Thoracic Outlet Syndrome Thoracic Outlet Syndrome/Brachial Plexopathy. In Memory Of DeAnne Marie.


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Old 05-03-2012, 03:03 PM #1
klm207 klm207 is offline
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Default Droopy Shoulder Syndrome - SO CONFUSED

Hi Everyone!

Just when I thought I had a handle on what was happening (TOS) and why (posture, shortened muscles, trigger points etc), a new PT has turned it on its head!
For the past 4 months I've been focusing on stretching (scalenes, pecs, scm, upper traps) and releasing (soft tissue work). In my mind, my rounded shoulders and forward-head posture had created chronically shortened scaleni, which then irritating the plexus, elevated the 1st rib, and caused further spasm due to neural inflammation, round and round. I've had dry needling, myofascial release and mobilisation, and I've been self-massaging and stretching as much as poss.

Things haven't really been improving so I sought out a new PT, basically wanting more of the above (thinking what I was having/doing wasn't enough). Anyway, I saw him today (after getting his assurance he was experienced in treating TOS), and HE TURNED IT ALL UPSIDE DOWN.

He thinks my traps are OVER-stretched and weak (scalenes same). Basically what he described was 'droopy shoulder syndrome', which is a sub-set of TOS, caused by TRACTION of the brachial plexus, rather than strict compression. Of course, this also causes the 1st rib to rise, so also causing compression. When I elevate my shoulders the awful tight pulling pain down my arms immediately stops, and though it feels unnatural to me, I look a lot more 'normal'. He pointed out I'm also hypermobile (which I knew), and therefore although I'm addicted to stretching, I MUST NOT STRETCH, I must strenthen my upper traps (I thought I had to switch them off) and correct posture.

As you can image this all feels very wrong. Can I accept this PT's view that my scalenes are not the problem, and that I should not stretch, only strengthen? I've read so much on this forum about the dangers of PT regimes that get you building strength straight away, but I wonder if the difference with me is this peculiar 'droopy shoulder' diagnosis, and therefore if the usual rules don't apply?

I've just spent $99 on Sharon Butler's protocol - which is all about stretching and sticky fascia - so am now totally confused. Stretch or strengthen??

All opinions greatly received! Thanks x
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Old 05-03-2012, 05:36 PM #2
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I don't know anything about droopy shoulder syndrome. I do know first hand that certain strengthening and stretching can be counter productive when there are other underlying disfunctions.

Once I started seeing the therapists at http://www.andoaston.com/staff they really opened my eyes. They showed me that nerves can shorten/tighten and be perceived as muscle tightness (which lead to overstretching of muscles in my case).

It sounds like your new therapist may be on to something with you. I hope he is educated on nerve mobilization and gliding. Also, evaluation and treatment of rib subluxation is also important (all ribs, not just the 1st).

Here is Dr. Ando's 5-Step Functional Approach:

Quote:
STEP 1: True Source Evaluations. Finding the root problem is the 1st and most important Step. Our training as CFMTs allows us to look beyond just what is painful or what has been assessed by x-rays.

STEP 2: Skilled Joint Mobilization. Getting the joints to move is a critical step in regaining mobility and preparing the body to exercise successfully.

STEP 3: Skilled Muscle and Nerve Mobilization. Hands-on manual therapy to muscles and nerves decreases pain and completes the body's preparation for exercise.

STEP 4: Therapeutic Exercise. Neuromuscular re-education through individualized exercises is the 4th Step. Core strengthening in spine cases uses time-honored methods such as Pilates. All patients are trained in their home exercise program, receive them in writing or video format, and are encouraged to do them responsibly.

STEP 5: Body Control Training. Education and training in posture and body mechanics is the 5th and final Step. This allows patients to regain basic functions such as pain-free sitting, walking and lifting or, if a patient desires, more vigorous activities like gardening or sports. Patients that understand how to use their body safely and efficiently in functional activities have the best chance of maintaining their health and lifestyle of choice.
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Old 05-03-2012, 07:16 PM #3
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To date, none of the following have had any significant, lasting effect on my TOS: stretching/strengthening, trigger point therapy, ART, massage therapy, nerve glides, FSM (frequency specific microcurrent), chiro, etc. In fact, stretching/strengthening, and some trigger point therapy have put me into some serious flare ups that took 6-8 months to resolve.

I've bought Sharon Butler's book, many books about trigger points and looked at Simons and Travell, "it's not carpal tunnel syndrome", and countless other books ---- nothing gave me my life back or allowed me to continue doing the job I loved.

Be caferul with PT as it can reeeeaaaallllly f you up.

However, it's possible that these things may help you get your life back and be very effective for you. Just sharing my experiences. I wish you the best.
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Old 05-03-2012, 11:06 PM #4
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Sometimes we just have to try things and take it day by day to see if you feel better or worse.

But if you feel uncomfortable with what the PT is wanting you to do, or if you are getting worse, say no and hopefully they will listen.. and make adjustments to the PT plan. If not walk out.

Stretching + hyper mobility is a fine line, you don't want to over extend yourself.
And some muscle tone does help to balance & protect the lax joints.

Does that PT place have expert /advanced team?
Maybe they could each evaluate you and compare notes??

I'm assuming you had x rays / MRI to rule out any obvious things.

Do you know how you acquired TOS?
Repetitive work or some other injury - sports , car accident etc?
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Old 05-04-2012, 09:41 AM #5
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if you are truly hypermobile (can u touch your thumb to your wrist?)

then you must strengthen but i wouldnt strengthen your upper traps wtf. do your lower traps..rotator cuff muscles. DO NOT stretch or you will end up like me!! i used to have droopy shoulders now my shoulders are hiked up to my ears from overstretching as a defense mechanism. theres no middle ground. and your neck will hate you for it.

what works for me is strengthening without weights just holding up your body weight, dont let them talk you into resistance bands, you will get worse! trust me then you combine that with the barest MINIMUM of stretching...one stretch i do is just lying down on my back and putting my arm over my head to stretch my armpit. THATS IT and if i ihave any slight tingling or nervy sensations i dont even do that. people who are hypermobile don't know how to stretch properly. they overstretch. nerves go into protection mode. repeat ad nauseum.
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Old 05-04-2012, 12:08 PM #6
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Here is one website that shows how you can test/score for hyper-mobility -
http://hypermobility.org/beighton.php
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Old 05-04-2012, 01:51 PM #7
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Don't any of you recall that study where shoulder elevation was used to resolve TOS?

See:
-- http://neurotalk.psychcentral.com/sh...d.php?t=162369
-- http://www.silcom.com/~dwsmith/ajs293.html

Sounds like klm207's PT wants to go this route. Also, klm207 says "things haven't really been improving", so it doesn't seem too surprising that a PT comes up with a different model of what is wrong. And it seems reasonable to try it.
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Old 05-04-2012, 04:22 PM #8
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Thanks so much for your comments everyone. The new PT has me doing 15 simple shoulder shrugs 10 times a day, alongside wall push ups (20 each hour), and rowing with a theraband. And I'm not allowed to stretch anything! I've been doing the shrugs for 2 days now and my shoulders feel exhausted, and my left shoulder (less bad tos) has started crunching away like mad. Haven't done the other exercises yet as I'm scared! He also has me elevating my shoulders at all times by about 2 inches, so that my clavicles are at approx 30 degrees (they are normally horizontal or sloping down towards my shoulders). Am feeling quite tingly in my arms and hands, but not the deep achey pain that has me crying!
This new regime is so counter-intuitive to me I don't know what to do. One interesting thing that makes me think this new PT might have a point is that on my cervical spine MRI the scalenes on the right (bad tos side) were actually hypotrophied, as are my upper traps on that side. And then I went on madly stretching these weak muscles for 5 months!
It would be really interesting to hear more thoughts on shoulder elevation for treating tos, and for us to think that maybe, the model we read everywhere about stretching and releasing the scalenes might not be right for everyone...

Regarding my particular case - pain symptoms came on in December but I'd been having tingling and numbness in my hands for a while before that. At first I thought it was cervical radiculopathy as an mri showed up some disc bulges, but then the neuro didn't think they were pressing on nerves. I'm a massage therapist so I guessing having my arms outstretched contributed, my shoulders are rounded and droopy, my head is forward and I have a super straight cervical and thoracic spine. I keep getting told I'm hypermobile, and yet I can't get close to touching my toes with my hands since all this started as all my nerves and muscles feel incredibly tight. The thing that really throws me is that since Jan I've had the same tos-like pain in my right leg - down through the groin, front of thigh and into calf, and cold/numb toes at times. No one thinks I have a lumber disc problem. EMGs all normal, no cervical ribs. Most muscles in my body hurt to touch, and I'm now worrying I've developed some kind of central hypersensitivity (doc wants me to take amytriptiline but I'm currently tapering off paxil). And all this can be fixed with shoulder shrugs??
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Old 05-04-2012, 05:05 PM #9
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I don't like wall pushups. My therapist had me stop these because my upper traps were getting overworked (causing pain) while my mid and lower traps were atrophied.
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Old 05-05-2012, 04:33 AM #10
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Don't be afraid to adjust the reps your PT gave you based on feelings and symptoms. Sometimes they don't realize we have to go easier.

The shrugs are consistent with that study I linked to.

Also, I have your same problem of collar bones that are too flat. Originally my left one, which is my TOS side, was even slightly pointed down.

For me, wall pushups were an awful experience. As I built up muscle and tightness in the upper chest, the compression increased. Wall pushups are now on my personal "DO NOT DO" list.

Another bad move for me is sitting in a chair with my hips forward and my trunk leaned back such that my upper back is pressed into the back of the chair. Too much of that and I can flare up.

I get a lot of muscle tightness too. Stretching helps, but I haven't been told not to stretch. If you want a really small and effective stretch set to try, I recommend the book "3 Minutes..." by Weisberg. The title is overhyped, but still a great book.

Other tightness helps are supplementing with magnesium (search the forums) and some kind of muscle relaxant. Diazepam can be used for that purpose and some of us take it 2mg 2 X per day.

I've also gotten decreases in muscle tone by listening to relaxation audios. I really like Infinite Relaxation for the iPhone/iPad.

HTH. Good luck.
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