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.

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?

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

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.