Schenardi C. Whiplash injury. I believe I have TOS/Winged Scaps which is causing a lot of this when I pull the funny face on the cover of your Muscle Clenching article I get some numbness in the SCM on the side where I have the suspected TOS is this a sign? The longer the arms stay up, the worse the symptoms can get. Are there any possible ligaments implications that mighr further compress the structures. with due respect Larsen, I could assign the jawbones position hundred percent for the reason of such problems, backward maxilla and mandible cause scalene drop and so on . Would a knotted muscle in the neck or suprascrapular area cause symptoms similar to TOS? I recommend David Weinstocks book Neurokinetic Therapy, as it demonstrates the MMT tests well. Watch my video on how to do it properly. The American Journal of Orthopedics. Hi, can uneven hips cause this? Blue discoloration. Annals of Surgery. other information we have about you. down the exact cause on the evidence of symptoms alone. Tightness (due to weakness) of the scalenus muscles will compress the subclavian artery, especially during ipsilateral rotation and extension of the neck. This animation illustrates how physicians at the Johns Hopkins Thoracic Outlet Syndrome Clinic perform interscalene brachial plexus blocks using botulinum toxin type A injections to provide temporary pain relief for patients. The point here is to assess the specific muscles functions, not to win. Thanks for the reply. This cycle will need to be practiced over and over until it feels more normal or occurs automatically. There is a great level of detail that goes into the exercises, as the patients body will have learned many compensatory strategies, often for years on end, in order to cope with daily life. Except in the more Diagnosis and Tests How is venous thoracic outlet syndrome diagnosed? Thoracic outlet syndrome (TOS) causes pain in the shoulder, arm, and neck. Can thoracic outlet syndrome affect chest? 2015; doi:10.5435/JAAOS-D-13-00215. I have seen examples of this, mainly in type A, extremely motivated patients, overloading the scalenes to the extent of ruining the conservative treatment and unable to recover, even after months, and ending up needing surgical release. In vascular thoracic outlet syndrome, symptoms such as coldness and numbness reflect limitations in blood flow to the hand. I have seen several patients with severe pain upon pressure to the interscalene triangle, positive myotome tests etc., who still did not have any findings upon EMG. Weakness is usually not a cause of muscular entrapment, but rather of costoclavicular space compression (i.e. Nothing else really makes it do this. In neurogenic TOS, neurogenic symptoms occur in the upper extremity and may radiate to the shoulder, neck, and occipital regions if the upper trunk is involved; Raynaud phenomenon is frequently seen due to an overactive sympathetic nervous system, whose fibers run along the C8 and T1 nerves. Thoracic radiculopathy is irritation or . The stretching makes the client feel better! Buller LT, et al. Thoracic outlet syndrome. A small percentage of people with a cervical rib develop thoracic outlet syndrome. i understand one of the first things they will do is botox as a partly diagnostic measure. Daily stretches focusing on the chest, neck and shoulders can help improve shoulder muscle strength and prevent thoracic outlet syndrome. can i also introduce mobility exercises? Thanks! 2004 Sep;71(5):430-2. doi: 10.1016/j.jbspin.2003.07.007. Research has demonstrated a connection between compression of the subclavian artery and compromise of the vertebral artery, an artery that supplies the posterior brain with blood. 2011;21(3):366-373. doi:10.1007/s10926-010-9278-9. If left untreated, thoracic outlet syndrome can lead to serious consequences like blood clots, permanent loss of nerve function, and chronic pain or swelling of the arm. Forensic medical aspects. Most of the time, however, the scapula is so depressed that even with anterior rotation it will not be in line with T2, such as with the person in the picture below. Heres the problem. J Chiropr Med. It is ridiculous what has happened to our healthcare system. Woods [6] noted dizziness, vertigo, and blurred vision in some patients with upper plexus le-sions. 2020). Neurology. Weakness in . Regulate exercise volume and intensity based on how much it hurts (it should just hurt a little), and start very easy. Result of this one was post op horners syndrome and lower trunk damage. They are not unique, and this is one of the main reasons why making a diagnosis is difficult. in relation to surgical intervention of atherosclerosis. Neurogenic TOS is very easy to trigger, and this is tremendously helpful while diagnosing and identifying nervous entrapment points down the branches of the brachial plexus. https://www.youtube.com/watch?v=dCI-Qa6Fu-Y. I have to assume this is from what you said, that it further compresses the thoracic outlet. And, of course its relation to breathing dysfunction. It makes sense tough, cause my nose is pretty much always clogged up. (it is unlikely that the jugular vein) Symptoms: whistling (ringing) in the head, sometimes stuffs up the ears, after lifting weights, the whistling (ringing) intensifies nasal congestion, there is a lack of air, a cloudy spot in the eyes, fatigue, I never get enough sleep in the morning and a mesh in my eyes. Im still quite active (weight lifting, drumming, yoga). The Tinels sign is a very good indicator of entrapment. We get treated like lab rats being sent from one 15 minute appointment to the next. Dr James Stoxen says in his book Advertising revenue supports our not-for-profit mission. Deep venous thrombosis usually begins in venous valve cusps. The hypertrophied scalenes you are talking about, are fatty-atrophied. I would like to make you a few questions. Thank you and congratulations! The patient leaves the arms up for 1-2 minutes, and the therapist looks for a White hand sign (WHS), which implies cadaveric paleness of the affected hand, usually along with tiredness and/or pain. An anterior scalenotomy was done with preservation of the phrenic nerve. I have three rules that need to be fulfilled before I decide to release a muscle. This test, however, is not all that useful. Our heart health checklist can help you determine when to seek care. The takeaway is therefore to very gradually reintroduce chest breathing and to closely monitor your symptoms during this period to avoid progressive overloading and inflammation of the scalenes. When the pelvis is tucked down and in (posterior pelvic tilt, lumbosacral flexion), it causes a shift in the bodys gravitational points so that the mid back hyperextends and the shoulders and head comes forward. A typical TOS patient will often present with similar scapular resting position, as many studies (cited below) also show. 1998-2023 Mayo Foundation for Medical Education and Research (MFMER). All symptoms of significant TOS. Upper plexus (C5-C7) symptoms may manifest as headache; face, jaw, or occipital pain; vertigo; blurred vision; or paresthesia of the first three digits. Grunebach H, et al. I think you are misleading yourself by presuming that the pain location is also exactly where it is originating from. No More often than not, however, it is very difficult to pin Symptoms of neurogenic-TOS vary widely depending on the site of impingement and parts of the brachial plexus involved. band in a muscle, pushing against a nerve or blood vessel. I have written extensively about the topic of correcting swayback posture numerous times in my other norwegian articles, but also in this lower back article in english. i appear to be having arteial tos symptoms, just had one of my worse cold and white hand episodes. The tinels sign has been shown to have poor specificity in the literature, but because plexopathic problems are so controversial, there is not reason to rely on this. The anterior scalene is a muscle located in the neck that attaches to the first rib in the area known as the thoracic . Subclavius muscle 6. Connolly JF, Dehne R. Nonunion of the clavicle and thoracic outlet syndrome. Then, try to make the thorax and abdomen expand in all 360 degrees as you inhale, getting into a calm rhythm of balanced respiration. Do you also advise on post-op TOS? Sorry to keeping it too long, your advises will be soo much valuable for me. J Thorac Dis. PMID: 15977087. Treatments include: Medication:Blood thinners to treat clots, Thrombolysis:A procedure to remove a clot from the vein, usually done before TOS surgery. If it does, this is a region thatll need corrections. The purpose of this study was to evaluate the use of SEPs in the diagnosis of TOS. We were more impressed with the deep cervical fascia as the cause of intermittent rotational obstruction rather than the anterior scalene muscle. Chahwala V, Tashiro J, Li X, Baqai A, Rey J, Robinson HR. Can you help me? Evaluation of the axillary nerve under the teres minor, suprascapular nerve under the supraspinatus muscle, musculocutaneous nerve within the coracobrachialis, etc., must be done and treated accordingly. I have a hypertrophied Scalene on my left side and an elevated hip on my right. Start light and gradually go hard(er), to see if the symptoms reproduce. TOS commonly shows itself as It is therefore extremely difficult to quantify its involvement and thus, in my view, highly unlikely that this estimate is reliable. PMID: 19008742. Latissimus dorsi muscle 10. Sleeping positions should be changed. Stretch daily, and perform exercises that keep your shoulder muscles strong. This can be hyperventilation, heavy carrying and working overhead, or especially horizontal pushing. Furthermore, studies have demonstrated that the interaction between sympathetic and parasympathetic nervous systems in developing AF by recording nerve activities directly from stellate ganglia, and vagal nerve (39). PMID: 15474397. The thoracic outlet is the space between your collarbone (clavicle) and your first rib. it seems to be their protocol. I dont know if she trained them (the scalenes) more properly the last day, or if it was the cumulative loading that made the muscles inflammate, but these symptoms are of course vagus nerve irritation as well as vertebrobasilar insufficiency. why is botox generally not a good idea unless awaiting surgery? (tos symptoms are on the right). If an artery Specifically: Cervical rib: A cervical rib is an extra rib that grows from the cervical spine the neck part of the spine. Venous thoracic outlet syndrome Arm fatigue, heaviness, and swelling. Hello, Thus, if this differentiation was necessary, it would have been mentioned in the article. Sometimes, a congenital (from birth) abnormality can cause thoracic outlet syndrome, but it is more likely to occur after injury or bodybuilding. In this case report we relate a young patient with bilateral supernumerary ribs (cervical ribs) inducing an . Surgeryis usually recommended for arterial TOS. Symptoms typically include: Pain, paresthesia, and possible motor weakness in the affected arm. Symptoms of thoracic outlet syndrome include pain and paraesthesias. Feeling so thirsty that no water can saciate me is one of the symptoms I started to develop as a pre adolescent when breathing became a problem. Beware that painful muscles tend to be weak, not strong. Its just much less important than optimization of habits. he did not mention surgery. We are vaccinating all eligible patients. Thank you! My scalene I believe the middle one sticks out and is hard to the touch does they mean its weak and hypertrophied? Sympathetic comorbidity such as tremors, Reynauds syndrome or causalgia may develop. But it also seems like I could alleviate a lot of my symptoms from the exercises outlined above based on what I was reading. This is especially important when there is pre-compression within the scalenes and costoclavicular passage, as this sensitizethe whole nervous chain and makethe distal branches more vulnerable to additional irritation. The treatments are of course the same; the scalenes and SCM requires significant strengthening over a period of time. privacy practices. The superior scapular angle is significantly inferior (lower than) the T2 vertebrae, and they rest in considerable anterior and downward rotation. Why do they become irritated or compromised? As explained, the supinator and triangular interval are by far the most common regions of radial nerve compression. The transaxillary approach alone is satisfac- . Sometimes I can barely get them to activate for just one rep. Here are some interesting quotes. Ive got some questions though that I was hoping you might be able to answer/give advice, This article connected a lot of dots for me and I really appreciate the information. Should I reduce the exercise intensity? Going on hard on these exercises may trigger tremendous pain and significant worsening of the symptoms. Thoracic outlet syndrome in brief. Evaluate by history to rule out nerve-related conditions, such as carpal tunnel syndrome, cubital tunnel syndrome, cervical spine diseaseor other types of nerve entrapment, which have similar symptoms and may be confused for thoracic outlet syndrome. PMID: 2287384. Regardless of what you have heard, no amount of strengthening will solve this problem. 2004, Four patients with elevated creatine phosphokinase (CPK) values and recurrent chest pain were found to have thoracic outlet syndrome. I thought my TOS might have been just genetics or purely innate anatomical defect in nature.. Powers et al., 1961, We report a patient who developed occasional vertigo when turning his head to the right side. Four operations were used: transaxillary first rib resection (26); supraclavicular first rib resection with neurolysis (15); scalenectomy with neurolysis (58); and brachial . Compression of C7,C8,and T1 nerves fibers is responsible for the neck pain. Is this 10 reps for each of the middle and anterior scalene exercises, or 10 reps total (eg 5 each). Genius Just wondering what are you studying on TOS ? Diagnosis of thoracic outlet syndrome. Extreme muscular inhibition will cause severe abrasiveness and tightening, greatly increasing its potential of irritating / compressing nearby structures such as nerves and blood vessels. Thistakes the guess-work away, and the therapist will know where the further assessment and correctives should be initiated in order to resolve the issue.Manual muscle testing of muscles that are responsible for nervous compression, will often reveal a false negative (appear strong) at first. Signs and symptoms of venous thoracic outlet syndrome can include: Discoloration of your hand (bluish color) Arm pain and swelling Blood clot in veins in the upper area of your body Arm fatigue with activity Paleness or abnormal color in one or more fingers or your hand Throbbing lump near your collarbone Abnormal muscle or first rib formation: Some people may have an extra or aberrant scalene muscle (an inner muscle of the neck) or an abnormal first rib or clavicle (collarbone). TOS occurs when the blood vessels or nerves in the thoracic outlet area become compressed, irritated or injured. Would the strengthening of scm and scalene make this go away? You'll soon start receiving the latest Mayo Clinic health information you requested in your inbox. She was having difficulty breathing, clogged ears, neck and shoulder pain, and dizziness. Elsevier publishing, 2014. Pain can be present on an intermittent or permanent basis. 1990;32(6):514-5. doi: 10.1007/BF02426468. I want to do your Scalenus anterior & medius exercises, but can not lie on my side, because I have Ehlers Danlos Syndrome, and my shoulders sublux/dislocate in that position. He was intrieged! Thoracic outlet syndrome (TOS) occurs when nerves or blood vessels are compressed by the rib, collarbone or neck muscles at the top of the outlet. Kojima N, Tamaki N, Fujita K, Matsumoto S. Vertebral artery occlusion at the narrowed scalenovertebral angle: mechanical vertebral occlusion in the distal first portion. Note the difference in echogenicity between the sternocleidomastoid (scm) and scalenes (white structures = fat; the muscle should be relatively dark). These symptoms occur because compression of the vein may cause blood clots. Mayo Clinic. Weak grip happens because of an injury is a symptom to watch out for in thoracic outlet syndrome. Testimonials Triggering the symptoms may be a little challenging. Thoracic outlet syndrome is sometimes considered controversial, as symptoms can be vague and similar to other conditions. Signs That You May Have Thoracic Outlet Syndrome Regardless of what type of TOS a person may be suffering from, there are several tell-tale symptoms that could indicate that they have TOS, including: Pain, numbness or tingling in the arm, forearm or fingers Loss of pulse in the wrist Swollen, bluish arm Clumsiness of the affected arm Occasionally, the postganglionic sympathetic fibers may pierce the anterior scalene muscle. Outlook. Many breathing experts claim that diaphragmatic (belly)-breathing is the ultimate cure to virtually anything. hi Kjetil, thank you for this how to guide. Ignore the muscle size, it is not important nor a criteria for proper positioning. Thoracic outlet syndrome can lead to a wide range of symptoms. Ulnar neuralgia or paresthesia is also a common initial symptoms of TOS, as the C8 and T1 roots lie more susceptible for compression in the costoclavicular interval. Surgery and anticoagulation therapy!! Ferri FF. Knattlia 2, 3038 Swayback posture is the most common stabilisation strategy I see utilised by clients with thoracic outlet syndrome. I may have to book a Skype call with you. The patient attributed his symptoms to TOS. Only two patients showed unequivocal poststenotic dilatation as evidence of severe anterior scalene muscle compression. Patients with thoracic outlet syndrome will most likely present pain anywhere between the neck, face and occipital region or into the chest, shoulder and upper extremity and paresthesia in the upper extremity. Bluntly, the myth of stretching (releasing) is one of the main reasons why most therapists are not able to cure thoracic outlet syndrome(or other nervous compression issues of muscular origin, for that matter) with conservative measures. Be sure not to sleep on the affected side! Symptoms and CPK values improved with anti-inflammatory medications and/or proper posture instruction. This is called a positive Tinels sign. My surgery is scheduled for June 20th. The cell bodies of the two types of neurons are situated in the dorsal root ganglia of the corresponding spinal segments. However its necessary the increase the work capacity of the given muscles to such extent that they no longer irritate the nervous structures that either pass through, or next to them. Its rooted in habits, and must be corrected primarily by habitual changes. I recommend working on thoracic posture and angles (swayback) as an underlying cause when treating dyskinesia, but not as a direct intervention. I am just curious on your general opinion on conservative approaches to vein compression in TOS, or if you think any compression means surgery is required. Silva & Selmonosky, 2011, Reports of transient blindness resulting from this condition are even more rare. Please read this article if you've just started practicing Clinical Somatics exercises and are experiencing any of the following sensations: Nausea, dizziness, feeling off-balance. The therapist may also force the clavicle caudally. Dadsetan & Skerhut, 1989, Rotational positioning of the head showed vertebral obstruction in one direction, and unobstructed filling of the vessel when the head was turned to the opposite side. [The total treatment time for this patient could be 2930 hours with no breaks on a severe thoracic outlet syndrome case. One small rule of thumb may be useful; working with the arm above the head worsens the tingling . Sweating more often (when I first get up in the morning)? However, there is still some question as to whether EMG is adequately sensitive to detect changes in NTOS patients with milder symptoms.42,45 Sanders et al., 2008, Somatosensory evoked potentials (SEPs) are used in the diagnosis of thoracic outlet syndrome (TOS), even as an indication for surgery. If the shoulders appear relatively symmetrical in resting height after surgery, this suggests that an inadequate amount of rib was removed. There may also be venous insufficiency, causing venous distention and purpuric skin color indicative of cyanosis. In TOS, the rib elevation caused by scalenus tightness also causes rib rigidity. Heat therapy may be a solution for numbness in the fingers. Similar to that of hypopefusion (flow deficit), hyperperfusion is also associated with migraines, headaches, dizziness, transient bells palsy, nausea, hemiplegia palsy and more (Adhiyaman 2007,Tehindrazanarivelo 1992,Coutts 2003,Sundt 1981). Pre surgery i had some range of motion issues on my related side tight scm, scalene muscles and trap pain. advertisement. For the anterior scalene, resist above the eyebrow while client the head toward the shoulder. Muscle Nerve. Gentle strengthening once to twice per week of the offending muscle is the appropriate treatment. 2) I wasnt surely clear about this after reading the article: Could Scapular problems (scapular dyskinesis) be the cause of TOS with neck and head symptoms? Therefore, this study suggests that SEPs are not helpful in the diagnosis of TOS. There is a problem with Some pain in the process is inevitable, so dont let it scare you. The conservative physiotherapy regimen outlined in this article will be suitable for patients presenting with TOS where there is a strong postural contribution to their symptoms. Mayo Clinic is a not-for-profit organization. It may get better for an hour or so, but then comes back with a vengeance. The symptoms of thoracic outlet syndrome depend on what is being squashed (compressed) in your thoracic outlet. Kojima et al., 1985, Rotation-induced vertebrobasilar artery hypoperfusion causes transient ischemic attacks (TIAs), affecting the cerebellum, brainstem and spinal cord. July 1963;158(1):133-137, Alcocer F, David M, Goodman R, Jain SK, David S. A forgotten vascular disease with important clinical implications. Many forms of scapula asymmetry may well exist in TOS populations, but in the limited research that has been done, scapula or shoulder girdle depression or drooping has been consistently observed (Kenny et al., 1993; Walsh, 1994; Pascarelli and Hsu, 2001; Skandalakis and Mirilas, 2001). Aralasmak et al., 2010. It concerns compression of either nerve or blood supply in the thoracic outlet (the area of the body between the neck and the shoulder) region (1). Pectoralis minor muscle 9. Visible veins in one shoulder, arm or on one side of your chest. Breathing habits will need to be worked on, especially with regards to thoracic vertical expansion during inhalation. A diagnosis is based on information from the patients history, a physical exam, and It may potentially lead to tractional stress being placed on the nerve, vascular and muscular elements as well as compression as the clavicle descends closer towards either the first rib or any other bony element present. She was fine a few days after, but was of course mortified of starting those exercises again. Its important to be evaluated by someone who can distinguish between the various types of thoracic outlet syndrome and rule out other conditions. Physical therapyis typically the first treatment. Major indications for dorsal sympathectomy include hyperhidrosis, Raynauds phenomenon or disease, causalgia, SMPS, reflex sympathetic dystrophy, and vascular insufficiency of the upper extremity. Symptoms are worse when you use your arm and better when you rest. There has been increasing evidence that dysfunction of the autonomic nervous system that encompasses the sympathetic, parasympathetic and intrinsic neural network is involved in the pathogenesis of AF (atrial fibrillation). or variation, or who have experienced a physical injury or trauma that is found to more forward. "Mayo," "Mayo Clinic," "MayoClinic.org," "Mayo Clinic Healthy Living," and the triple-shield Mayo Clinic logo are trademarks of Mayo Foundation for Medical Education and Research. While strengthening on the other hand, makes it feel worse. If this reproduces the pain, test the muscle. Its hard work, but well worth it. If neurogenic thoracic outlet syndrome is suspected: Brachial plexus block: Local anesthetic is injected into the scalene muscles of the neck. 1983 Mar;83(3):461-3. doi: 10.1378/chest.83.3.461. Review/update the and hard to get a doctor to take seriously. Common causes of thoracic outlet syndrome include physical trauma from a car accident, repetitive injuries from job- or sports-related activities, certain anatomical defects (such as having an extra rib), and pregnancy. Swift TR, Nichols FT. (1984). All the patients had an anomalous vertebral artery. Sign up for free, and stay up to date on research advancements, health tips and current health topics, like COVID-19, plus expertise on managing health. Thoracic outlet syndrome. What are your general thoughts on having a rib-sparing scalenectomy, especially in TOS-CVH? Neurosurgery. I stopped sleeping on my stomach and everything came back. Edema (swelling) of the arm, hand or fingers, Very prominent veins in the shoulder, neck and hand. We will now look more closely on these, and how each branch can beaddressed. Thoracic outlet syndrome (TOS) is a symptom complex attributed to compression of the nerves and vessels as they exit the thoracic outlet. She was stressed out of her mind because patients were waiting for her. . Privacy policy, How to truly identify and treat thoracic outlet syndrome (TOS). Severe TOS also has been known to result in gangrene You may opt-out of email communications at any time by clicking on Seek a PMR doctor with TOS specialty or a cardiothoracic surgeon. This is why public health care is good if you have a simple medical problem but a tragedy if theres any complexity to the matter. PMID: 14580271. Additionally, because the scalenes attach to the ribs, they may elevate the first rib, greatly increasing the potential of secondary compression between the 1st rib and the clavicle. I will be booking an appointment with you soon. EDS is genetic with a cascade of comorbidities and POTS is a common comorbidity, why wouldnt a ten year old be able to be diagnosed with them? Thoracic means region of the thorax (chest), and outlet is self explanatory. Innormal breathing patterns, the ribs and clavicle should elevate slightly during inspiration, and this is done in syncronization by the scalenes, trapezius and several other muscles. This can cause a truly weird and confusing constellation of symptoms. This is known as effort thrombosis, or Paget-Schroetter syndrome. I went to therapy for TOS, but didnt seem to help but worsen my neck it seemed. If any relevant symptoms appear after the provocation, that is a strong indication that there are vascular implications in the given case of thoracic outlet syndrome. Arteriography demonstrated occlusion of the left vertebral artery only when her head was rotated to the left. I have a first rib resection surgery booked for two weeks from now. Also I broke my neck about 6 years ago so Im sure thats where the problem is from as well as bad posture. Southern Med Journal. Unfortunately, none of the physicians can explain my strange symptoms. Ive gotten 4 different opinions from vascular surgeons. The ribs are normally quite flexible, thus the ability for ribcage expansion during respiration. 2. Breaking your neck certainly didnt make your neck muscles stronger. For me, this has been caused by the alignment of my head and neck, and the way the skull sits on the spine. Biceps short head muscle 7. If you are a Mayo Clinic patient, this could Neurology 34, 212- 215. Godfrey NF, Halter DG, Minna DA, Weiss M, Lorber A. Thoracic outlet syndrome mimicking angina pectoris with elevated creatine phosphokinase values. She was also very, very stressed, worked 10 hour days (with a horrible posture as a dentist), almost without breaks, for 30 years. Pronator teres syndrome. https://youtu.be/HezNZkdt4Ug. Thoracic outlet syndrome (TOS) refers to the compression of one or more of the neurovascular structures traversing the superior aperture of the chest. He specializes in the treatment of chronic pain and has developed several distinctive protocols both with regards to diagnosis and conservative rehabilitation of difficult conditions. Chest Pain, Dizziness & Thoracic Outlet Syndrome Symptom Checker: Possible causes include Angina Pectoris. Now remember, these patients have been to many different healers, they have had thoracic outlet syndrome for 210 years, which means the reflexes are locked deeply in the brain and there might be a lot of scar tissue in the muscles and joints.] Is there any way to know if this is a styloid problem, or scalenes/SCM? I found your site and did the head exercise, not letting it reach the floor seemed to have helped a lot. 2015; doi: 10.1177/1358863X15598391. Education The symptoms of thoracic outlet syndrome depend on the type of TOS. So im very confused because you say that myofascial Release is not necessary. The obstructing extra-luminal fascia was quite dense, fibrotic and often completely encircling the artery.
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