Shoulder elevations for treatment of TOS
 

I'm kicking off a new topic thread for this. The article was brought to our attention by boytos:

It was published in the American Journal of Surgery, Feb 1993. Hey it's nice to see surgeons being respectful of non-surgical approaches. :)

Table and Figure

The first link is missing the Table I and Figure I, but I have purchased the article. I'm not allowed to share copies of the article according to the terms of service of the site that sold it. However, I will describe some things from it.

The exercise is to elevate shoulders and hold for count of 5, then relax shoulders. Then repeat.

There is no warning to be careful not to engage the scalenes, scm, etc. Although I'm sure you all would agree with me that there should be.

The first table shows 3 weeks of exercise, as mentioned in the public abstract. Exercise is every day, so 21 days straight. Number of times per day is 5 - 6 which surprised me. Reps range from from 10 to 20. Week 1 is no weights; week 2 is 3 lb weight in each hand; week 3 is 5 lb weight in each hand.

Perhaps this is how one exercises when trying to change posture or body shape, as opposed to just simply strength.

Figure 1 shows mean symptom levels before and after the program for things like pain in hands, in arms, in neck, pins/needles, weakness in hands, in arms. On a 10 scale these were between 5 - 7 with the pain elements being higher than the weakness. After the program, these were between 1.5 - 3 for improvements in all areas.

Additional Comments

Note that the researchers excluded patients with serious problems like cervical rib or positive EMG results showing nerve entrapment. Basically they seem to be treating people with what I often see called "disputed NTOS" and/or mild ATOS/VTOS.

Also, the following site which was linked from ScienceDirect shows that 31 articles referenced this one. I'm guessing most of them cite it in passing like "...physical therapy has been used to treat thoracic outlet syndrome [3]...", but it would be interesting to know if any of them say anything more specific, whether critical or complimentary. boytos, I nominate you for that research. :D

http://www.scopus.com/results/citedb...QGTpVKrpzN%3a2

That's a gnarly URL; I don't know if it will last. But if you poke around the web you should be able to get the list.

My Plans

Regarding me personally, I do have a depressed shoulder girdle on my TOS side although it looks better to me than it did months ago when my health crisis hit and this journey started. And I've also improved with fewer and less severe symptoms. Furthermore when my shoulder girdle became more depressed by power walking with arms straight, that's when my symptoms got worse.

So I may try this protocol in order to make further progress, but probably not til mid-Jan or later as I'm in the middle of other things.

I may also share it with my PT and see what she says first.

Further Research

This was written in the early 90's. Is the information still current? Did anyone replicate this? It's only 8 patients.

If it does work there are further interesting questions like: Should you do it for 4 weeks? 5? How many times per day is optimal?

This also stimulates the idea of doing further searching on the web with terms like:
"thoracic outlet syndrome" elevate shoulders
"thoracic outlet syndrome" shoulder elevations

...to see what else comes up. I have not done this yet.

Hey boytos, any other papers on exercise programs for TOS besides that PRI/football one?

Hi,

Hypothesis about the results

The results of the cyriax release and the orthosis for TOS seems valuable to explain the results of shoulders shrugs ( if any ) : passively elevating shoulders with the trapezius.

Problems about this exercice :

It is know to aggravate symptoms in some patients. That sure. Why ? i don't know. I make a hypothesis :

First, it does not seem to involve scalenes. So scalenes hypertrophy is unlikely to explain the aggravation. But it is a possibility
Maybe it stimulate nerve irritation, so the inflammation spread. The nerve inflammation can then induce muscle hypertrophy and increase vascular and nerve compression. But if it was the case, it would induce ulnar and carpal tunnel entrapment. Not necessary, but at least sometimes. If nerve symptoms are already important, then there is more chances for aggravating symptoms by this method. Because it would mean that nerves are hightly sensitives.

If it is, then specific anti-inflammatory may be valuable. I think about anti tnfa, heparin, and all that.

Then it has been tried for 'pure' Vtos, with failure. Hypothesis :
If there is compression of the vein between the anterior scalene and ligament, it may not help.
Direct damage like aneurysm may prevent healing.

For the moment it is very unclear. My advice is to try it before surgery.

As i try shrugs, i start to think it involve scalenes.. but anterior, medium, scm ? confusing....

Maybe heparin injection in scalenes can prevent their hypertrophy ? :

Heparin inhibits skeletal muscle growth in vitro.
http://www.ncbi.nlm.nih.gov/pubmed/3342932

It seem that it involve scalene when you roll too much shoulders..

i think there is a risk of scalene hypertrophy, you realy need to do this propely in perfect alignment to isolate shoulders and trapezius to the best.

I'd be curious to know how exactly this "shrug" is recommended to be done.

Is it a straight up shrug? Or more of an up and back so you are squeezing your scaps together on the way down?

If there is proof that this helps, I'd add this into my workout rotation.

KY

My text "elevate shoulders and hold for count of 5, then relax shoulders" is straight from the paper. They did not give any finer points to how to do the exercise.

I'd really like to know if, since 1993, anyone has tried reproducing the results. Also, did the authors continue to use this approach for TOS patients over the years?

Yes, and sometimes it work, sometimes not, sometimes it aggravate the problem.

In http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2953353/

There is :

http://www.ncbi.nlm.nih.gov/pmc/arti...53/figure/F10/

I couldn't find "Figure 10" in the text, so I'm not sure if they discuss it at all. I'm not sure what they are trying to convey from the diagram. What's your interpretation and how do you think it is significant to the shoulder elevation approach?

Any luck?
 

I know it's an old post - but did anyone have any luck with these? I've been advised to incorporate shrugs into by my PT, however, the levator scap just seem to flare up. It's apparent I have upper trap wasting and is a cause of my TOS, due to the droopy shoulder, but it seems I need to stall the levator scap and scalenes from firing, in order to get the upper trap working in isolation.

Any info, please shout up.

Dan

Upper Trapezius exercise
 

This is my first post but I may be able to help.

I have some experience with this after consulting Lyn Watson, an Australian PT who has published two recent and significant papers on TOS:

Watson L, Pizzari T, Balster S. 2009, Thoracic outlet syndrome part 1: Clinical Manifestations, differentiation and treatment pathways. Manual Therapy, 14(6):586-595

Watson L, Pizzari T, Balster S. 2010, Thoracic outlet syndrome part 2: Conservative management of thoracic outlet syndrome. Manual Therapy 15(4):305-314

**

Lyn is a very strong proponent in the "Upper Trap" school of TOS, which states that it is largely delayed and insufficient recruitment of the UT that causes poor scapula mobility. Her main exercise for me was to (for the right hand UT):

Lay on left hand side, with your right arm along your body and left hand across your chest and loosely gripping your right UT between the neck and shoulder. Try and engage the muscle so you can feel it tense and draw your shoulder upwards. Try to isolate the UT and make sure you don't use any rhomboid. The aim is not to build strength yet but to engage the muscle independently of the others. Do 20 times holding for 5 sec. As you progress you can hook a thera band around your feet and hold tensioned in right hand to add resistance.

I have worked with the UT alot, but have found greater success working with the serratus. There is quite a contrary school here in Europe that says TOS is largely a result of poor scapula upward rotation by the serratus. I found a PT who was a shoulder specialist and had amazing results.

Now if only I could cure the herniated cervical disk that has caused all this...

I'm hoping you might describe your work with the shoulder specialist you note who had good results, specifically the serratus focused therapy you mention. Also, what symptoms did you have that resolved with this therapy? Like so much regarding TOS, unfortunately there seems to be little consensus on appropriate therapy. My doctor, Dr. Donahue says that the purpose of shoulder shrugs is to strengthen the shoulder girdle so the clavicle is held up, away from the first rib.

My symptoms originated in the neck after a ski accident 4 years ago then spread to the shoulders, arms and hands a year later. I have had trigger points in almost all muscles in the shoulders, chest, neck and upper back. I have measurable EMG anomalies in the RHS medial nerve caused most likely by C7 nerve root compression. I have pain in teh arms that can only be described as nerve related.

My understanding of TOS is that in many cases (and specifically my case) the symptoms are caused by incorrect scapula recruitment and mobility. In Lyn Watson's first paper she talks about a depressed and downwardly rotated scapula, often winged along the medial border. My understanding of her "upper trapezius" thoery of TOS is that the UT pulls the superior border of the scapula up and towards the neck.

My understanding of the serratus view of TOS is that it is this muscle that causes the scapula to elevate during normal arm movement and not the UT and levatator. It is inadequate recruitment of this muscle that causes the entire shoulder and clavicle mechanics to function incorrectly. Nerves can be compressed either by the clavicle not moving correctly or from the many strained muscles that results from the poor mechanics. When you see a working model of the scapula and clavicle during normal arm movement, it is clear that if the scapula does not upwardly rotate, the entire mechanics are thrown out.

A diagnostic:

This tests whether your scapula is moving correctly, specifically upwardly rotating.

Stand (shirtless) with your back to a large mirror and holding a hand mirror (in your left hand) in front so you can see your right hand side scapula reflected in the large mirror. Get someone to touch their finger on the lower (inferior) corner of the right hand scapula. Now raise your right arm straight out in front to about 90 deg or higher. As you raise your arm, your helper's finger marking the lower corner of the scapula should move sideways at first and then upwards towards your right arm pit. This scapula movement is called (unsurprisingly) upward rotation. It is mostly the serratus that does this. The serratus also holds your scapula against your ribs. Winging along the medial border is a sign that the serratus is not doing its job.

I have several exercises that have been key in getting my previously winged and downwardly rotated scapula to behave correctly. Within 3 months of starting the exercises I was in much less pain. Unfortunately things are not completely better for me as the original trauma to the neck, which caused the TOS, has not resolved.

I can recommend exercises, but my first recommendation would be to find a PT who is an expert on shoulders. After seeing Lyn Watson in Australia, I actively sought out a shoulder clinic in my home in Switzerland who then referred me to a shoulder PT.

It has been my experience with seeing many surgeons, chiropractors and physios over the last 4 years, that physios are the real experts on mechanics but have very varied specialties. I have found surgeons very unhelpful as they are the experts on structures but I have also found physios who think that trigger points are the cause of all problems.

I hope this helps and am happy to provide any further information if desired. Like many on this forum, I have had to become my own expert.

Thank you for having taken the time to share all this information. It's very helpful.

Thanks Smaug
 

I have always felt that my problems originated from my scalpula. My first injury was scalpular pain from yoga . Everytime I get a bad flare up it seems to come after doing someting which pulls muscles or joints or ribs out in or around my scalpula. Wheter it is over streching or working in the garden.

None of the doctors I see seem to really address this. Sometimes it looks like I have slight winging and sometimes not.My PT Dr. Ando has adjusted the joint below my scalpula that attaches to the rib. So complicated and after 3 years no clear answers.

What exercises do you recommend?

serratus exercises part 1)
 

I'm happy to recommend some exercises for the serratus that have worked for me. I hope others can chime in too.

There are several serratus muscles; here I'm referring to the serratus anterior and, specifically, the superior strands. The serratus anterior has a strand from each rib (attaching just forward of your sides) which run backwards under the scapula and attach to the medial (closest to the spine) border. When they contract, they pull the scapula flat towards the ribs and outward.

I have found that fixing muscle imbalances can be divided into three steps:

1) activation: isolating a muscle and then getting it to move. This is the hardest part if a muscle has not been used in a while and if there has been nerve damage. It is the step which requires the greatest care to make sure it's done correctly.

2) strengthening: often the part that people jump straight to and end up strengthening the wrong muscles if the correct muscles have not been activated.

3) motor learning: getting your body to use the newly activated and strengthened muscle in everyday activities.

The serratus exercises here are aimed at getting your shoulders up and forward. This goes against completely classical shoulder stability theories that require you to use your lower trapezius to pull your shoulders back and down. Whenever I pull my shoulders back and down I feel significantly more pressure on the nerves running into the arms. If an exercise gives more nerve pain then it is mostly likely the wrong movement.

Exercise 1: Activation phase.
I'll call these air push ups, maybe they have another name.

1) Lie on your back, ideally lengthwise on a pilates roll running from your head to tail bone. Otherwise the floor is fine but it's better if your scapula are free and your shoulders can sink below the level of your chest slightly.
2) Raise your arms so they are vertical with your elbows locked and fingers straight and palms facing each other. Your hands should be about a shoulder width apart.
3) Tighten your deep abdominal (pilates core) muscles by curling your pelvis up so your lower back is flat along the pilates roll/floor. It's worth reading Pilates references on how to do this correctly.
4) Activate your deep neck flexors by nodding slightly (without lifting the head). Again, read up on this.
5) Now the important part. Push upward vertically with your shoulders to raise your entire arm a few inches so that your shoulders leave the floor.

• Concentrate very hard on what your shoulders are doing. Think about the movement being at first outwards (think wide shoulders) before going up.
• Keep hands shoulder width apart. Don't let them move together as this encourages serratus use and discourages you using the pectorals.
• Do things very slowly and deliberately. Try and be very conscious of what is moving in your shoulders. Close your eyes and really feel what your body is doing.
• Push up far enough that it is a slight effort but don't strain it. Keep effort less than 50%.
• Hold for 5 sec then slowly relax and lower the shoulders.
• Start with 10 reps

Enough for a start. If anyone would like to hear more, please let me know. I've learnt much from this forum and hope I can contribute in some small way.

Smaug - thanks very much for this serratus exercise.

Would you mind sharing some other serratus exercises? Or do you progress this exercise somehow? I have already added light weights in each hand.

thanks again!

*admin edit*

Thoracic outlet syndrome part 1: clinical manifestations, differentiation and treatment pathways
http://www.ncbi.nlm.nih.gov/pubmed/19744876
http://www.researchgate.net/publicat...1ad4d0408d.pdf

Thoracic outlet syndrome part 2: conservative management of thoracic outlet
http://www.ncbi.nlm.nih.gov/pubmed/20382063
http://osteobcn.files.wordpress.com/...ome-part-2.pdf

Great articles - thank you Chroma.

What exercises are you doing for serratus? I am now doing this activation exercise and a variant of the push-up plus.

Anyone have other suggestions??

Could you provided descriptions of the other exercises that you were doing. Thanks

shrugs for tos compression-seems counter intuitive
 

but if it works-go for it!
My p.t. has me doing shoulder squeezes now, after 3 months of working with me to calm some things down, and the squeezes hurt like heck the first few weeks i dod them, but seem to help now.
I will ask about shrugs now that ive looked at the links to the pgs in this thread!
Such gret info-love it.

Back again - more exercises.
 

I was offline for the past 8 weeks due to neck surgery. I'm now the proud owner of a prosthetic disc. The surgery went very smoothly and seems to have resolved the compression at the C7 nerve root, so now I can do training without feeling much worse afterwards.

8 weeks off training has definitely made the TOS symptoms worse, but after a week back training the serratus, things are much better. However it's difficult to say definitively what is a TOS symptom and what is directly resulting from nerve root compression.

I'm convinced that (in my case) the serratus is the main culprit. Another simple diagnosis:

• Stand shirtless in front of a mirror with arms to the side, fingers pointing upwards (ie elbows bent) and palms to the mirror.
• Raise and straighten the arms, keeping palms towards the mirror.
• Look closely at the space just above the top of the trapezius between the neck and shoulder. As I raise my arms, the shoulder on bad side (that suffered nerve root compression) collapses and the shoulder moves towards the neck. This is corrected by pushing the shoulder outwards using the serratus. This is very hard work on my affected side.

I found this to be a great exercise to strengthen the serrratus: raise the arms slowly and count to 4 without allowing the shoulder to collapse. If you have a good side, try and make the bad side look like the good side. If raising the arms gives pain, do it very minimally at first. As it gets easier, add hand weights.

Other serratus exercises:

1) Hold hands in front of you, palm upwards (thumbs outward), elbows at 90 deg.
Hold a thera band in tension between the two hands.
Raise the arms slowly, keeping elbows at 90 deg, all the time trying to push the elbows outwards (causing the serratus to push the shoulders forwards).

2)Wrap a thera band around your your upper back, across your upper arms and held by the hands about 30cm in front.
Push the shoulders outward then forward against the thera band.

Note that strengthening the serratus is not about compression. It's the exact opposite. The serratus pulls the shoulders outward and upward, lifting the clavicle off the ribs and taking the weight off the upper trapezius.

Can you describe the exercise in detail as @smaug did above for his exercise?

Thanks.

@smaug what do you think a good frequency for these exercises is? Meaning:
- Every day
- Every other day
- 3 X week
- 2 X week
- etc.

What does your PT recommend?

For initial activation exercises (not strength building) I have been recommended at least 3 times a day with each session < 10 mins. These exercises also help relieve pain during the day by getting muscles moving that are not being used properly.

Once I get on to using weights and the exercises are more strength building (after a couple of weeks) I reduce to once a day then every second day. It is vital that the progression to these exercises only happens after the activation is correct. Many times I have been guilty of being too eager to get the muscle strengthened and jump straight to this step causing incorrect movement and more pain.