Jim Pickles Posted August 16, 2017 Posted August 16, 2017 I thought I’d post this, in case anyone has similar symptoms, as it might be helpful. For years, on an off, I had a mild pain along the inner side of my arms when I raised them to the side. I never thought about it much, and imagined it might be a muscle or tendon pain. Then it went away. However, some months ago, it came back more strongly, just on the right side. At its worst, there was a radiating burning pain along the inner side of the upper arm, in the thumb, and around the ring finger. The dull burning pain was strongest on a patch on the front of the shoulder, and all the muscles around the shoulder joint were tender. Feeling along the line of the pain on the arm (which gave strong burning sensations after a delay) gave a line overlying the median nerve. Shooting pains in e.g. fingers are a sign of nerve damage too. After reading posts on this board, I heard about thoracic outlet syndrome (thank you whoever posted them). The very great majority of cases of thoracic outlet syndrome are due to nerve damage, most of the remainder being due to blocked blood flow. The nerves to the arm leave the neck at levels C4-T1, and travel to the arm through a fairly narrow gap under the collar bone. Then the nerves intermingle, rearranging their fibres, in what is known as the brachial plexus which is on the front of the shoulder, before the different nerves travel down the arm. Trapping of the nerve under the collar bone will lead to pain in the brachial plexus, and in the areas supplied by the nerves. In more severe cases it can also lead to paralysis. The symptoms showed that mine was clearly neural. But why was the nerve getting trapped (if that was what was happening)? One reason is that when I sleep on that side, my shoulder tends to crunch forward, squeezing the front of the shoulder. Stopping sleeping on that side helped, but the pain still didn’t go away. Being thin and unmuscular with mobile shoulders I probably hold my shoulders too low, which means the gap between the collar bone and rib is smaller than normal. So my exercises have focussed on trying to lift the outer edge of the shoulder and collar bone, by lifting the outer edge of the shoulder blade. After experimenting, three exercises have been particularly good. (1) One is to try to target the lower trapezius, by shrugging the shoulders up while holding weights (10 kg in each hand – that is just what I had conveniently available). The action is to try and concentrate the lifting from the inner lower part of the shoulder blade, which is made easier by slight squeezing together of the bottom of the shoulder blades, as well as a strong lift to push the tops of the shoulder blades up and out to the side. (2) To target the anterior serratus, by doing mini-pushups against a wall, with elbows close in to the side. (3) The other is to roll the upper and back part of the top cm or two of the shoulder up and backward. It is a very minimal action, and may in fact be lifting the top of the shoulder blade (the acromion?) by targeting the anterior serratus, though I can only feel it in the top of the shoulder. It is a strange minimal lift and roll of the bone just at the top back outer edge of the shoulder – if you roll the whole shoulder it does not help. This one is particularly useful if I’m sitting at a desk and I’ve been holding the arm relaxed while just the wrist is supported on the desk. Generally the pain has gone now, though it can sometimes recur unexpectedly while using my arm. I suspect most of the pain is due to inflammation of the nerve sheath, because the most tender points are along the line of the median nerve and over the brachial plexus, and we expect inflammation and irritation to take time to die down. The other thing, is that if I cant get a comfortable position to lie in at night (lying on my back often irritates the nerve, for reasons I’ve not been able to work out), lying on my good side and closely hugging a pillow in both arms seems to keep the arms in a stable and restful position (I found this advice on a site for Ehlers-Danlos syndrome). It may look as though I’m missing my teddy bear, but it is all for medical reasons. Cheers, Jim. 1
Kit_L Posted August 18, 2017 Posted August 18, 2017 On 8/16/2017 at 10:36 PM, Jim Pickles said: which means the gap between the collar bone and rib is smaller than normal. This is unlikely to be the location of the impingement, Jim. This thing we live in is pretty well-designed, in my experience. The thoracic outlet, so called, is simply a space between the anterior and medial scalenes, but this is not the whole story. The emerging nerves immediately pass under the tendon of pec. minor (there is a clear illustration of all the involved anatomy in Overcome neck & back pain, clearest in the new illustrations in the 4th edition). Netter's illustrations are highly informative here, too. The points here are 1), research (start with Travell and Simons) the scalenes alone can create the impingement phenomena if tight, 2), that a head-forward posture combines with any excess kyphosis exacerbates this, because of the increased distance the nerves must span in daily life movements. See here (you may not know this one): And once you have done the C–R and re-stretched, use the muscles under the arm on the stretching side to draw that shoulder even further down to the hip—activating the lats and pecs in this position yields the strongest stretch and the most permanent stretch. This can be made much stronger if you need it, but please play with this version first and report back. 1
Jim Pickles Posted August 18, 2017 Author Posted August 18, 2017 Well, well, well... that's intriguing. I started off thinking that it was bound to be somewhere round the collar bone (or maybe the pec minor pressing) but I tried the scalene stretch (starting with some scepticism, I'm afraid to say, as I'd never felt any tightness in the scalenes) and got immediate alleviation of the symptoms. I need to do it a bit more, as the symptoms have not been troubling me much today, to see if that is maintained over days, and try the stretches more fully tomorrow. So thank you very much, that was very educative indeed!!!!!!!!!!! I'll keep exploring things, and report back. Jim (a.k.a. happy Jim, now).
Jim Pickles Posted August 19, 2017 Author Posted August 19, 2017 Well, well, well, continued - shoulder is now well...... The improvement is maintained, only a little pain today, movements that gave discomfort before do not generally do so now... and an unexpected benefit is that I slept right through the night instead of waking every couple of hours. Just did another scalene stretch, which I will repeat daily. So that looks as though it got to the root of the problem, and very quickly. Thank you very much indeed! Concerned that I could not work this out myself. Probable reasons: 1. Lack of experience. 2. The reading that I'd done had emphasised pressure from the collar bone (maybe that's for more serious cases), and I know I hold my shoulders low (told by a physiotherapist I trust). (3) Had never felt tight in the scalenes, though I've done the above stretch from time to time. (4) Though sites had said "the problems may also arise higher in the neck" I had imagined that related to nerve entrapment in the vertebrae, rather than the scalene muscles. (5) the sensations were concentrated lower down in the shoulder (though that is an unreliable guide). Thought about and written down here to make it part of the learning process. Of course, also Kit knows my posture well, so also knows what to look for. It also means that I should use scalene stretches more often in my classes. I include them occasionally (they are part of the original ST program), but not enough. I dont do them more often because people do not seem to appreciate them particularly, but that is not a good enough reason. Also one of my students has similar problems and could do with knowing this stretch in case it deals with her situation. So many thanks indeed for your help, Jim.
Kit_L Posted August 19, 2017 Posted August 19, 2017 21 hours ago, Jim Pickles said: I tried the scalene stretch (starting with some scepticism, I'm afraid to say, as I'd never felt any tightness in the scalenes) and got immediate alleviation of the symptoms. Hahahahaha! That's how it works, my friend—none of this "try this three times a day for six weeks" stuff. If you have any impingement phenomenon, the right stretch will change the experience (even if it does not fix it outright) the first time you try it. Travell and Simons say look to the scalenes in a multitude of chest, shoulder, arm, and hand pain problems. For them, it is even the precursor to carpel tunnel syndrome. Janet was a very, very clever person. Their treatment protocols can always be improved upon, but their understanding of the underlying neurophysiology is first class, IMHO. 2
Jim Pickles Posted September 13, 2017 Author Posted September 13, 2017 Update a few weeks later - though the scalene stretch was very helpful, it was not the whole answer. I still get discomforts from time to time. I find the weighted shrugs that are intended to target the lower trapezius are most helpful in those situations. I guess there are multiple contributing factors in my case. 1
Kit_L Posted September 13, 2017 Posted September 13, 2017 For sure. This is why I always recommend some strengthening work to follow any successful stretching intervention: both are necessary. Once you get strong enough, you can use your lats and pecs to stretch traps, too (the current way we do the shoulder pushdown). Good luck with it. 1
dannyg Posted September 22, 2017 Posted September 22, 2017 Hello, hope you don't mind me chiming in a bit late - how is your TOS? Has it improved? As Kit mentioned, the anterior and middle scalene are very common causes, but also the elevation of the first rib can be a factor. Techniques using manual therapy or a stick (https://i.ytimg.com/vi/dFWBeJ-V6kw/maxresdefault.jpg) be be really useful. I use a large diameter dowel with a cut open tennis ball on the end. Ah, I just discovered Kstar has a video on it. While I am not always a fan, and his approach might not be entirely appropriate, some interesting concepts discussed: https://www.youtube.com/watch?v=aUy7plm004M
Jim Pickles Posted September 23, 2017 Author Posted September 23, 2017 @dannyg - generally a lot better thanks, although as mentioned above, some twinges from time to time - e.g. yesterday after doing a lot of backbends and shoulder extensions the day before. I still think there are multiple factors, as multiple things help - e.g. strengthening the lower trapezius with weighted shrugs (this has the most immediate positive effect) which suggests the collar bone might be applying pressure as it sits low in me, scalene stretches as suggested by Kit (hence tight scalenes). Also think tight pec minors and a forward-head position might be contributing. Currently working on all of those. Didnt manage to feel the first rib in the exercise in the video however - is it obvious? Thanks, Jim.
dannyg Posted September 24, 2017 Posted September 24, 2017 Not really obvious, no. Unfortunately. It's quite deep and the structures above it often have enough connective tissue and muscle that it's hard to feel. It should move superiorly upon deep inspiration (breathing in kind of inspiration, not the other kind). The anterior and middle scalenes attach to the first rib, if they are tight they can draw in superiorly. So while the clavicle might be 'low', it would be exacerbated by a 'high' first rib. In my eyes, the clavicle wouldn't just be pulled down, but the whole upper chest forward and down. Which makes me think you might be spot on with the forward-head position as a factor. Muscles such a Sternocleidomastoid (SCM), subclavius, platysma etc might be tight also. It's quite possible to release them manually if you need to. Opening the upper chest and anterior neck (including SCM in this) would likely have a good effect. My instinct says that if it twinges during back-bends, it might be a factor. For a simple way of gently articulating it, I can give some simple instructions: (technically this isn't an articulation, but a different approach to stretching the scalenes. Maybe a 'decoupling exercise' would be a better term) 1) Perform an active neck side bend to the right, noticing how it feels. And return to neutral 2) Using your right hand, reach to touch your left clavicle, (Don't worry about finding your 1st Rib) 3) Slide your hand so your palm is resting on your clavicle, and your fingers are resting roughly where the first rib is, just in front of the upper fibres of trapezius, with the thumb-side of your hand touching the side of your neck. 4) Apply some downward pressure 5) Side bend your head to the right again, noticing how it feels. 6) If it feels different, or a stretch is felt more strongly, repeat several times. 7) Note if it feel different on the side that has been 'worked' afterwards. When side bending the neck, if the scalenes are tight, the first rib often elevates. (which would also happen if the neck is in extension, as the anterior scalenes can draw it up). I'll do some research and see if there are better ways. I'm a big fan of the 'gently & often' approach to self treatment. The Anterior scalenes, first rib & pec minor (and TOS) are associated with upper rib breathing. Apologies if this is a foolish question, but are you breathing with your diaphragm primarily? I've attached a screen shot of the first rib, from 'complete anatomy' which is really useful software I use to show my patients anatomy. If my instructions are unclear let me know, I'll take a photo at work tomorrow explaining more - if you think it would be helpful! PS. Reading though my post, I apologise if I'm presumptuous or giving un-asked for advice. I'm wearing my Osteo hat and enjoy the puzzle solving. 1
Kit_L Posted September 25, 2017 Posted September 25, 2017 @dannyg: wear that hat whenever you want, brother; I too am madly attracted to problem solving (hence our respective careers!!!). I really appreciate and respect your erudite contributions.
Jim Pickles Posted September 25, 2017 Author Posted September 25, 2017 Thanks for all that. I'll work though it and let you know. In your sequence above; however, at stage 7 there was no difference on the worked side. Many thanks, Jim.
dannyg Posted September 25, 2017 Posted September 25, 2017 @Jim Pickles No worries. Apologies! The only other thing I can think of mentioning is that rather than structures, habitual behaviours (such as the forward head carrying you noted) might be maintaining/predisposing it. Hope it continues to clear up until it is nothing but a distant memory.
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