Table of Contents
The Human Spring Approach to Thoracic Outlet Syndrome

Preface

Doctor's Note: I Know How You Feel

Doctor's Note: I Know How You Feel

Like many of you, I didn’t know I had thoracic outlet syndrome (TOS). I did not know what the thoracic outlet syndrome symptoms were. All I knew was that I had chronic neck pain, shoulder pain, upper back pain, tingling hands, and arm numbness caused by thoracic outlet syndrome.

Unfortunately, I was misdiagnosed and mistreated for seven painful years with thoracic outlet syndrome.

This book is written to ensure you don’t end up suffering as I did from thoracic outlet syndrome or live with untreated thoracic outlet syndrome symptoms.

The thoracic outlet (inlet or compartment) is a tunnel under the shoulder and over the rib cage that allows the safe passage of the subclavian artery, subclavian vein, and nerves (brachial plexus) that pass from the chest and neck area into the arm and hand. Understanding the thoracic outlet anatomy is essential for understanding thoracic outlet syndrome (1).

The thoracic outlet anatomy and how the subclavian artery, subclavian vein, neurovascular bundle, including the brachial plexus, pass through the passageway require an even more complex understanding of how the body moves— biomechanics. Subsequently, there is inadequate professional understanding about the thoracic outlet, thoracic outlet syndrome, thoracic outlet syndrome symptoms, and what causes thoracic outlet syndrome.

If you believe you are getting nowhere being treated for thoracic outlet syndrome, I know how you feel. I suffered from chronic neck pain, chronic upper back pain, constant shoulder pain, arm numbness, tingling arms, and tingling hands, which were misdiagnosed for seven years. What I was suffering from was bilateral thoracic outlet syndrome, a severe form of thoracic outlet syndrome.

Here is the really pathetic part of the story.

During that seven-year period, I was a chiropractic student in a top chiropractic college surrounded by teachers who were doctors of chiropractic and experts in chiropractic medicine. I asked for help from everyone, yet I graduated in chronic pain caused by undiagnosed thoracic outlet syndrome.

As a licensed chiropractor, I went to every back pain center to consult with physical therapists, sports doctors, orthopedic surgeons, neurologists, family practitioners, neurosurgeons, many massage therapists, and acupuncturists. Then I went to all the sub-specialty medical specialists, such as the back specialist, the sports chiropractor, a neck pain specialist, a shoulder doctor, a spine doctor, a carpal tunnel doctor, pain physicians, and even a specialist called an upper cervical chiropractic physician. I didn’t go to a thoracic outlet syndrome specialist, and I wasn’t the biomechanics expert back then because there weren’t any back then.

I got opinions from all these doctors, but not one of them could properly diagnose or explain this chronic pain syndrome, which I eventually came to know was thoracic outlet syndrome (TOS).

Why can't anyone diagnose my pain?

Traditional orthopedic examinations, neurological tests, X-rays, MRI scans, CT scans, and nerve conduction studies are designed to identify structural abnormalities such as fractures, disc herniations, arthritis, tumors, or permanent nerve damage. However, according to the Human Spring Theory, thoracic outlet syndrome is often not a disease of damaged tissues but a failure of the thoracic outlet spring suspension system. The thoracic outlet is designed to expand, recoil, and continuously maintain a protective space around the brachial plexus, arteries, and veins during movement. When the thoracic outlet spring suspension system loses its elasticity and becomes stiff or compressed, the available space narrows dynamically, creating thoracic outlet compression that places abnormal mechanical stress on the nerves and blood vessels—even though the anatomy may appear normal on an MRI scan or other static imaging.

This is why so many patients with thoracic outlet syndrome are told that their MRI scan, neurological tests, and orthopedic examinations are "normal" despite experiencing significant pain, numbness, tingling, weakness, or arm fatigue. These diagnostic tests are performed while the body is at rest and cannot determine whether the thoracic outlet spring suspension system is functioning normally during movement. The Human Spring Approach identifies the loss of spring function that produces dynamic thoracic outlet compression, rather than searching only for permanent structural damage. By restoring the elasticity and biomechanics of the thoracic outlet spring suspension system, the underlying mechanical cause of thoracic outlet syndrome can be identified and corrected instead of merely treating its symptoms.

For every expert I saw, I got a different differential diagnosis—from a herniated cervical disc, rotator cuff syndrome, pinched nerve in the neck, nerve compression between the thoracic ribs (called intercostal neuritis), and herniated discs in my neck instead of the correct diagnosis of thoracic outlet syndrome.

Why do doctors disagree about my diagnosis?

Doctors often disagree about a diagnosis because each specialty is trained to recognize problems within its own area of expertise. An orthopedic surgeon may focus on bones and joints, a neurologist on nerve function, a physical therapist on movement, and a vascular specialist on blood vessels. Each may identify findings that fit their specialty, yet none of these evaluations may determine whether the thoracic outlet spring suspension system is functioning normally. As a result, patients with thoracic outlet syndrome are often given multiple diagnoses that describe the symptoms rather than identify the underlying mechanical cause.

According to the Human Spring Theory, the thoracic outlet is a dynamic spring suspension system designed to maintain a protective space around the brachial plexus, arteries, and veins during movement. When this spring system loses its elasticity, the resulting dynamic thoracic outlet compression may not be visible on an MRI scan, X-ray, or routine neurological examination. Because each specialist evaluates only one part of the problem, they may disagree on the diagnosis, while the true mechanical failure of the thoracic outlet spring suspension system remains undetected. The Human Spring Approach unifies these seemingly different diagnoses by identifying the biomechanical dysfunction responsible for the patient's symptoms.

I tried almost all the chiropractic techniques taught in chiropractic medicine, involving every way to adjust the spine. The only non-surgical treatment that helped me was my father’s adjustments for an elevated first rib, a condition commonly associated with thoracic outlet syndrome.

I did a lot of work with massage therapists trying different styles of bodywork, such as manual therapy, neck stretching, nerve gliding, which did nothing for my chronic nerve compression, deep tissue therapy, and Swedish massage. None of these treatments addressed the underlying thoracic outlet syndrome.

When those didn’t provide lasting relief, I tried more drastic measures, such as muscle injections for pain, injections for back pain, and trigger point injections. How long do trigger point injections last?

Most lasted a few days and gave a little relief or no change. How much do trigger point injections cost? Too much!

I eventually started losing my faith in the alternative care approach and started to consult with medical physicians. I was offered just about every approach to treatment, such as nonsteroidal anti-inflammatory drugs (NSAIDs), muscle relaxants for back pain, analgesic drug therapy, and even painkillers for symptom reduction. I did not take the medications for my thoracic outlet syndrome, neck pain, shoulder pain, or upper back pain.

Some people think of chiropractors as doctors practicing holistic medicine, alternative medicine, or complementary medicine. My father and I practiced together for the first 12 years I was in practice. He was a naturopathic doctor and a good chiropractor. As a naturopathic physician, he offered natural healing with holistic therapy, so I guess you would consider our center an alternative health center specializing in chronic pain, neck pain, and thoracic outlet syndrome.

Toward the end, I was referred to spine doctors. These three orthopedic surgeons and neurosurgeons said, “Well, you tried everything already, so why don’t you try neck surgery or cervical disc surgery?” One doctor examined me for three minutes, did not order magnetic resonance imaging (MRI), and then recommended rotator cuff tear surgery for my shoulder pain.

I tried many different approaches, which the practitioners all assured me would work. I got no better and, in fact, got progressively worse. My thoracic outlet syndrome, neck pain, shoulder pain, upper back pain, and chronic pain continued to worsen despite treatment.

Why doesn't treatment work?

Many thoracic outlet syndrome treatments fail because they are designed to reduce symptoms rather than restore the function of the thoracic outlet spring suspension system. Medications may reduce pain, injections may temporarily decrease inflammation, and manual therapies may loosen tight muscles, but if the thoracic outlet cannot once again expand, recoil, and maintain the protective space around the brachial plexus, arteries, and veins, the abnormal mechanical compression simply returns. As a result, the symptoms improve for a short time but often come back because the underlying cause has not been corrected.

According to the Human Spring Theory, successful thoracic outlet syndrome treatment requires restoring the elasticity, mobility, and biomechanics of the thoracic outlet spring suspension system. When the spring system regains its ability to absorb forces and maintain adequate space during movement, compression of the nerves and blood vessels is reduced naturally. Instead of repeatedly treating the symptoms of thoracic outlet syndrome, the Human Spring Approach focuses on correcting the mechanical dysfunction that caused the compression in the first place, creating the opportunity for lasting recovery.

So, if this chiropractic doctor can’t find the right treatment and lifestyle approach to reverse thoracic outlet syndrome after seven years, you shouldn’t feel bad that you haven’t found the solution to your chronic thoracic outlet syndrome, thoracic outlet syndrome symptoms, neck pain, shoulder pain, and chronic pain.

In fact, 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 the chronic pain, neck pain, shoulder pain, upper back pain, and thoracic outlet syndrome symptoms.

I was once confused myself, but I discovered why so many doctors have such a difficult time with thoracic outlet syndrome. I have been free from chronic neck pain, upper back pain, shoulder pain, and thoracic outlet syndrome for the past 25 years.

What I found was a huge misunderstanding of human engineering. The secrets behind thoracic outlet syndrome, neck pain, shoulder pain, upper back pain, and lasting recovery are revealed in great detail in this book.

Why am I getting worse?

According to the Human Spring Theory, you continue to get worse because the thoracic outlet spring suspension system is no longer absorbing and distributing mechanical forces the way it was designed. Every time you lift your arm, work at a computer, sleep, exercise, or simply go through your daily activities, the weakened spring suspension system places repeated stress on the brachial plexus, arteries, veins, muscles, and connective tissues. Instead of recovering between activities, the tissues become increasingly overloaded, causing the compression, inflammation, and symptoms of thoracic outlet syndrome to gradually worsen.

As the thoracic outlet spring suspension system continues to lose its elasticity, the protective space surrounding the nerves and blood vessels becomes progressively smaller. This creates increasing dynamic thoracic outlet compression, allowing less room for normal movement while producing more irritation with every repetition. According to the Human Spring Approach, recovery cannot occur until the spring suspension system is restored. Otherwise, each day adds another cycle of mechanical overload, causing symptoms to slowly progress instead of heal.

Here Is My Painful Story

While in college, I played rugby for the Las Vegas Rugby Club. The two-hour practices of running and agility drills motivated me, as I knew they were making me run faster and I was at less risk for injury.

This is really important, as I was 140 pounds, playing full-on tackle without pads or a helmet against former, top-university, football players weighing 200–260 pounds.

At 20, I felt I was indestructible. It seemed like it would all last a lifetime until one day in a tournament in Santa Barbara, California, I sustained a whiplash spinal injury that left me with constant neck pain, shoulder pain, extreme upper back pain, severe pain in the shoulder, and back rib pain from first rib dysfunction. I had symptoms of thoracic outlet syndrome but did not know it until seven years later. My thoracic outlet syndrome, neck pain, shoulder pain, and upper back pain became constant companions.

It happened in a scrum, a potentially dangerous pushing-and-shoving competition between 16 players that is an integral part of the game. A scrum is a play that restarts play after a minor violation or penalty. It involves up to eight players from each team jamming, then interlocking, their necks and shoulders, creating tremendous stress on the cervical spine, first rib, neck muscles, shoulders, and the structures that can later contribute to thoracic outlet syndrome.

The scrum is one of the most dangerous plays in rugby, since a collapse can lead to the most dangerous sports injury, where a player can get a serious neck injury, including a broken neck. A rugby scrum collapse is a devastating sports injury mechanism that can result in severe neck injury, spinal trauma, and long-term disability.

I was playing hooker, a position in the middle of the rugby scrum. Imagine me, at 140 pounds, being lifted by my shorts off the ground by two, 260-pound, former college linebackers. Then they slammed me into the opposing player’s head, neck, and shoulders like a battering ram and we all interlocked to form the scrum. This also formed a tunnel between both teams during one of rugby's highest-risk situations for neck injury and catastrophic sports injury.

Scrums are one of the most dangerous plays in rugby, because a collapse can lead to a serious traumatic head injury or spinal trauma, such as an acute spinal cord injury, leading to spinal paralysis or a concussion. You have probably heard the media talking about the dangers of post-concussion syndrome, leaving the athlete with signs of brain damage. In fact, a top surgeon in the United Kingdom has called for the ban of scrums, asserting they are too dangerous (1) (2). Every collapsed rugby scrum increases the risk of neck injury, traumatic brain injury, spinal cord injury, and catastrophic sports injury.

As the props (the rugby forwards) jammed my neck and shoulders into the opposing team’s props and hooker, both teams started to push. Just as the ball was thrown into the tunnel, I felt the prop next to me slip in the mud. He fell, thrusting me headfirst into the puddle of mud, until my head struck the hard, clay bottom. In an instant, a routine rugby play became a catastrophic sports injury with the potential for permanent neck injury.

As my forehead hit the hard clay, I felt my neck snap like a twig. I felt a tingling pain shoot through my entire body, and then I had numb arms and legs, as if I had spinal paralysis. Then the weight of our entire team of 2,000 pounds of players piled on my rib cage and back, causing severe, sharp, stabbing rib, chest, and back pain. This neck injury created immediate neurological symptoms consistent with a severe cervical sports injury.

The weight of the players piled on me collapsed my rib cage, as the air was forced out of my lungs. I had the wind knocked out of me and I was underwater. I gasped for air—only to inhale mostly muddy water in my nose and mouth. I was drowning. The combination of crushing force, drowning, and neck injury made this one of the most terrifying sports injury experiences of my life.

Finally, the huge hand of my teammate, Dave Handwerker, latched on to me, and I was lifted out of the water. All I remember as they carried me off the field was this excruciating pain under my right rib cage. Even then, I knew this sports injury involved much more than broken ribs and that my neck injury was severe.

My fourth, fifth, and sixth ribs had broken like toothpicks. When I took a breath in, I could feel a sharp lower neck pain and a sharp shoulder pain between the shoulder blades. I remember telling the team sports chiropractor that my arm felt numb, my hands felt tingly, and I felt my fingers going numb. Those classic symptoms of neck injury, cervical nerve involvement, and serious sports injury would ultimately change the course of my life.

The players of the Las Vegas Rugby Club with Dave Handwerker, the player that rescued me from drowning when submerged in 6 inches of mud and water at a tournament in Santa Barbara, California.

The Neck and Upper Back Pain I Got from Learning How to Treat Neck Pain

A year later, I was at National College of Chiropractic, now called National University of Health Sciences in the western suburbs of Chicago, Illinois, studying my passion in the fast track, taking between 18 and 27 credits, three semesters a year, and between 24 and 27 credits in the summer.

The problem was that sitting with my head down, studying 12 hours a day, aggravated my chronic neck pain, neck pain, chronic upper back pain, and shoulder pain. It was called “student syndrome” back then. It would be called “office syndrome” or “computer syndrome” now. You know, the muscle spasms in the neck, neck stiffness and pain, chronic upper back pain, sore neck, neck pain, shoulder pain, lower back pain, while sitting for hours or working for a long time at the computer. The long hours of studying also made my neck pain and upper back pain progressively worse.

Next Injury? Car Accident... Rear-Ended... Whiplash Injury!

Then to make matters worse, I got rear-ended by a drunk driver going 70 mph, which caused a whiplash injury to my upper spine! I remember on impact that I had sudden upper back pain and sharp middle back pain. I suffered from the typical whiplash injury symptoms, the cervical sprain symptoms of extreme neck pain, constant upper back pain, severe middle back pain, shoulder muscle pain, and shoulder pain at night when I turned over in bed. The whiplash injury dramatically increased my neck pain and upper back pain.

I suffered a head trauma from hitting my head on the steering wheel, which caused a head contusion. I was diagnosed with a mild concussion, but the doctor in the emergency room said I had no signs of brain damage.

I remember that my ribs hurt! When I breathed, I could feel rib cage pain from the separation of the broken ribs. It was such intense rib pain that it took my breath away.

I started to wake up with swollen hands in the morning. I started to suspect carpal tunnel syndrome. In my work as a chiropractor, I’d do 10 to 12 hours of trigger point therapy per day. I thought the swelling was coming from too many myofascial trigger points or pain points. Then I switched the trigger point therapy techniques to take the pressure off my hands, but the swollen hands did not go away. Even when I did not do hands-on treatment, I had swollen hands. Now I realize these were all thoracic outlet syndrome symptoms.

I recognized later that the swollen hands were not a sign of carpal tunnel syndrome. I did not have the wrist pain. Also, when I took a photo of both arms and hands side by side, I noticed my forearm on the right was thicker, more swollen than the left. The signs of carpal tunnel syndrome swelling are only from the wrist down and not in the forearm, arm, or shoulder. What was causing my swollen hands and fingers?

I did not know that the swelling in my arms was a sign I had vascular thoracic outlet syndrome. No one told me that if the muscle spasms in my neck and shoulder got bad enough, I could get costoclavicular syndrome or compression of my collarbone to my rib cage. This form of thoracic outlet syndrome is worse than neurogenic thoracic outlet syndrome because, if the compression of the vein gets bad enough, a blood clot can form. This is what we call vascular thoracic outlet syndrome.

This is why it is vital you determine if you have a thoracic outlet syndrome diagnosis.

If the clot, or thrombus, breaks off, it becomes a pulmonary embolism. A clot would have traveled to my lungs, causing a lung infarction, which is the death of lung tissue due to inadequate blood supply to the cells. I could have died.

You are probably thinking what I was thinking. That won’t happen to me. That is what the other 600,000 people in the United States probably thought before they had a pulmonary embolism. What did the 60,000 who died from it think? They didn’t have much time to think because most of those who die do so within 30 to 60 minutes after symptoms start.

One of the worst complications of my chronic thoracic outlet syndrome and undiagnosed thoracic outlet syndrome was the effect on my social life. I couldn’t find a good chiropractor near me, so I started cracking my neck. This neck cracking started once every few days. Then the neck popping happened every day. Then my neck started cracking when I wasn’t trying to crack it, like when I was close to my date in a romantic moment.

I called my father and asked him, “Is it bad to crack your neck?”

“Are you cracking your neck? Stop doing that or you will get a pinched nerve!” he admonished me. I should have listened to him, but I didn’t.

I got to the point where I developed motor tics in my neck that were noticeable. These are nervous tics that feel like muscles jumping in the neck. I had excessive muscle twitching that would show up as shoulder twitching, neck twitching, and muscle twitching. It felt like an involuntary twitching of muscles, because I didn’t know I was doing it.

It was really bad when I went on a date with this beautiful girl I really liked. She asked me, “What are these muscle twitches you do constantly? Your neck keeps twitching.” She noticed my arm twitching and shoulder twitching too. “You have these twitching movements all the time! Are you nervous, or is there something wrong with you?”

I told her the truth, looking for sympathy. “I know I have twitching muscles. My muscles twitch, because I have over-reactive nerves, muscle spasms, and muscle twitching all over my neck and shoulders. These chronic muscle spasms lead to muscular twitching, neck twitching, and shoulder twitching.”

The next question was, “What do you do for a living?”

I told her, “I’m studying to be a chiropractor.”

“Oh, I see,” she commented, combined with a shake of her head movement.

Then I’ll never forget what she asked me next, “Why don’t you go to the doctor for some thoracic outlet syndrome treatment?” I guess I looked fairly pathetic to her, unable to solve my own problem. What she didn’t realize was that none of the doctors I’d seen could solve my problem! I knew this thoracic outlet syndrome, neck twitching, muscle twitching, and spasmodic twitching would not only affect my love life but also my professional reputation. Who would go to a chiropractor who has a twitching neck from thoracic outlet syndrome?

I desperately needed help.

My father was a chiropractor. His first rib adjustments helped me a lot. Unfortunately, I would have to drive one hour to his office and then another hour back to school. By the time I got back to school, my pain had returned. I couldn’t spend 2.5 hours of treatment and travel, just to feel the same. After many months, I asked my father, “How long does whiplash last?”

He said that sometimes people have whiplash syndrome pain that lasts for the rest of their life. The chronic rib pain caused by the inflammation of the rib cage from the twisted and broken ribs was becoming daily upper middle back pain. One chiropractor had a referred pain chart and told me I had fibromyalgia pressure points or fibromyalgia trigger points. To some doctors, if patients have chronic pain syndrome, muscle pain, or body pain, and they can’t get rid of it, it must be fibromyalgia.

No one seems to know how to clearly define fibromyalgia, how to diagnose fibromyalgia, how to cure fibromyalgia, or even the best treatment for fibromyalgia, but there is a medication for fibromyalgia. Numbing the brain with drugs for a few hours wasn’t an option, as I was committed to finding the cause and a permanent, drug-free solution for this chronic pain, fibromyalgia symptoms, and thoracic outlet syndrome!

Patients often feel there is no cure for fibromyalgia, so they think they have to just go on living with fibromyalgia. This is why you see many patients with fibromyalgia and depression in fibromyalgia support groups. No one is talking about the difference between fibromyalgia vs thoracic outlet syndrome, thoracic outlet syndrome symptoms, and fibromyalgia symptoms either.

Natural healing was failing me. I almost quit my healthcare profession and considered going on disability.

· Why weren’t the adjustments working?

· Why wasn’t exercise working?

· Why wasn’t anything working?

· Doesn’t natural healing work?

When do you lose hope, give up, and just live with the pain?

When do you get so frustrated that you beg the doctor to cut the pain out of your body? Yes, I contemplated neck surgery. Thank God, I still remained a rational thinker. Can neck surgery cut out the pain? NO!

When do you turn to painkillers? When do you stop taking painkillers?

When do you give up? Giving up means a lifetime of chronic pain. That is what I was contemplating. Is that what you are contemplating?

Please don’t!

I know how you feel right now.

I felt that same way.

I found my way out of pain, and I can help you like I’ve helped thousands of others with thoracic outlet syndrome, chronic pain, muscle pain, neck pain, and fibromyalgia.

Please read on, be optimistic, and prepare for the aha moments!

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References

  1. Burry HC, Gowland H. Cervical injury in rugby football—a New Zealand survey. Br J Sports Med. 1981 Mar;15(1):56-9. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1859087/.
  2. Freitag A1, Kirkwood G1, Scharer S1, Ofori-Asenso R1, Pollock AM1. Systematic review of rugby injuries in children and adolescents under 21 years. Br J Sports Med. 2015 Apr;49(8):511-9. doi: 10.1136/bjsports-2014-093684. Epub 2015 Jan 6. http://www.ncbi.nlm.nih.gov/pubmed/25564004.

Glossary

Browse terms by letter or search the glossary.

A Anatomy
Anatomy is the study of the structure of the human body and how its parts work together. It includes the bones, muscles, joints, ligaments, tendons, nerves, blood vessels, and organs. Understanding anatomy is essential for understanding thoracic outlet syndrome (TOS) because the condition develops when the brachial plexus, subclavian artery, or subclavian vein becomes compressed within the thoracic outlet. A solid understanding of anatomy makes it easier to understand why symptoms develop and how treatment is designed to relieve compression.
B Biomechanics
Biomechanics is the science of how the human body moves and how forces affect the body's tissues during movement. It explains how the bones, muscles, joints, ligaments, and connective tissues work together to produce normal movement. Throughout this book, biomechanics is central to understanding thoracic outlet syndrome, because abnormal movement, poor posture, muscle tightness, and repetitive activities can reduce the space within the thoracic outlet, leading to nerve and blood vessel compression.
B Brachial Plexus
The brachial plexus is a network of nerves that begins in the neck and travels through the thoracic outlet into the shoulder, arm, and hand. These nerves carry signals that allow you to move your arm and hand while also providing feeling to the skin. Compression of the brachial plexus is the most common cause of neurogenic thoracic outlet syndrome (NTOS) and may produce neck pain, arm pain, hand numbness, tingling, burning pain, and muscle weakness.
C Carpal Tunnel Syndrome
Carpal tunnel syndrome develops when the median nerve becomes compressed as it passes through the carpal tunnel in the wrist. Common symptoms include hand numbness, tingling, pain, and weakness, particularly in the thumb, index finger, and middle finger. Because these symptoms may resemble thoracic outlet syndrome, many patients are initially diagnosed with carpal tunnel syndrome even though the actual source of nerve compression is higher in the neck and shoulder.
C Cervical Radiculopathy
Cervical radiculopathy is a condition in which a nerve root leaving the cervical spine becomes compressed or irritated, often by a herniated disc or bone spur. Symptoms may include neck pain, arm pain, numbness, tingling, and weakness. Because these symptoms closely resemble thoracic outlet syndrome, distinguishing between cervical radiculopathy and brachial plexus compression is an important part of making an accurate diagnosis.
C Chronic Pain
Chronic pain is pain that continues for three months or longer or lasts beyond the normal healing period. Unlike acute pain, chronic pain often persists because the underlying cause has not been corrected. In thoracic outlet syndrome, chronic pain commonly develops when ongoing compression of the brachial plexus, muscles, or blood vessels continues to irritate the surrounding tissues during everyday activities.
C Conservative Treatment
Conservative treatment refers to non-surgical treatment used to improve a condition without an operation. Examples include physical therapy, manual therapy, exercise, massage, posture correction, and other rehabilitation techniques. In this book, conservative treatment focuses on restoring normal biomechanics and reducing thoracic outlet compression rather than simply controlling pain.
C CT Scan (Computed Tomography)
A CT scan, or computed tomography scan, is an imaging test that uses X-rays and computer technology to produce detailed cross-sectional pictures of the body. Doctors may use CT scans to identify fractures, bone abnormalities, tumors, or other structural problems. Because CT scans capture the body while it is still, they may not detect the dynamic compression that occurs in many people with thoracic outlet syndrome during movement.
D Deep Vein Thrombosis (DVT)
Deep vein thrombosis (DVT) is the formation of a blood clot inside a deep vein. In patients with venous thoracic outlet syndrome, compression of the subclavian vein may slow blood flow enough to allow a clot to form. A DVT can become dangerous if part of the clot breaks free and travels to the lungs, causing a pulmonary embolism.
D Differential Diagnosis
A differential diagnosis is the process doctors use to determine which medical condition is causing a patient's symptoms. Because thoracic outlet syndrome shares symptoms with conditions such as carpal tunnel syndrome, cervical radiculopathy, rotator cuff syndrome, and herniated discs, careful differential diagnosis is necessary to identify the true source of the problem.
D Dynamic Thoracic Outlet Compression
Dynamic thoracic outlet compression is narrowing of the thoracic outlet that occurs during movement rather than while the body is at rest. According to the Human Spring Theory, the thoracic outlet spring suspension system should expand and recoil to protect the brachial plexus, subclavian artery, and subclavian vein. When this spring system loses its elasticity, normal movements can compress these structures, even though MRI scans or other imaging tests may appear normal.
E Electromyography (EMG)
Electromyography (EMG) is a diagnostic test that measures the electrical activity of muscles and the nerves that control them. Doctors use EMG to help identify nerve injuries, muscle disorders, and other neurological conditions. Although EMG may help rule out other problems, many people with thoracic outlet syndrome have normal EMG results because the compression often occurs only during certain positions or movements.
F Fibromyalgia
Fibromyalgia is a chronic pain condition that causes widespread muscle pain, tenderness, fatigue, sleep problems, and difficulty concentrating. Because its symptoms can overlap with those of thoracic outlet syndrome, some patients are incorrectly diagnosed with fibromyalgia when the true cause of their pain is nerve compression within the thoracic outlet. Careful examination is needed to distinguish between these conditions.
F First Rib Dysfunction
First rib dysfunction is abnormal movement or positioning of the first rib, usually caused by injury, muscle tightness, or poor biomechanics. When the first rib becomes elevated or restricted, it can reduce the space within the thoracic outlet, increasing pressure on the brachial plexus, subclavian artery, and subclavian vein. Restoring normal movement of the first rib is an important part of many conservative treatment programs for thoracic outlet syndrome.
H Human Spring Approach
The Human Spring Approach is the examination and treatment system presented throughout this book. It is based on the idea that the body functions as a system of springs that absorb force, recycle energy, and protect important structures during movement. Rather than focusing only on symptoms, the Human Spring Approach identifies and corrects the biomechanical problems that create thoracic outlet compression, helping restore normal movement and long-term function.
H Human Spring Theory
The Human Spring Theory is the biomechanical model that forms the foundation of this book. It proposes that many chronic pain conditions develop when the body's natural spring-like support system loses its elasticity and ability to absorb mechanical forces. In thoracic outlet syndrome, reduced spring function allows abnormal compression of the brachial plexus, subclavian artery, and subclavian vein during normal movement, producing pain and other symptoms.
M Magnetic Resonance Imaging (MRI)
Magnetic resonance imaging (MRI) is a diagnostic imaging test that uses powerful magnets and radio waves to produce detailed pictures of the body's soft tissues. MRI is useful for detecting herniated discs, tumors, ligament injuries, and other structural problems. However, many patients with thoracic outlet syndrome have normal MRI findings because the compression often occurs during movement rather than while the body is lying still during the scan.
M Muscle Spasm
A muscle spasm is an involuntary tightening or contraction of a muscle that may cause pain, stiffness, and reduced movement. In thoracic outlet syndrome, muscle spasms involving the scalene muscles, pectoralis minor, and other muscles surrounding the thoracic outlet can reduce the available space for the brachial plexus and nearby blood vessels, increasing compression and worsening symptoms.
N Nerve Conduction Study (NCS)
A nerve conduction study (NCS) is a diagnostic test that measures how quickly electrical signals travel through a nerve. It is commonly performed together with electromyography (EMG) to evaluate nerve injuries or disorders. While an NCS may identify certain nerve problems, many patients with thoracic outlet syndrome have normal results because their nerve compression occurs only during movement or certain body positions.
N Neurogenic Thoracic Outlet Syndrome (NTOS)
Neurogenic thoracic outlet syndrome (NTOS) is the most common form of thoracic outlet syndrome. It develops when the brachial plexus becomes compressed within the thoracic outlet. Common symptoms include neck pain, shoulder pain, arm numbness, hand tingling, burning pain, muscle weakness, and reduced grip strength. Most patients diagnosed with thoracic outlet syndrome have the neurogenic form of the condition.
N Neurovascular Bundle
The neurovascular bundle is the group of structures that travel together through the thoracic outlet. It consists of the brachial plexus, subclavian artery, and subclavian vein. These structures supply movement, sensation, and blood flow to the shoulder, arm, and hand. When the available space within the thoracic outlet becomes too small, one or more parts of the neurovascular bundle may become compressed, producing the neurological and vascular symptoms of thoracic outlet syndrome.
P Paget-Schroetter Syndrome
Paget-Schroetter syndrome, also called effort thrombosis, is a serious form of venous thoracic outlet syndrome in which a blood clot develops in the subclavian vein. It most often occurs after repeated overhead activity or prolonged compression of the vein. Symptoms may include sudden arm swelling, pain, heaviness, bluish skin discoloration, and enlarged veins. Because the clot can travel to the lungs, Paget-Schroetter syndrome requires prompt medical evaluation and treatment.
P Pulmonary Embolism
A pulmonary embolism occurs when a blood clot breaks loose, travels through the bloodstream, and blocks an artery in the lungs. This is a potentially life-threatening emergency. In thoracic outlet syndrome, a pulmonary embolism may occur if a clot forms in the subclavian vein because of venous thoracic outlet syndrome and then moves to the lungs. Symptoms may include sudden shortness of breath, chest pain, rapid heartbeat, or coughing up blood.
R Rotator Cuff Syndrome
Rotator cuff syndrome is a group of shoulder conditions involving irritation or injury to the muscles and tendons that stabilize the shoulder joint. It commonly causes shoulder pain, weakness, and difficulty lifting the arm. Because these symptoms often resemble thoracic outlet syndrome, some patients are initially diagnosed with a rotator cuff problem when the actual source of their pain is compression of the brachial plexus within the thoracic outlet.
S Scalenectomy
A scalenectomy is a surgical procedure that removes part or all of one or more scalene muscles to reduce pressure within the thoracic outlet. It is sometimes performed in patients with severe thoracic outlet syndrome when conservative treatment has not relieved nerve or blood vessel compression. Although surgery may reduce compression in some patients, it does not always correct the underlying biomechanical problems that contributed to the condition.
S Subclavian Artery
The subclavian artery is the major artery that carries oxygen-rich blood from the chest to the shoulder, arm, and hand. It passes through the thoracic outlet beside the brachial plexus and subclavian vein. Compression of the subclavian artery may reduce blood flow, causing cold hands, arm fatigue, weakness, pain during activity, and other symptoms of arterial thoracic outlet syndrome (ATOS).
S Subclavian Vein
The subclavian vein is the major vein that returns blood from the arm back to the heart. As it passes through the thoracic outlet, it can become compressed by surrounding muscles or other structures. Reduced blood flow may cause arm swelling, hand swelling, heaviness, skin discoloration, and venous thoracic outlet syndrome (VTOS). Severe compression may lead to deep vein thrombosis (DVT) or Paget-Schroetter syndrome.
T Thoracic Outlet
The thoracic outlet is the narrow passageway between the neck and shoulder through which the brachial plexus, subclavian artery, and subclavian vein travel from the chest into the arm. It is formed by the surrounding bones, muscles, and connective tissues. Maintaining adequate space within the thoracic outlet is essential for normal nerve function and blood circulation. Narrowing of this space is the defining feature of thoracic outlet syndrome.
T Thoracic Outlet Spring Suspension System
The thoracic outlet spring suspension system is the Human Spring Theory's description of the muscles, connective tissues, and supporting structures that protect the brachial plexus and nearby blood vessels during movement. This system is designed to expand, recoil, and maintain space within the thoracic outlet. According to the Human Spring Theory, loss of elasticity in this system allows dynamic thoracic outlet compression to develop, producing the symptoms of thoracic outlet syndrome.
T Thoracic Outlet Syndrome (TOS)
Thoracic outlet syndrome (TOS) is a compression disorder that develops when the brachial plexus, subclavian artery, subclavian vein, or a combination of these structures becomes compressed within the thoracic outlet. Symptoms may include neck pain, shoulder pain, upper back pain, arm numbness, hand tingling, muscle weakness, cold hands, or swelling. Throughout this book, thoracic outlet syndrome is explained as a biomechanical condition in which restoring normal movement and reducing compression are the keys to long-term recovery.
T Thoracic Tunnel
The thoracic tunnel is the term used in this book to describe the pathway that extends through the thoracic outlet, allowing the brachial plexus, subclavian artery, and subclavian vein to travel from the neck into the arm. It includes the scalene triangle, costoclavicular space, and subcoracoid (pectoralis minor) space. Compression may occur in one or more of these areas, contributing to the symptoms of thoracic outlet syndrome.
T Trigger Point Injection
A trigger point injection is a procedure in which medication, such as a local anesthetic or anti-inflammatory drug, is injected into a painful, tight muscle. The goal is to temporarily reduce muscle spasm and relieve pain. While trigger point injections may improve symptoms for a short time, they do not correct the underlying biomechanical causes of thoracic outlet syndrome, so symptoms often return if the compression is not addressed.
V Vascular Thoracic Outlet Syndrome (VTOS/ATOS)
Vascular thoracic outlet syndrome occurs when compression within the thoracic outlet affects one or both of the major blood vessels supplying the arm. This includes venous thoracic outlet syndrome (VTOS), which involves the subclavian vein, and arterial thoracic outlet syndrome (ATOS), which involves the subclavian artery. Symptoms may include arm swelling, cold hands, changes in skin color, reduced circulation, fatigue, or blood clot formation. Although less common than neurogenic thoracic outlet syndrome, vascular forms of the condition require prompt medical evaluation because they may lead to serious complications.
W Whiplash Injury
A whiplash injury is a neck injury caused by the head being forced rapidly backward and then forward, most often during a motor vehicle accident, sports injury, or other sudden impact. This motion can injure the muscles, ligaments, joints, and other soft tissues of the neck. In some people, whiplash alters normal biomechanics, increases muscle tension, and contributes to thoracic outlet syndrome by reducing the space available for the brachial plexus and nearby blood vessels.
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