscular function.

The Circulation Theory

The Circulation Theory proposes that the vibration and plow effect of the Massage Assist head create a vacuum effect to draw blood circulation, microcirculation, and tissue perfusion into the area. The increased circulation penetrates rigid muscles and helps restore healthier muscle metabolism, oxygen delivery, and nutrient transport.

1. Oxygen soaks muscles by switching from anaerobic metabolism to aerobic metabolism, thus reducing the production of lactic acid. The reduction of lactic acid increases the tissue pH, allowing the acetylcholinesterase enzyme to break up the acetylcholine to slow or stop abnormal muscle contractions, muscle spasms, and trigger point activity.
2. Vibration therapy and deep pressure into the muscles, tendons, and ligaments mechanically push out the inflammatory chemicals, inflammatory mediators, and acetylcholine that are soaking the tissues. The inflammation no longer stimulates nociceptors ( pain receptors ) to trigger the super contractions, allowing improved pain relief, muscle relaxation, and soft tissue recovery.

The Combination Filament Tension Release and Circulation Theory

I really feel strongly that the way this treatment works is by way of the combination of both theories. I have found vibrating massage, vibration therapy, and mechanical soft tissue therapy work in two ways to mechanically release the area.

1. The vibrating massage stimulates and vibrates the microscopic muscle cells, muscle fibers, and muscle spindle cells at the same time as it compresses the spindle cells to unload the tension from the spindle cells. That message is sent to the brain, which then releases the protective reflex spasm, protective muscle guarding, and abnormal muscle contraction in the muscle that is being treated.
2. It mechanically stretches the skin away from the underlying fascia, connective tissue, and myofascial layers to help break adhesions, soft tissue restrictions, and fascial adhesions between the tissues that have developed as a result of stagnation of movement from the chronic pain syndrome effect. The effect is similar to a vibrational Rolfing®, myofascial release, or fascial mobilization.

How Vibration Therapy May Normalize Muscle Biochemistry and Inflammation

Vibration therapy helps tremendously to normalize the biochemistry, muscle physiology, and cellular environment in two ways.

1. When applied properly, it acts like a plow with vibration to plow the inflammatory chemicals, inflammatory mediators, metabolic waste, and pro-inflammatory cytokines out of the tissues. It also stimulates a vacuum effect that increases blood flow, circulation, and microvascular perfusion to help bring healthy oxygen, nutrients, and healing factors to the area for rapid tissue healing, muscle recovery, and soft tissue repair to take place.
2. It also increases blood flow into the area to flush the lactic acid out of the tissues, neutralizing the acidic environment. This helps to allow the acetylcholinesterase to become activated so it can break up the acetylcholine, so it does not keep retriggering the trigger points, myofascial trigger points, muscle spasms, and super contractions.

Research on Vibration Therapy for Neurological, Musculoskeletal, and Pain Conditions

There has been a lot of research on vibration therapy, whole-body vibration, local vibration therapy, and mechanical vibration therapy lately in treating patients with muscle spasticity due to stroke, multiple sclerosis (MS), dystonia, fracture healing, peripheral neuropathy, fibromyalgia, depression, muscle soreness, osteoporosis, wound healing, urinary incontinence, balance disorders, temporomandibular joint (TMJ) dysfunction, delayed onset muscle soreness (DOMS), fibrous cellulite, multiple sclerosis, muscular dystrophy, functional constipation, and pressure ulcers.

Research Showing Reduced Inflammation Following Vibration Therapy

There has been one research study that showed significant reduction in inflammation with vibration massage. This research study was conducted on 29 runners who completed a 40-minute downhill run, which produced exercise-induced muscle soreness, muscle damage, and delayed onset muscle soreness (DOMS). Vibration therapy was performed on half and no vibration therapy was applied to the other runners (25). The runners got about five sessions of vibration therapy for 30 minutes for each treatment (25).

The researchers tested the pain levels in the calf muscles and gluteal muscles for pain values. When they compared runners who had vibration therapy to runners who did not, they noticed the runners who got vibration therapy had the following:

• Significantly decreased calf muscle pain, 30–40 percent
• Significantly decreased gluteal muscle pain, 30–40 percent
• Significantly decreased IL-6 (interleukin-6), 30 percent
• Significantly decreased histamine, 48 percent (25)

How Vibration Therapy May Reduce IL-6, Histamine, and Inflammation

The vibration therapy significantly lowered IL-6 (interleukin-6) concentration by either clearing it out of the tissue or reducing the production. The study suggested that vibration therapy might reduce inflammation, exercise-induced inflammation, and the inflammatory response, accounting for a decreased IL-6 release from muscle (25).

Histamine increases inflammation in the area. You might take antihistamines for colds. This study also noted a significant reduction in levels of histamine by an average of 48 percent. So, according to the results of this study, vibration therapy, vibration massage, and mechanical soft tissue therapy could be effective in reducing inflammation, muscle inflammation, exercise-induced muscle soreness, and soft tissue inflammation in the area (25).

How I Use Vibration Therapy for Pain Relief, Inflammation Reduction, and Muscle Recovery

When I use vibration therapy, patients have a noticeable reduction in aches and pains, muscle soreness, musculoskeletal pain, and soft tissue discomfort, and these aches and pains do not return to the same intensity during the next 72 hours. Therefore, I think there is a large reduction in production and an increase in clearance of the inflammation-stimulating proteins, pro-inflammatory cytokines, and inflammatory mediators that contribute to chronic inflammation, pain sensitization, and delayed tissue healing.

The Massage Assist handheld vibrating massager can be directed to the specific muscle, fascia, connective tissue, or soft tissue I want to target. Because it has a soft, deformable applicator head, I can get into tight areas where a whole-body vibration platform or vibrating platform plate cannot. I can also direct the vibrating massager head on an angle, like a plow, and starting at one end of a muscle, I plow deep into the muscle to help mobilize interstitial fluid, encourage lymphatic drainage, improve microcirculation, enhance blood flow, and assist the body in clearing inflammatory waste products from one end of the muscle to the other.

It is also suggested that vibration therapy, mechanical stimulation, and therapeutic vibration might activate muscle satellite cells through compression, increased blood circulation, enhanced tissue perfusion, and the tonic vibration reflex (25). Activation of adult muscle satellite cells is a key element in this process of muscle repair, skeletal muscle regeneration, tissue remodeling, and recovery after injury. In addition, recent evidence supports the possible contribution of adult stem cells, muscle stem cells, and regenerative cells in the muscle regeneration process (30).

Reducing Chronic Inflammation and Cytokines to Support Healthy Aging

Many scientists believe that chronic inflammation, controlled by these tiny proteins called cytokines, including interleukin-6 (IL-6), is the common denominator of many age-related diseases, degenerative conditions, and chronic inflammatory disorders. Therefore, keeping your cytokine levels lower may help reduce the effects of inflammaging, systemic inflammation, and chronic immune activation. Cytokines play an important role in the body's immune response, tissue repair, and inflammatory response. While acute inflammation is essential for a healthy immune response and normal healing, excessive or prolonged production of pro-inflammatory cytokines has the potential to induce cellular damage, oxidative stress, pain, and progressive tissue degeneration.

How Vibrational Massage Changes Pain During Treatment

You can feel pain, muscle tension, soft tissue tightness, and myofascial restriction subside by the minute.

Patients can feel the vibrational massage reducing the pain with each pass of the massager. It has a drastic, positive effect on improving tissue health, muscle function, blood circulation, lymphatic circulation, soft tissue mobility, and reducing aches, muscle pain, myofascial pain, and speeding healing, tissue recovery, and functional restoration.

This vibration therapy is the only therapy I use in my office for patients with neck pain, cervical pain, upper back pain, shoulder pain, myofascial pain syndrome, and thoracic outlet syndrome (TOS). For more information, go to www.massageassist.com and watch the videos of the machine in action.

9. You Must Know How the Symptoms Progress During Treatment

Initially, the first few applications exhibit moderate to severe and, at times, extreme pain upon each application. The duration of pain is longer in the beginning, dropping off slowly as time passes while I am holding the point. This is common in patients with chronic pain, muscle trigger points, myofascial dysfunction, central sensitization, and long-standing muscle tension.

At approximately visits three, four, and five, you will start to feel the intensity drop on the initial application, and the tenderness under the application site will reduce much faster. This is an indication that you are successfully reprogramming the brain, central nervous system, pain pathways, and neuromuscular movement pattern.

By visits six, seven, and eight, you should feel intensity of pain reduced on initial application, and the intensity will drop quickly with each application. By applications nine and ten, there should be minimal muscle tenderness, trigger point sensitivity, and soft tissue pain, and the tenderness will drop off fast. After visit 10, we are just fine-tuning the area, looking for tender muscles that are activated and identifying any remaining muscle dysfunction, movement compensation, or residual myofascial restriction.

10. You Need to Know How Long Each Thoracic Outlet Syndrome Treatment Will Take

This is one of the key areas where well-designed thoracic outlet syndrome treatment approaches fail to remove the compression on your thoracic outlet. If it takes 90 minutes to meticulously treat the areas of pathologic muscle tension, myofascial tightness, and muscle shortening that are compressing your thoracic outlet, brachial plexus, subclavian artery, and subclavian vein, and your insurance only covers 45 minutes, does your therapist stop at 45 minutes and leave you only half treated? Most do. In hospital physical therapy centers, the therapist is limited to only the maximum amount of time allocated by your insurance plan.

To get an estimate of how long each treatment should take, you have to know how many muscles are compressing the outlet, perform a measurement of how long each muscle is, then determine how chronic or resistant to treatment the trigger points, myofascial adhesions, and muscle dysfunction are in this pattern.

The Chinese measure the body with the thumb pad, described as one cun. The cun is a way to measure distance in the body. In this application, we are using the cun to measure the length of the muscle we have to treat.

Once you have determined how many cun you have to cover, you can get an estimate of the full treatment by treating a few points and clocking the time it takes to drop the pain to zero pain. This provides a practical estimate of the treatment time required for soft tissue therapy, myofascial release, and muscle rehabilitation.

If it takes two minutes for a muscle pain to drop under your contact point, then you multiply three times the estimated amount of cun necessary to treat the entire area affected. This is an estimate of how many cun each muscle measures on an adult male.

Estimated Muscle Length Using the Cun Measurement System

Scale—1 cun = 1 square inch = one thumb pad

1. Anterior scalene muscle —5 cun
2. Middle scalene muscle —5 cun
3. Posterior scalene muscle —5 cun
4. Subclavius muscle —6 cun
5. Biceps short head muscle —4 cun
6. Coracobrachialis muscle —4 cun
7. Pectoralis minor muscle —5 cun
8. Anterior cervical (neck) muscles —4 cun
9. Latissimus dorsi muscle —4 cun
10. Lower trapezius muscle —6 cun

Additional Muscles to Be Considered

• Upper trapezius muscle —6 cun
• Levator scapulae muscle —6 cun

Calculating the Total Treatment Area and Pressure Points

The total area to cover is 60 cun, or 60 total therapeutic pressure points, per side. This treatment area includes the muscles, fascia, connective tissues, and anatomical structures that may directly or indirectly contribute to thoracic outlet compression, neurovascular compression, muscle tension, and restricted upper-body biomechanics.

The total surface area depends on whether you are treating a person with a small frame, a bigger frame, smaller muscles, or bigger muscles. Manual therapy applications, deep-tissue treatment, and the amount of tissue covered also depend on the size of the therapist’s thumb or hands. Larger hands mean a larger thumb pad and a larger treatment contact area. I have larger hands. Patients take photos of my hands and post them on Facebook. That’s embarrassing.

Treatment Time for Severe Chronic Thoracic Outlet Syndrome

If you have a chronic, severely compressed upper body, it might take three or more minutes per application point. In a patient with severe chronic thoracic outlet syndrome, long-standing muscle compression, fascial restriction, protective muscle guarding, or significant soft-tissue adhesions, each treatment point may require additional time.

If you are that patient, it would take an estimated 180 minutes to treat all the muscles that directly or indirectly compress the outlet on one side of the body during each of the first three visits. These may include muscles and tissues associated with the thoracic outlet, cervical spine, shoulder girdle, upper chest, rib cage, scalene triangle, costoclavicular space, and pectoralis minor space.

If the thoracic outlet syndrome, or TOS, is severe and occurs on both sides, you have to double the treatment time. Bilateral thoracic outlet syndrome requires treatment of the muscular, fascial, and biomechanical contributors on both sides of the body.

Here is a mathematical estimate of how much time it would take to treat a severe chronic case of thoracic outlet syndrome that is extremely resistant to other conservative treatments, including previous physical therapy, chiropractic care, massage therapy, stretching programs, or other forms of nonsurgical treatment.

Treatments 1, 2, and 3—Severe-to-Moderate Inflammation and Pain Phase

• Vibrational massage therapy —30 minutes before treatment to stimulate local circulation, warm the tissues, reduce muscle guarding, and prepare the muscles and fascia for deep-tissue treatment.
• Deep-tissue treatment —3 minutes per pressure point (cun) × 60 pressure points (cun) = 180 minutes, or 3 hours, per treatment. This extended manual therapy session is designed to address severe muscle tightness, fascial restriction, myofascial tension, and tissues that may contribute to brachial plexus compression or compression of the subclavian artery and vein.
• Vibrational massage therapy —30 minutes after treatment to help move the inflammation and toxins moved out of the muscles by the deep tissue out of the area through the lymphatic and circulatory systems. More specifically, post-treatment vibration may support venous circulation, lymphatic drainage, movement of interstitial fluid, and clearance of metabolic waste products released or mobilized during intensive soft-tissue therapy.

That means it will take a total of about four hours to complete a thorough treatment of one side of the body in a patient with chronic, severe thoracic outlet compression. This does not include breaks to use the restroom, answer calls, or the time it takes to change positions during the thoracic outlet syndrome treatment session.

It is common for me to work for three to four hours on one side of the body during the first application in a severe case of thoracic outlet syndrome. This amount of time may be necessary when treating extensive muscle tension, fibrotic tissue, scar tissue, myofascial adhesions, and chronic neuromuscular guarding patterns.

Total Deep-Tissue Treatment Time

Total deep-tissue treatment time = 180 minutes per pass × 3 treatments = 540 minutes, or nine hours.

Vibrational massage therapy —one hour per treatment, or three hours total.

Severe-to-Moderate Inflammation and Pain Phase Total Treatment Time = 12 hours

Treatments 4, 5, 6, and 7—Moderate-to-Mild Inflammation and Pain Phase

• Vibrational massage therapy —30 minutes before treatment to stimulate blood circulation, encourage tissue warming, reduce muscle stiffness, and prepare the area for continued manual soft-tissue treatment.
• Deep-tissue treatment —2 minutes per pressure point (cun) × 60 pressure points (cun) = 120 minutes, or 2 hours, per treatment. During this phase, treatment continues to address remaining muscle compression, fascial adhesions, trigger points, soft-tissue restrictions, and impaired shoulder-girdle mobility.
• Vibrational massage therapy —30 minutes after treatment to help move the inflammation and toxins moved out of the muscles by the deep tissue out of the area through the lymphatic and circulatory systems. This post-treatment application is intended to support circulatory recovery, lymphatic flow, interstitial fluid movement, and the removal of cellular and metabolic waste products from the treated tissues.

Total deep-tissue treatment time is 120 minutes per pass × 4 treatments = 480 minutes, or eight hours.

Vibrational massage therapy —one hour per treatment, or four hours total.

Moderate-to-Mild Inflammation and Pain Phase Total Treatment Time = 12 hours

Treatments 8, 9, and 10—Mild-to-Minimal Inflammation and Pain Phase

• Vibrational massage therapy —30 minutes before treatment to stimulate circulation, improve tissue mobility, decrease residual muscle tightness, and prepare the tissues for the final phase of thoracic outlet rehabilitation.
• Deep-tissue treatment —1 minute per pressure point (cun) × 60 pressure points (cun) = 60 minutes, or 1 hour, per treatment. During this phase, treatment focuses on remaining myofascial restrictions, residual muscle guarding, persistent tender points, and restoration of more normal muscle function and upper-extremity biomechanics.
• Vibrational massage therapy —30 minutes after treatment to help move the inflammation and toxins moved out of the muscles by the deep tissue out of the area through the lymphatic and circulatory systems. This final application may support post-treatment circulation, lymphatic drainage, fluid exchange, and recovery of the treated muscles and connective tissues.

Total deep-tissue treatment time is 60 minutes per pass × 3 treatments = 180 minutes, or three hours.

Vibrational massage therapy —one hour per treatment, or three hours total.

Mild-to-Minimal Inflammation and Pain Phase Total Treatment Time = 6 hours

Total Estimated Treatment Time

Total estimated treatment time for severe chronic thoracic outlet syndrome on one side = 30 hours.

This thoracic outlet syndrome treatment time is just an estimate. Every patient has a different degree of neurovascular compression, muscle tension, fascial restriction, scar-tissue formation, pain sensitivity, and biomechanical dysfunction.

If you have TOS on both sides, the treatment time will be longer, but it may not be exactly double. Also, if you add occasional breaks to rest my hands, restroom breaks, and time to make phone calls, it will add up to more time. With no complications and allowing some time for restroom and meal breaks, you could estimate that it would take about 30–40 hours.

Treatments would be three hours long at the longest. The exact length of each manual therapy session depends on the patient’s condition, tolerance, response to treatment, degree of soft-tissue restriction, and the number of anatomical areas requiring treatment.

Why Long-Standing TOS May Require Extended Treatment

The total treatment time for this patient could be 29–30 hours with no breaks in a severe thoracic outlet syndrome case. Now remember, these patients have been to many different healers, and they have had thoracic outlet syndrome for 2–10 years. This means the protective reflexes may be locked deeply in the brain and central nervous system, and there might be a lot of scar tissue, fibrosis, adhesions, and chronic tension in the muscles and joints.

Long-standing pain may be associated with persistent neuromuscular guarding, altered motor-control patterns, pain sensitization, restricted joint mobility, and chronic changes in the way the brain coordinates movement. These factors may make a severe case of neurogenic thoracic outlet syndrome, vascular thoracic outlet syndrome, or combined thoracic outlet compression more resistant to conservative care.

Restoring the Human Spring

I don’t make the rules. I work with what I have, do the math, and do whatever it takes to get the patient not only out of pain but also to restore that patient’s Human Spring to as close to perfect as humanly possible.

Restoring the Human Spring requires more than temporarily reducing symptoms. The objective is to improve biomechanical function, restore elastic movement, reduce abnormal muscle and fascial tension, improve joint spacing, and decrease the mechanical forces contributing to compression of the brachial plexus, subclavian vessels, and surrounding thoracic outlet anatomy.

Why I Use Intensive Conservative Treatment

Some doctors and therapists might think this is excessive compared with their treatment approaches. However, I have an obsession with ensuring that none of my patients’ conditions stagnate or get worse, causing them to end up in surgery.

I see the statistics from studies of conservative thoracic outlet syndrome care performed at hospital-based physical therapy centers. I cannot tolerate failure, so when a case starts to stagnate, I provide more intensive treatment for longer sessions until we get over the hump.

The objective of this intensive nonsurgical thoracic outlet syndrome treatment is to overcome persistent soft-tissue compression, restore more normal thoracic outlet biomechanics, improve upper-extremity function, reduce pain and neurological symptoms, and help the patient avoid unnecessary thoracic outlet surgery whenever possible.

11. Know When the Muscles Are Completely Released

You continue to treat the muscles until all muscles are pain-free during pressure treatment. The treatment and duration of care is not predicated on how many visits, but how much time you spend each visit. Outcomes are always better when treatments are closer together. The goal is to achieve complete muscle release, muscle relaxation, myofascial release, reduced muscle guarding, reduced muscle spasm, neuromuscular recovery, and restoration of normal muscle tone before ending treatment.

For physical therapists who work for hospitals, they have supervisors who tell them when they have extended beyond the time that the insurance will pay. If you can find a talented physical therapist who is willing to work on all 12 of these muscles with manual therapy, deep tissue therapy, myofascial therapy, trigger point therapy, and takes the necessary time to drop each spasm under each thumb pad application, they will often extend beyond what you are covered for on even the best insurance plan in the world in 45 minutes. Then, magically you are done.

Because this is not enough time to turn off the muscle spindle reflex, protective muscle spasm, neuromuscular reflex, and super-spasm reflex in the brain; that is why you end up feeling only a little better after your therapy is done. Thoracic outlet syndrome (TOS) recovery requires enough treatment time to restore normal muscle function, reduce nerve compression, improve blood circulation, and decrease chronic soft tissue tension.

The Self-Help Approach to Treating Your Thoracic Outlet Syndrome (TOS)

Step #1 – 30 Minutes of Vibration Therapy for Thoracic Outlet Syndrome

Do a 30-minute application of vibration therapy, mechanical vibration therapy, or vibration massage therapy to the 10 muscles that are compressing the thoracic outlet, contributing to thoracic outlet syndrome (TOS), nerve compression, vascular compression, and muscle tightness.

• The vibrating applicator head should be angled like a plow to plow out the inflammation, lactic acid, metabolic waste products, interstitial fluid, and cellular waste from the area.
• On the back end this plow action will vacuum fresh blood to flood the oxygen-starved, damaged, and fatigued muscle cells with oxygen, nutrients, and improved microcirculation to rejuvenate them.
• This creates a river of fluids to carry away the inflammatory chemicals, cytokines, lactic acid, and metabolic waste products away from the area while improving lymphatic drainage and tissue recovery.

Step #2 – Deep Tissue Therapy for Thoracic Outlet Syndrome

Do deep tissue therapy, manual therapy, and myofascial release to the 10 muscles that are compressing the thoracic outlet.

• Manipulate the muscle spindle cells and Golgi tendon organ reflex cells of the sensory nervous system so they will send a message to the brain to reset the tension on muscles surrounding the thoracic outlet, improving neuromuscular control, muscle relaxation, and muscle flexibility.
• Direct deep pressure pushes the inflammation, lactic acid, metabolic waste products, and interstitial fluid out of the muscles into the interstitial space (space between the cells), preparing them for improved lymphatic drainage and circulation.

Step #3 – Repeat 30 Minutes of Vibration Therapy

Do a second 30-minute application of vibration therapy to the 10 muscles that are compressing the thoracic outlet.

• Again, the vibrating applicator head should be angled like a plow to plow out the inflammation, lactic acid, metabolic waste products, interstitial fluid, and cellular debris from the area that were created by the deep tissue treatment, further improving lymphatic flow, venous return, muscle recovery, and soft tissue healing.

Repeat the Treatment Cycle

Continue repeating the vibration therapy, deep tissue therapy, and lymphatic drainage sequence until the muscles become completely released and remain pain-free during treatment. Repeated treatment cycles help reduce chronic muscle spasm, improve soft tissue mobility, decrease nerve entrapment, and promote long-term thoracic outlet syndrome recovery.

The Self-Help Approach to Treating Your Thoracic Outlet Syndrome (TOS)

Step #1 – 30 Minutes of Vibration Therapy

Listen, treating a severe chronic case of thoracic outlet syndrome (TOS) is extremely exhausting and grueling for me even with the massager and I have very powerful resilient precision hands and Ive been doing it for years. When you or someone you love try to get through all these points in all 10 of these muscles and get tired in the first 15 minutes its time to get some help. Severe chronic pain, muscle fibrosis, myofascial restriction, muscle spasm, soft tissue dysfunction, and nerve compression often require persistence, proper technique, and assistance to achieve full muscle release.

Lymphatic Drainage System Treatments

The circulatory system is composed of the heart (pump), arteries that supply blood to the cells, and veins which return the blood to the heart. That is why it is called the circulatory system because it circulates the blood around the body, delivering oxygen, nutrients, and removing metabolic waste.

There is another system that works in a similar way called the lymphatic system. It is composed of lymphatic organs, lymph nodes, lymph glands, and a plumbing system that moves a clear fluid called lymph through the body. This important part of the immune system helps remove inflammation, cellular waste, proteins, and excess interstitial fluid.

On an average day you will move 2–3 quarts of lymph through your body. That is a lot! Healthy lymph circulation plays an essential role in immune function, tissue healing, fluid balance, and waste removal.

The lymphatic system has a superficial layer, which is closer to the skin, which drains fluids from the tissue by the skin. The deep layer drains around muscles, tendon sheaths, fascia, and the peripheral nerves. Together they drain this lymph away from the surface and into increasingly larger vessels (pipes) back to the heart.

When we push the toxins, inflammation, lactic acid, metabolic waste, and cellular debris out of the muscles it flows in the space between the cells and space between the skin and muscles called interstitial space. Then from there it enters tiny lymphatic capillaries where the lymph fluid begins its journey through smaller vessels to larger vessels until it returns back to the heart.

When you do a lot of work on muscles you must work the waste away from the muscles via the lymphatic system. We use the vibrating massager to plow this lymph through the lymphatic drainage system by plowing the lymph in the direction of smaller to larger vessels. This may help improve lymphatic flow, fluid movement, circulation, soft tissue recovery, and post-treatment healing.

If you would like to see a video demonstration of how it is done with the vibrating massager go to www.thoracicoutletsyndrome.com or our YouTube channel and look for the tutorials on lymphatic drainage, vibration therapy, thoracic outlet syndrome treatment, and manual therapy.

Step #2 – Deep Tissue Therapy for the 10 Muscles Compressing the Thoracic Outlet

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)

Anterior neck muscles (compression of the neck)

Anterior and Middle Scalene Muscles

SELF HELP

Anterior Scalene – Side lying

Anterior Scalene Muscle - Sitting

Middle Scalene Muscle – Side Lying

Middle Scalene Muscle – Sitting

Posterior Scalene Muscle – Sitting

Subclavius Muscle

Illustration Subclavius Purple

Subclavius Muscle

Pectoralis Minor Muscle

Illustration Pectoralis Minor Purple

Pectoralis Minor Muscle

Biceps Short Head & Coracobrachialis Muscles

Illustration Bicep Short Coracobrachialis Purple

Coracobrachialis &

Biceps Short Head - Sitting

Illustration Upper Trapezius Levator Scapula Purple

Latissimus Dorsi Muscle

Illustration Latissimus Dorsi Purple

Lower Trapezius Muscle

When Do You Need Help from a Professional for Thoracic Outlet Syndrome?

Many of you are going to find out that self-help treatment, self-care, and home therapy for minor aches and pains, muscle tightness, and soft tissue discomfort work well. However, if you have Thoracic Outlet Syndrome (TOS), neurogenic thoracic outlet syndrome, or thoracic outlet compression, the amount of work necessary to reverse this condition is daunting. Chronic thoracic outlet syndrome, nerve compression, vascular compression, muscle dysfunction, postural dysfunction, myofascial restrictions, and connective tissue tightness often require far more treatment than most people expect.

I have very strong hands that don’t get a bit tired after 10–12 hours of deep tissue therapy, manual therapy, myofascial release, soft tissue mobilization, and trigger point treatment per day.

In fact, in 2009, my staff calculated that I worked more than 16 hours per day for 135 days in a row without a day off until I worked 27 hours straight for Steely Dan Tour. My hands finally needed a day off. After that day off I worked 16 hours a day for 101 days straight before my hands needed a day off.

So if treating a chronic case of Thoracic Outlet Syndrome, chronic nerve entrapment, musculoskeletal dysfunction, and soft tissue compression is grueling for me, I guarantee it will be even more difficult for you to resolve, especially if you don’t even use vibrational massage, vibration therapy, therapeutic vibration, circulation therapy, and mechanical muscle stimulation!!!!

Professional Treatment Techniques for the 10 Muscles That Compress the Thoracic Outlet

In this section I am presenting my core treatment techniques for treating the 10 muscles that compress the thoracic outlet, contributing to Thoracic Outlet Syndrome, brachial plexus compression, neurovascular compression, shoulder dysfunction, neck pain, arm pain, nerve irritation, and restricted movement. I do a lot more techniques than this because treatment for me is like an art form rather than something technical, but if you bring this book to your best hands-on practitioner, manual therapist, physical therapist, chiropractor, massage therapist, or soft tissue specialist, they should be able to help you.

Step #1 – Apply 30 Minutes of Vibration Therapy to the 10 Muscles Compressing the Thoracic Outlet

Step #1 – I use a 30-minute application of vibration therapy, vibrational massage, mechanical vibration, therapeutic vibration, and soft tissue vibration to the 10 muscles that are compressing the thoracic outlet. This helps prepare the tissues for treatment by promoting muscle relaxation, circulation, blood flow, microcirculation, lymphatic drainage, soft tissue mobility, fascia mobility, myofascial release, and reduced muscle guarding before deeper manual treatment begins.

Vibrational Massage Effect on Circulation

Vibrational massage, vibration therapy, and mechanical muscle stimulation help improve local circulation, microcirculation, blood flow, venous return, lymphatic drainage, oxygen delivery, nutrient delivery, and the removal of metabolic waste, creating healthier tissue conditions before performing deep tissue therapy and manual soft tissue treatment.

Latissimus Dorsi / Lower Trapezius Muscle

The Latissimus Dorsi and Lower Trapezius play important roles in shoulder biomechanics, scapular stability, postural alignment, thoracic mobility, and upper extremity movement. Dysfunction within these muscles can contribute to Thoracic Outlet Syndrome, scapular dyskinesis, muscle imbalance, shoulder pain, neck pain, and nerve compression.

Coracobrachialis / Biceps Short Head Muscles

The Coracobrachialis and Biceps Short Head can become chronically shortened and contribute to anterior shoulder tightness, brachial plexus compression, pectoral tightness, restricted shoulder motion, nerve irritation, and Thoracic Outlet Syndrome. Proper treatment of these muscles helps restore normal shoulder mechanics, soft tissue mobility, and functional movement.

Video Tutorials for Thoracic Outlet Syndrome Treatment

Team Doctors® has many video tutorials on the proper form and technique for massaging the 10 muscles that compress the thoracic outlet in the video tutorial section of www.teamdoctorsacademy.com and in our YouTube channel. These educational videos demonstrate proper manual therapy, deep tissue massage, myofascial release, soft tissue mobilization, Thoracic Outlet Syndrome treatment, self-treatment techniques, muscle release techniques, and recovery strategies designed to help improve mobility, circulation, and nerve decompression.

Do You Need a Professional to Lower Your First and Second Rib?

Do you need a professional to lower your first rib and second rib out of the thoracic outlet? In many cases involving Thoracic Outlet Syndrome, rib elevation, rib dysfunction, costovertebral joint dysfunction, scalene muscle tightness, and rib mobility restrictions, professional evaluation and treatment by an experienced manual therapist, physical therapist, chiropractor, or Thoracic Outlet Syndrome specialist may be necessary to restore proper rib mechanics, thoracic outlet space, and neurovascular function.

Step #2 – Deep Tissue Treatment to the 10 Muscles Compressing the Thoracic Outlet

Step #2 – Apply deep tissue therapy, deep tissue massage, manual therapy, myofascial release, trigger point therapy, soft tissue mobilization, and muscle release techniques to the 10 muscles that are compressing the thoracic outlet. This stage focuses on reducing muscle tightness, myofascial adhesions, trigger points, connective tissue restrictions, nerve compression, brachial plexus irritation, and soft tissue dysfunction while restoring normal biomechanics, range of motion, circulation, and functional movement associated with recovery from Thoracic Outlet Syndrome.

PROFESSIONAL TREATMENT

Anterior Scalene Muscle

Scalene Muscles (Underhook Grip)

Middle Scalene Muscle

Latissimus Dorsi Muscle

Lower Trapezius Muscle

Pectoralis Minor Muscle

Coracobrachialis &

Biceps Short Head

Muscles

Supraspinatus Muscle

Rotator Cuff (External Rotation Muscles)

Upper Trapezius Muscle

Subclavius Muscle

Anterior Deltoid Muscle

How Frequently Should Thoracic Outlet Syndrome Treatment Be Applied?

There are many studies that say conservative treatment, conservative therapy, and non-surgical treatment for thoracic outlet syndrome could be attempted for 2 days, 12 days, 12 weeks, or 12 months. The average is approximately six months (21–22). I have never had a patient take 12 weeks to reverse thoracic outlet syndrome (TOS). When scheduling a patient, I asked them a simple question, “How fast do you want to get better? Slow? Fast? Exceptionally fast?”

The standard of care for many patients usually consists of three treatments per week, with approximately 15 minutes of deep tissue therapy, manual therapy, and soft tissue treatment per session. At this rate, it could take weeks to months to fully reverse the condition and, in many cases, the ongoing postural dysfunction, poor biomechanics, gravity-related compression, repetitive strain, and continual violations of the laws of gravity might be enough to reverse the positive effects of the treatment. Consistency, corrective treatment, and reducing daily thoracic outlet compression are critical for long-term recovery.

All Ribs and Shoulder Joints Must Be Readjusted for Thoracic Outlet Syndrome Recovery

Rib Cage Compression and First and Second Rib Elevation

If you have an advanced case of thoracic outlet syndrome, you could have a few ribs, many ribs, or all of the ribs restricted by shortened muscle spasms, muscle contractures, and myofascial tightness. You might have sharp pains in the ribs during deep breathing, rib expansion, or chest wall movement. The collarbone attachment at the sternum ( sternoclavicular joint ) and the shoulder must be mobilized to restore normal joint mobility, rib cage mobility, and shoulder girdle biomechanics.

The subclavius muscle has been shortened for so long that it has compressed the clavicle (collarbone) and entire shoulder downward into the thoracic outlet, jamming the outlet and neurovascular tunnel. This ongoing compression syndrome can reduce the available space for the brachial plexus, subclavian artery, and subclavian vein, increasing nerve compression, vascular compression, pain, numbness, tingling, weakness, and other thoracic outlet syndrome symptoms.

Because the pectoralis minor muscle, the coracobrachialis muscle, and the short head of the biceps muscle have been contracting for so long, the entire shoulder girdle, scapula, and clavicle have shifted downward and forward into the thoracic outlet. Restoring mobility of the first rib can increase the space between your ribs and collarbone, improve thoracic outlet space, reduce neurovascular compression, and decrease compression on the blood vessels and nerves traveling through the thoracic outlet tunnel. Practitioners have reported decreased thoracic outlet syndrome symptoms by restoring the mobility of the first rib through hands-on treatment, manual therapy, and joint mobilization techniques (31–33).

Can I Adjust My Own First and Second Ribs?

In one scientific paper I read, the author suggested that patients might be taught a first rib self-mobilization technique to be performed as part of a home exercise program, self-care program, and rehabilitation program (34).

Honestly, I’ve never heard of a successful self-mobilization of the first rib. The problem is that it is almost impossible to get your body sufficiently relaxed to adjust the ribs from the top downward and get them to release. Effective rib mobilization, joint manipulation, and manual correction require overcoming years of muscle guarding, protective muscle spasm, connective tissue restriction, and myofascial shortening, which is extremely difficult to accomplish on yourself.

In fact, when my first and second ribs were raised and locked, I tried everything for three years to get them to release and move but couldn’t find a way.

The shortened scalene muscles elevate the first and second ribs and can cause pain between the shoulder blades, upper back pain, and/or intermittent pain with deep breathing. This is caused by a shortened pectoralis minor muscle lifting the third, fourth, and fifth ribs. This altered rib cage biomechanics, muscle imbalance, and postural dysfunction contribute to the pain between your shoulder blades and are common findings in people suffering from thoracic outlet syndrome, neck pain, shoulder pain, and upper extremity nerve compression.

Cracking Your Own Neck or Self-Adjustments—Don't Do This!

I often see patients self-adjusting their neck, performing neck cracking, or attempting self-manipulation of the cervical spine. I highly recommend you never do this. You might find temporary relief from the release of tension caused by the magic crack, but in the long run you will find this to be a bad idea. While it may briefly reduce neck stiffness, muscle tension, or the feeling of cervical tightness, it does not correct the underlying biomechanical dysfunction or thoracic outlet syndrome (TOS) that is causing the problem.

You feel the tension in the neck and the urge to stretch it sets in. You stretch your neck to the side, then hear the magical cracking noise and feel the relief. You are thinking that you just performed a self-adjustment, neck manipulation, or cervical adjustment and don’t need a chiropractor. Unfortunately, that temporary relief is often misleading because it does not restore proper joint mechanics, rib position, posture, or soft tissue function.

The Hidden Damage of the "Stretch-Crack"

The problem is that you used the 9–12-pound mass (your head) to stretch ONLY the muscles from the base of the neck to the top of the neck. I call this a “stretch-crack.” A stretch adjustment, or stretch-crack, creates tiny microtears, ligament strain, and muscle fiber injury involving the muscles and the ligaments that support your cervical spine, causing them to become inflamed. The short-term reward of the magic stretch-crack and the temporary relief tempts you to do the stretch-crack again, so you do it. Soon you are stretch-cracking seven to ten times a day. Over time this repetitive habit may contribute to joint instability, chronic inflammation, neck pain, muscle guarding, and worsening cervical dysfunction.

Never Self-Adjust or Crack Your Neck Using Your Jaw

I see people grab their jaws and use it as a fulcrum to really crank on the neck. It makes me cringe. You can damage the jaw muscles, ligaments, temporomandibular joint (TMJ), and the alignment of the opening and closing of the mouth. The result could be temporomandibular joint disorder (TMJ disorder), TMJ dysfunction, jaw pain, facial pain, muscle disorders, or other problems or symptoms involving the muscles and joints that connect your lower jaw to your skull.

Protect Your Jaw and Cervical Spine

This could be much worse than thoracic outlet syndrome, and harder to find help for it. Don’t do this! Just work on the muscles around the neck with the exercises, and let the vertebrae in the neck release naturally. If you need help, seek the professional services of a chiropractor trained in cervical spine biomechanics, manual therapy, and thoracic outlet syndrome treatment. Never adjust another person without training. This is not part of your self-help training in this book.

Three dimensional Computed Tomography (3D CT scan) of facial bone, case of facial asymmetry, dislocation of left temporomandibular joint (TMJ)

First and Second Rib Adjustments Are Necessary for Maximum Medical Improvement of Thoracic Outlet Syndrome

If you don’t get the first rib adjusted down out of the thoracic outlet, it is most likely you will never reach maximum medical improvement (MMI). Proper first rib mobility, rib alignment, and thoracic outlet decompression are critical components of successful thoracic outlet syndrome treatment. Why do you think surgeons remove the first rib on patients who have failed to get relief from conservative treatment?

So, because you cannot find a good chiropractor to adjust the first rib you cut it out of your body. If anyone tells you that adjustment of the first rib or any adjustment will make you worse, find another doctor. This is not found in any scientific literature and absolutely not true.

1st Rib Adjustment

First rib and rib adjustments in general are tricky. You might find it challenging to locate a chiropractor who can give you a really good first rib adjustment, manual rib mobilization, or thoracic outlet correction. As a chiropractic student, I couldn’t find anyone in the student clinic who gave a solid rib adjustment, but they were newbies. I had to drive 40 minutes to my father’s office to get a really good adjustment. After I graduated, I went to many chiropractors’ offices and found only one or two who could give a solid rib adjustment. Once you find one, email me at teamdoctors@aol.com, so I can spread the word.

Proper Rib Position Matters More Than Professional Labels

I really don’t care what you think of chiropractic, me, or what profession I got my doctorate degree in. That doesn’t matter to me, but what should matter to you is that your rib is positioned too high in the thoracic outlet, creating nerve compression, vascular compression, and thoracic outlet narrowing, and it isn’t going to slide down on its own. There are no exercises to adjust the tension to pull the ribs down, so you have only one choice. You must get your ribs adjusted down manually by someone who knows how to do it and do it well.

If you don’t adjust the ribs down, the doctor will have to cut them out. I think for those of you who have an issue with chiropractic or chiropractors, drop it and get this adjustment. If you are stubborn, you will lose your battle with thoracic outlet syndrome (TOS) and most likely be unhappy with the results of thoracic outlet surgery too.

My Practice Is Very Different From Others

When a patient has a severe case of thoracic outlet syndrome (TOS), has a herniated disc, has been told spine surgery is the only way out, has a severe chronic pain case, or would like me to reverse their fibromyalgia, they are typically from out of town. They cannot fly in and get 30–45 minutes of deep tissue therapy, manual therapy, or myofascial treatment, 3–5 days per week for weeks because they will be here for more than a month and most would lose their job, etc.

An Intensive Treatment Model

Patients fly in to Chicago for 3–5 days and are treated 3 hours in the morning, three to five hours in the afternoon, and 3 hours in the evening. This intensive approach combines prolonged deep tissue therapy, soft tissue mobilization, myofascial release, biomechanical correction, muscle recovery, connective tissue treatment, and thoracic outlet syndrome rehabilitation to maximize progress in a short period of time. See if your deep tissue expert offers these all-day Treatment Intensives and Recovery Retreats.

I think they are better than spreading out the treatments over many weeks or months. If you are interested in learning more, please look for my next book about this treatment approach entitled, The Pain Exorcism. This treatment philosophy emphasizes intensive rehabilitation, comprehensive musculoskeletal treatment, non-surgical pain management, functional rehabilitation, manual therapy, soft tissue treatment, biomechanical correction, movement restoration, and accelerated recovery for individuals seeking lasting improvements rather than prolonged treatment schedules.

Some more wealthy clients may ask to be treated in their favorite health retreat, wellness resort, sports performance center, luxury rehabilitation destination, or recovery retreat somewhere anywhere in the world they wish. We refer to these as Treatment Retreats. If you go to my website, www.drstoxen.com you can see some of the venues where self-treatment, professional treatment, intensive rehabilitation, recovery retreats, and wellness retreats we had in the past and some that are coming up in the future. With me, you can get treated anywhere in the world you want. Just contact us and our staff will listen to your ideas and how we can accommodate your needs with personalized musculoskeletal care, biomechanical assessment, manual therapy, pain relief, functional recovery, and performance optimization.

12. You Must Learn How to Develop a Strong, Open Thoracic Outlet and Tunnel

In order to learn how to develop a strong, open thoracic outlet, thoracic outlet tunnel, neurovascular tunnel, and thoracic outlet space, we must spring to action to learn spring training, Human Spring® biomechanics, postural correction, movement mechanics, mobility training, thoracic outlet syndrome (TOS) rehabilitation, nerve decompression, vascular decompression, shoulder girdle stability, scapular mechanics, upper body biomechanics, soft tissue mobility, fascial mobility, and functional movement restoration through Steps 2 and 3 in the next chapter.