Thread by @BadgleyLaurence

THORACIC OUTLET SYNDROME: Classic case of imbalanced muscles. Let me explain:

https://twitter.com/drkristieleong/status/1396098536228392967

THORACIC OUTLET SYNDROME (TOS)
(Anatomy & Etiology)

DEFINITIONS:
Thoracic Outlet: anatomic space in proximal subclavicle region; traversed by a neurovascular bundle & brachial neural plexus.
Superior trapezium is plural
Superior trapezius is singular

Ipsilateral: on the same body side
Contralateral: on the opposite body side

Thoracic Outlet Syndrome (TOS) occurs as impinged brachial nerves & vessels arouse shoulder ache & extremity paresthesias. The condition can progress to a miserable chronic pain & sometimes total disability.

Functional Scoliosis: is curvature of upright spine as it bears upper body weight on a spinal structure wherein vertebral ligaments (the intervertebral disks) are abnormally flexible. Oft found above a pelvic girdle unstable d/t SIJ ligament injury.

Hypermobility & Functional Scoliosis: Scoliosis (when upright) is a common feature of the spine in persons with Hypermobility Syndrome, a genetic tissue variant found in an estimated 15% of women (author estimate).

A novel feature of Functional Scoliosis is that the spine curvature remits when the person is reclined; due to relative absence of bio-mechanical tissue stress from the force of gravity acting upon an upright spine & weighted upper body tower.

PRINCIPLE: muscle contractions evoke vectors of body part motions. Vector of range of motion of a primary muscle or muscle group is reversed by action of an opposing muscle or muscle group. Opposing muscle groups are widely populated in the human body.

HISTORY OF THORACIC OUTLET SYNDROME (TOS):
Until about 13 years ago, TOS was thought due to impingement of cervical spine nerve roots between irritating cervical Scalene muscles, the “Scalenus Anticus Syndrome.”

The era wherein surgeons theorized the Scalenus Anticus Syndrome was marred by butcheous surgical efforts that were infamously ineffective.

Perhaps best way to understand the complex bio-mechanics of TOS is to discuss this dynamic by tracking back from the end-symptom consequences, intermittent impingement of the neurovascular bundle within the Thoracic Outlet.

In life, the Thoracic Outlet is an ~1 cm dimension between inferior proximal clavicle & top of ipsilateral mid-1st rib (MRI imaging studies). All vascular conduits & neural tracks between arm & central body traverse Thoracic Outlet.

More recently, Thoracic Surgeons correct a tight Thoracic Outlet by accessing the rib cage via an axillary approach, wrenching 1st rib inferiorly, & then wiring 1st rib to 2nd rib; opening up the Thoracic Outlet.

The Thoracic Outlet relatively closes when distal clavicle shifts inferior. Remember, proximal clavicle is fixed at a pivot (Sterno-clavicle joint). Geometry informs that when the 18 cm long clavicle shifts inferior a few mm, Thoracic Outlet closes ~ 30%.

Abnormal inferior shift of distal clavicle occurs from diminished pull of Superior trapezius (effects upward draw on shoulder) & dominant pull of opposing muscle, Pectoralis minor, which inserts on Coracoid process; drawing Acromio-clavicle joint & distal clavicle inferior.

The Superior trapezius draws shoulder upward & opposing muscle, the Pectoralis minor, draws shoulder downward. When one of these muscles becomes spastic from repetitive stress, spasticity is induced in the other; to keep shoulder function balanced.

Dynamic spasticity of both the Superior trapezius muscle & the opposing Pectoralis minor muscle generates asynchronous shoulder hemi-girdle function that manifests as Thoracic Outlet Syndrome.

When arm is abducted, Superior trapezius shortens, incurs a reduced dynamic effort, & enables opposing spastic Pectoralis minor to become dominant; drawing Acromio-clavicle joint & distal clavicle inferior; closing Thoracic Outlet.

My latest research project has been to obtain X-ray oblique views of several shoulders with TOS, proven by ultrasound-detected Subclavian Artery impingement, & to observe abnormal Acromio-clavicle (AC) joint range of motion in these images.

This is first announcement of my findings in above-described study. In the few patients I have imaged, the Acromion & distal Clavicle clearly sublux in shoulders of those with TOS when the arm is abducted.

I was led to invent this imaging position by my sensitive-touch physical examination of shoulders of persons who have documented TOS proven by ultrasound exams of the Subclavian artery during shoulder abduction.

The physical exam is performed by placing my 2nd & 3rd fingers simultaneously on the Acromion & distal Clavicle, bilaterally, & this enabled me to monitor movement of these bony prominences during bilateral shoulder abductions.

What I discovered is that during shoulder abduction, the distal Clavicle head on the TOS side rolled posterior & inferior during abduction. On the normal side, the distal clavicle head shifted superiorly & in concert with the Acromion.

When I obtained oblique shoulder images taken during shoulder abduction, I was gratified to find that the X-ray images confirmed my physical examination findings.

I believe this is the first World announcement of an imaging study that documents abnormal Acromio-clavicle subluxation associated with Thoracic Outlet Syndrome.

The findings of my studies suggest the cure. Specific dedicated Physical Therapy modatilities, biofeedback guided by surface electromyography (SEMG), & dedicated Botox (Pectoralis minor) should be able to reverse TOS.

The goal of Biomechanical Functional Diagnosis (see below) is to identify chronic soft tissue disorders attendant with many of the chronic Pain Disorders that physicians have incorrectly labeled “functional” (see list below).

A goal of Biomechanical Functional Diagnosis is to discover non-toxic natural therapies & to avoid speculative major surgical operations intended to sculpt bone tissues into formations Surgeons regard to be more compatible with normal anatomy.

For TOS, Thoracic Surgeons excise the Pectoralis minor muscle off the Coracoid process; to “correct” Thoracic Outlet tissue impingement. I speculate that Botox injected into P. minor might accomplish the same beneficial bio-mechanical dynamic.

Now comes the explanation why Superior trapezius & Pectoralis minor muscles become contemporaneously hyperdynamic & spastic; leading to Thoracic Outlet Syndrome. Reason is a tilted head due to an underlying functional scoliosis (see definition above).

Functional scoliosis in females is oft attendant with Hypermobility Syndrome & subluxing sacroiliac joints (SIJ). In males, traumatic mechanical injury of SIJ is the more common etiology. Scoliosis of the spine induces shoulder girdle asymmetry.

I suspect the reason shoulder girdle asymmetry evaluations are not known by medical doctors is that doctors rarely look for this. Idea that the head is a perched (on neck) & weighted mass that can chronically tilt is also not considered.

Pattern recognition is not verboten for doctors; but is a neglected method of gathering knowledge. Modern medical diagnosis would rather ignore what is plainly seen in favor of double blind studies & wild speculation about “functional” mental aberrations. So what can be seen?

Crossed Muscle Syndromes were first named by Dr. V. Janda. He recognized that chronic asymmetric use could lead to unequal strength & mass of muscles that oppose each other, e.g., the Superior trapezium.

The head weighs ~10#, & when the head is chronically tilted to one side this leads to a Crossed Muscle Syndrome within the Superior trapezium.

The Crossed Muscle Syndrome of the Superior trapezium is observed by pinching the anterior leading edges of the Superior trapezium & finding different girths & pain intensities within the paired muscles.

An initial clinic observation is to have the patient stand at ease; to observe dissimilar shoulder heights & tilted head (oft seen in driver’s license). Next, leading edges of Superior trapezium muscle are pinched to gauge spasm, pain, & hypertrophy.

The higher shoulder side is usually the side that harbors the hypertrophic, hyperdynamic, & chronically spastic Superior trapezius; from holding up a chronically tilted head; a true bio-mechanical repetitive stress disorder.

Less often in TOS cases, the Superior trapezius muscle in the lower shoulder is spastic d/t a head chronically cantilevered in the contralateral direction; a compensation to maintain a medial station of the body center of gravity.

During arm abduction, the Superior trapezius folds & reduces shoulder upward draw; enabling the opposing/spastic Pectoralis minor muscle to evoke Thoracic Outlet closure within this lower shoulder.

The head falls to earth center at 32 feet per second per second; basic physics. This takes a toll on the major muscles that hold up the head, the Superior trapezium muscles. Head balance is problematic in cases of asymmetric shoulder hemi-girdles.

I believe that the Crossed Muscle Syndrome (unequal size of Superior trapezium in cervical/shoulder regions) is a self-begetting bio-mechanism. This Syndrome magnifies over time d/t ongoing asymmetric bio-mechanical forces.

As I tell patients, “when you wake in the morning your brain asks both Superior trapezium, ‘which one is going to hold up the head today?’ The larger muscle usually volunteers.” Over time, the volunteer becomes additionally hypertrophic/hyper-dynamic from excess exercise.

When the head is chronically tilted (usually toward lower shoulder side) the Superior trapezius muscle associated with the higher shoulder commonly becomes hypertrophic (larger); thereby evoking ipsilateral Pectoralis minor muscle spasm.

Why is an head chronically tilted? In most cases this is d/t asymmetric shoulder girdles & the head usually tilts toward lower shoulder side. Oft the asymmetric shoulders are d/t Functional Scoliosis.

Innate wisdom of the human organism includes unconscious bio-mechanical compensatory processes, such as a unilateral Superior trapezius undertaking most of the upright head-holding musculoskeletal effort.

Over time, as a weaker Superior trapezius on lower shoulder side rests & avoids head holding, it becomes additionally atropic, increasingly weak, & more intensely beset with painful chronic muscle spasm.

Now that the reader knows the true etiology of asymmetric shoulder hemi-girdles, the bio-mechanism of Thoracic Outlet Syndrome can be better understood; using the diagnostic principles elucidated herein.

The theories, data, & deductive proofs recorded herein & explanatory for Thoracic Outlet Syndrome are the novel inventions of the author. No other physician has seemed to describe a similar model of Thoracic Outlet Syndrome.

Methods of diagnosis used for Thoracic Outlet Syndrome are included in a novel diagnostic paradigm invented by the author & named Biomechanical Functional Diagnosis (BFD).

Biomechanical Functional Diagnosis (BFD) has been used by the author to explain the dynamic causes of Fibromyalgia, CRPS, Migraines, TMJ, Chronic Cervicalgia, TOS ....

Panic Attacks, Gastroparesis, many unexplained cases of chronic Low Back Pain & chronic Sciatica, Pseudo-seizures, IBS, IC, & several other chronic dysautonomias.

At Twitter, the author has created over 200 Threadreaders to discuss the bio-mechanical principals, soft tissue disorders, & etiologies of the variety of disorders listed above.

The BFD process uses vector of gravity, bio-mechanical analysis, a novel charting format, sensitive touch, monitoring of soft tissue functions in real time, & unique imaging studies to diagnose chronic soft tissue repetitive stress disorders.

The BFD process enables physicians to monitor patients over time to establish the mechanism of injury & causation(s) of pain generators. Only when the true cause of a condition is discovered can rational therapies be applied to evoke a cure. END

@threadreaderapp unroll