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METHOD OF TOS ASSESSMENT (continued)

Similarly, costoclavicular syndrome is caused by impingement occurring between the clavicle and first rib. To assess this, the client must assume a position that further approximates these two structures. This is accomplished by asking your client to stick his chest out (pushing the rib cage and specifically the first rib anteriorly against the clavicle) and pull the shoulder girdle back and down (pulling the clavicle posteriorly and inferiorly against the first rib), similar to the military posture of attention (Figure 5). Again, weakening of the strength of the radial pulse would be considered to be a positive sign. This procedure is called Edens test.

Figure 5 illustrates Edens test for costoclavicular syndrome, a second type of TOS. The client is asked to pull the shoulder girdle back and down and push the chest forward, while the radial pulse is palpated. Decrease in strength of the radial pulse is positive for costoclavicular syndrome.
a = median nerve
b = ulnar nerve
c = radial nerve
d = musculocutaneous nerve
e = axillary nerve

Pectoralis minor syndrome is caused by a tight pectoralis minor muscle compressing the brachial plexus and/or subclavian vessels against the rib cage. The assessment procedure for this type of TOS would be to ask your client to bring his arm up and back. This position stretches and pulls the pectoralis minor taut against the rib cage (Figure 6). Weakening of the strength of the radial pulse would be positive for the presence of pectoralis minor syndrome. This procedure is called Wrights test.

All three test procedures may be augmented by asking your clients to take in and hold a deep breath. With Adsons test, breathing in causes a further contraction and hardening of the scalenes (because these muscles can lift the ribs for inspiration) while they are being pulled taut. With Edens test, it causes the rib cage to lift, bringing the first rib closer to the clavicle and decreasing the space between these two structures.

With Wrights test, breathing in causes a further contraction and hardening of the pectoralis minor while it is being pulled taut against the rib cage. Most important when learning these TOS assessment procedures is to understand why the procedure is being done. If the underlying mechanism is understood, the procedure can be reasoned out instead of memorized.

Figure 6 illustrates Wrights test for pectoralis minor syndrome, the third type of TOS. The clients upper extremity is passively moved up and back, while the radial pulse is palpated. Decrease in strength of the radial pulse is positive for pectoralis minor syndrome.

THERAPY FOR TOS

The therapy approaches for the types of TOS also follow directly from an understanding of the mechanism of the condition. For example, the approach for anterior scalene syndrome is to loosen the tight scalenes by massage and stretching. For pectoralis minor syndrome, therapy is geared at both loosening the tight pectoralis minor via massage and stretching, and also recommending exercises that strengthen the antagonistic musculature of retraction of the scapula (e.g., rhomboids and middle trapezius). For costoclavicular syndrome, therapy is geared at loosening the tight muscles that cause the poor posture of rounded and slumped shoulders (pectoralis major and minor as well as subclavius). It is also important to recommend that muscles that resist this postural pattern are strengthened (rhomboids and middle trapezius).

SUMMARY

All three types of TOS are easy to assess and their treatment is ideally suited to massage, bodywork and exercise. Therefore, awareness and knowledge of TOS and the procedures to assess it can make a critical difference in the care of our clients.

For more information about TOS go to: www.nlm.nih.gov/medlineplus/thoracicoutletsyndrome.html.

Joseph E. Muscolino, DC, is an instructor at the Connecticut Center for Massage Therapy. He is also the author of The Muscular System Manual, Kinesiology: The Skeletal System and Muscle Function, and The Musculoskeletal Anatomy Coloring Book (Elsevier, 2006). Visit Josephs website: www.learnmuscles.com.

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