RIB(cage) THEORY

Dr Sanders reports on TOS
Common Symptoms
The most frequent complaints are numbness and tingling in the fingers; pain in the neck, shoulder, and arm; headaches in the back of the head; weakness of the arm and dropping things from the hand; worsening of the symptoms when elevating the arm to do such things as comb or blow dry one's hair or drive a car; and coldness and color changes in the hand. The symptoms are often worse at night or when using the arm for work or other activities. During the year 2005, we have become aware of a large number of patients who, in addition to these symptoms, also have pain in the anterior chest wall, just below the collar bone along with pain over the shoulder blade. Until recently it was thought that these later symptoms were also due to TOS, but now it has been learned that they are due to a condition frequently accompanying TOS, namely pectoralis minor syndrome.
Cause
TOS is most often produced by hyperextension neck injuries. Auto accidents that cause whiplash injuries, and repetitive stress in the workplace, are the two most common causes. Some of the occupations that we see causing TOS include, working on assembly lines, keyboards, or 10-key pads, as well as filing or stocking shelves overhead. In some people, symptoms develop spontaneously, without an obvious cause. An extra rib in the neck occurs in less than 1% of the population. People born with this rib, called a "cervical rib", are 10 times more likely to develop symptoms of TOS than other people. However, even in men and women with cervical ribs, it usually requires some type of neck injury to bring on the symptoms. Pectoralis minor syndrome appears in more than half of the patients who have TOS. It results from the same type of injuries that cause TOS.

And Peter I Edgelow suggests the following 5 points if TOS sufferers are to improve
In the physical examination of these patients, there are consistent findings that must be addressed before adequate progress can be attained:

1. The patient must become aerobically it. (read fit, towelhorse)
2. There is often present asymmetrical weakness of the small muscles that control movement of the thumb. (Flexor and abductor pollicis). This weakness can be reversed by self-traction for 30 seconds (diagram 1) and weakened again by mechanical stress to the neck such as compression.
3. There is a pattern of chest breathing and an inability for the patient to perform relaxed breathing with the diaphragm.
4. There is loss of mobility and increased sensitivity of the nervous system, especially the brachial plexus. (The nerves that pass from the neck to the arm.)
5. There can be coldness of the hand particularly the ring and little finger.

Treatment must be directed to reversing these 5 issues if they exist. The home program is designed to help the patient accomplish this on his or her own.

DR Steven D Feinberg writes
SYMPTOMS
The character and pattern of symptoms will vary depending on the degree to which the nerves and/or blood vessels are compromised. The patient may complain of tingling, numbness, weakness and discomfort particularly down the inside of the arm going into the hand. There may also be swelling, paleness and coldness of the arm and hand. Other related symptoms may include headaches in the back of the head and pain in the neck, shoulder and arm. Symptoms can be brought on by overhead activities such as hair combing, or at night when sleeping on one side which can put pressure on the structures within the thoracic outlet. Each of these maneuvers/positions causes a tightening or compression of the thoracic space. Thus the nerves and/or blood vessels may be compromised and produce the associated symptoms.
TREATMENT
More commonly and appropriately though, first-line treatment is directed towards a physical rehabilitation program, in which physical therapy plays a large role. Initial treatment emphasis is placed on weight loss, postural re-education, and shoulder girdle exercises along with stretching, strengthening, conditioning and the passage of time. Evaluation of activities of daily living and the workplace environment is a must. Physical therapy management of TOS requires accurate evaluation of the peripheral nervous system, posture, and the cervico-scapular muscles. Patients should be instructed in postural correction in sitting, standing and sleeping, stretching exercises, and strengthening exercises of the lower scapular stabilizers beginning in gravity-assisted positions to regain normal movement patterns in the cervico-scapular region. Other techniques include evaluation of joint mobility and muscular imbalance. Patient education, compliance to an exercise program, and behavioral and ergonomic modification at home and work are critical to long-term successful conservative management. Selected patients may benefit from trigger point injections or acupuncture treatments.

If one does an internet search there are hundreds of references to a) TOS and over-weight and b) TOS and chest breathing.

In my TOS situation I had a severe pain in my thoracic spine and subsequent wry neck (but still working 60-70 hours a week for 10 weeks after my injury fitting roller shutters, in built wardrobes, shower screens etc.). 6 months later I am laying down 16 out of 24 hours a day. At the end of the 10 weeks my family went on holidays and I was still doing 15 kilometre (10 mile) bush walks up mountain slopes. I am amazed at how significant the loss in physical ability that occurred with my body, 6 months after the injury. The less I did, the less I could do. It was a downward spiral that was made significantly worse by a rehab program which included neural stretching and lifting weights in the gym. Most days I would lie on the couch as soon as I returned from the gym sessions. I believe, I would have been better off at work where I could control what I could do rather than being told “no pain, no gain”

As my condition worsened I had great difficulty sleeping. I would end up sleeping on the lounge very often. I found that sleeping on the floor on a 1inch thick foam mattress meant that I was much less likely to wake up with pain in my neck and a headache which extended from the back of my head and made its way to my face depending on the severity. I slept on this mattress on the floor each night for over a year. The more comfortable I made the mattress, the more likely the headache. I worked out that the more comfortable the mattress the more likely I was to sleep on my back, this caused the headaches.

Physiotherapists told me that I was chest breathing and showed me exercises to correct this problem. I was unable to correct the problem. Muscle spasms in my upper back were persistent and very painful. Treatment for these spasms would often make them worse to the point where the soreness extended around to the front where my ribs joined my sternum. Sleeping on this ribcage was very uncomfortable. Laying on this ribcage made matters worse. An x-ray in 2006 for an unconnected matter showed that I had hyper-inflated lung fields. Medication to correct my breathing has changed my world around. Muscle spasms are significantly less, my mattress feels like a different mattress, I am not exhausted as I used to be, I now have a soft ribcage. A soft ribcage is a much more comfortable thing to have.
I know now that the changed breathing pattern combined with the increased pressure on my diaphragm from being 12 kilograms (26 pounds) heavier, much of it around my waist had contributed to the way that my rib cage affects the nerves, muscles and other structures in my upper body. (the experts say chest breathing and being overweight causes problems, they don’t say why, I believe it is under rated significance of the effect that an immobile ribcage has on TOS) The problems with my rib cage have caused deterioration in my condition and have been a significant hurdle in the quest for improvement. I am now closer to how I used to be preTOS.
Some people have cervical ribs removed, some have non-cervical ribs removed, some have botox in muscles which connect ribs (I was told that I had myofascial pain of the erector spinae muscles, and offered botox), some have muscles which connect to ribs removed (scalenectomy). My suggestion is try strategies which soften the rib cage, it will make nerves and muscles and joints between vertebrae and ribs feel so much better. Try not to lay too much on the ribcage, try not to put too much pressure on the diaphragm which forces the ribcage up.

Forget truncal strengthening.
Forget posture, if attempts to improve one’s posture mean increased pressure on tight muscles and nerve bundles this will only make you worse.
Neural stretching and nerve glides are much easier over a soft rib cage.

I hope this might help someone, regards Towelhorse

You usually impress me with your efforts and knowledge but I have to disagree with you here. That said, it may be that I do not have enough information from your post about what happened to you.

If I recall, you had a problematic Long Thoracic Nerve which was impinged/entrapped by a variety of things. IMHO one of which could have been your hyperinflated lungs (certainly enlarged lungs or ribcage would impinge on nerves etc).

When you say "soft ribcage" it sounds merely like the medication helped to reduce the hyperinflation. Which in turn reduced the space and possibly compression of the LTN. This, if true, would possibly be why you are being helped.

could it have been accomplished without medication? Sounds like you had some kind of condition that required the medication to help you breathe more "normally" so that you wouldn't have this hyperinflation. I know you had tried other methods to deal with your TOS.

The disagreement lies in the analysis. In your case, yes, posture might not have helped. Then again it may have. In many situations POSTURE is key. Yours may be one of the more minority versions where it isn't. So I have a hard time when you advocate "forget posture"

The ribcage is one of many structures that is a culprit in many TOSers symptoms. I have a new "pain" or sx that I've noticed (actually it's not really new, it just recently came to my forefront in attention) but it relates to my ribcage...go figure. So now I'm being given ways to lower my ribcage...again to increase the space and relieve any compression. In my case...it appears, if I understand this correctly, that my rib cage is drawn up by the scalene (attached to the first rib)...if I can keep the ribcage down...I can reduce or eliminate the compression. It's a tricky thing to isolate these muscles but I understand the goal and why. To me this still falls within the realm of posture/position/alignment that I still feel is very key with the majority of TOSers.

I love ya guy...hang in there. More power to you finding something that is helping you.

Dr Sanders reports on TOS
And Peter I Edgelow suggests the following 5 points if TOS sufferers are to improve
In the physical examination of these patients, there are consistent findings that must be addressed before adequate progress can be attained:

1. The patient must become aerobically fit. I surmise to help increase circulation which provides nutrients to muscles and nerves. My theory is that TOS somehow curtails or cuts of circulation
2. There is often present asymmetrical weakness of the small muscles that control movement of the thumb. (Flexor and abductor pollicis). This weakness can be reversed by self-traction for 30 seconds (diagram 1) and weakened again by mechanical stress to the neck such as compression.
3. There is a pattern of chest breathing and an inability for the patient to perform relaxed breathing with the diaphragm.
4. There is loss of mobility and increased sensitivity of the nervous system, especially the brachial plexus. (The nerves that pass from the neck to the arm.)
5. There can be coldness of the hand particularly the ring and little finger.

Treatment must be directed to reversing these 5 issues if they exist. The home program is designed to help the patient accomplish this on his or her own.

DR Steven D Feinberg writes
SYMPTOMS
Symptoms can be brought on by overhead activities such as hair combing, or at night when sleeping on one side which can put pressure on the structures within the thoracic outlet. Each of these maneuvers/positions causes a tightening or compression of the thoracic space. Thus the nerves and/or blood vessels may be compromised and produce the associated symptoms. TREATMENT
More commonly and appropriately though, first-line treatment is directed towards a physical rehabilitation program, in which physical therapy plays a large role. Initial treatment emphasis is placed on weight loss, postural re-education, and shoulder girdle exercises along with stretching, strengthening, conditioning and the passage of time. Evaluation of activities of daily living and the workplace environment is a must. Again, IMHO to see how the posture/position of the body and/or anatomy is causing YOUR particular compression. Physical therapy management of TOS requires accurate evaluation of the peripheral nervous system, posture, and the cervico-scapular muscles. Patients should be instructed in postural correction in sitting, standing and sleeping, stretching exercises, and strengthening exercises of the lower scapular stabilizers beginning in gravity-assisted positions to regain normal movement patterns in the cervico-scapular region. Other techniques include evaluation of joint mobility and muscular imbalance. Patient education, compliance to an exercise program, and behavioral and ergonomic modification at home and work are critical to long-term successful conservative management. Selected patients may benefit from trigger point injections or acupuncture treatments.



Physiotherapists told me that I was chest breathing and showed me exercises to correct this problem. I was unable to correct the problem. So medication helped you to breathe properly which reduced the hyperinflation and corrected the compression.Muscle spasms in my upper back were persistent and very painful. Treatment for these spasms would often make them worse to the point where the soreness extended around to the front where my ribs joined my sternum. Sleeping on this ribcage was very uncomfortable. Cause it causes compression. Laying on this ribcage made matters worse. An x-ray in 2006 for an unconnected matter showed that I had hyper-inflated lung fields.Hyperinflated lungs...less space for BP to pass, increased likelihood of compression. Medication to correct my breathing has changed my world around. Reduced his ribcage size which reduced his compression or likelihood for compression. Muscle spasms are significantly less, my mattress feels like a different mattress, I am not exhausted as I used to be, I now have a soft ribcage. A soft ribcage is a much more comfortable thing to have.
I know now that the changed breathing pattern combined with the increased pressure on my diaphragm from being 12 kilograms (26 pounds) heavier, much of it around my waist had contributed to the way that my rib cage affects the nerves, muscles and other structures in my upper body. (the experts say chest breathing and being overweight causes problems, they don’t say why, Because over weight creates more pressure on nearby tissues and structures and more stress on muscles and nerves...weight loads all of these structure...if you have TOS you want to REDUCE the load/stress. Chest breathing causes the ribcage to inflate...rise up into the space where the BP may pass ...first rib and clavicle...causing it to be compressed..belly breathing reduces this "rising up" I believe it is under rated significance of the effect that an immobile ribcage has on TOS) The problems with my rib cage have caused deterioration in my condition and have been a significant hurdle in the quest for improvement. I am now closer to how I used to be preTOS.
Some people have cervical ribs removed, some have non-cervical ribs removed, some have botox in muscles which connect ribs (I was told that I had myofascial pain of the erector spinae muscles, and offered botox), some have muscles which connect to ribs removed (scalenectomy). My suggestion is try strategies which soften the rib cage, it will make nerves and muscles and joints between vertebrae and ribs feel so much better. Try not to lay too much on the ribcage, try not to put too much pressure on the diaphragm which forces the ribcage up.

Forget truncal strengthening. BS flag...sorry
Forget posture,BS flag again
if attempts to improve one’s posture mean increased pressure on tight muscles and nerve bundles this will only make you worse. True pressure will cause compression...but improving posture and structure usually is to DEcompress...OPEN the space.
Neural stretching and nerve glides are much easier over a soft rib cage.

Edits added to a select portion of Towelhouse's earlier post.

Rib cage theory 2

Hi noname I am not sure of your circumstances but I believe that your criticisms are a little harsh. If you are aware of what is causing your problems and the methods that should be used to sort them out then you are very fortunate. It is a pity that it is not so simple for all.

A soft rib cage is one which will allow you to twist without muscles in ones back going tight.
A soft rib cage is one which allows you to lie down on your back or sides without the very uncomfortable feeling that you are compromising nerves and muscles start to “tick”

A soft rib cage is one where it is easy to breathe and deep breaths don’t cause a heavy arm feeling or cyanosis or cold hand.
A soft rib cage is one which is free of muscle imbalances, spasms and what I had prior to getting TOS
Chest breathing is caused by?
Some say that it is as a consequence of neural compromise of some of the nerves in the autonomic nervous system. It may not be as a consequence .of tight scalenes

Many believe that the majority of brachial plexus compromise is behind the pec minor and not between the scalenes. It is unfortunate that this was not understood earlier so as to avoid a considerable number of ineffective scalenectomies.

Why is the compromise behind the pec minor? What causes this muscle imbalance? Why is there serratus anterior weakness?
If the B.P. compromise is not between the scalenes but behind the pec minor why do so many people associate the condition with a wry neck or auto accident?
How does a wry neck cause pec minor tightness?
How do they know that bad posture causes TOS?
Why isn’t the bad posture attributed to the fact that someone has muscle imbalances in their shoulder girdle after they had a wry neck?
If the muscle imbalances are as a consequence of neural compromise to those muscles and there are many tight muscles in the thoracic spine, won’t using the “compensatory” muscles to achieve correct posture only make the problem worse?
I maintain that until the muscles that are in spasm in one’s shoulder girdle and upper back are relaxed you are only going to make matters worse if you attempt “correct posture” with tight or weak or neurally compromised muscles.

When I was at my worst, attempting to pull my head back to correct the head forward posture immediately made the symptoms down my arm worse. I maintain that I was moving my head forward to lessen the total compromise to the BP because the normal pressure on the B.P. through the scalenes was now significant when added to the new compromise under the Pec minor, the insignificant became significant (double crush). I still had to use my arm out in front of my body (use pec minor) therefore my head went forward to minimise the total compromise. The head forward was not the problem it was a consequence but it was what they saw.
If the physiotherapists suggestions of how to keep your rib cage down don’t work, obviously it isn’t working now, try the medication, it has turned my world around. I don’t take any other medication for TOS.

The essence of my theory is based on my circumstances and the precept that medical knowledge has always evolved. What is a given today may well be found to be mistaken tomorrow. Medical history is full of misconceptions. Continuous improvement is about reviewing what we thought were truths and reconsidering them in light of new information. Regards towelhorse

soft rib cage is exactly the goal of my PT. She is always working to help the ribs be "bouncier" so that they move up and down with the breath the way they are supposed to. I can really feel it when she gets them there, because my upper body allows a much freer range of motion. I had it just before surgery, but them lost it during recovery and am working to get it back again.

The stiff and unmoving thoracic spine that plagues so many of us is something that precludes the ability to stand up straight because it is just stuck forward- If it is stuck in the wrong position and cannot move into the correctly aligned position or move back and forth with the breath, all the pulling shoulders back in the world won't help it.

Johanna

It wasn't meant as a criticism. It was meant to point out that each of us is different. Where posture may not be your situation, it IS crucial in many TOSers including mine. Hence my harshest point was your advocating "forget posture" Forget "truncal strengthening" For you, perhaps you can forget it. For many others, we can't if we want to get relief. Strengthening certain muscles to overwhelm the pull of others which is creating postural imbalances and then compression is KEY for many. If it is not for you, more power to you. I was already flamed for advocating something when I clearly did not advocate it. I usually, if not always, post MY experiences and MY findings to the extent that they may help another. I would never say "forget posture" or "forget trunctal strengthening"

Gotta defer to you about "soft rib cage." Never heard of the rib cage referred to as hard or soft. My suspicion, based on your description, is that the medication helped you to relax your breathing so that your ribcage did not expand as much (hence your reference to hyperinflated...i.e. larger than normal ribcage). You say hard, I say large..you say soft, I say reduced in size. Probably the same thing. But it helps my point which is that "reduced space" whether by a hard or larger than normal ribcage will impinge on the space for nerves and muscles and other tissue...less space, creates impingement/entrapment/irritation/compression and voila...TOS or the like. That's all I said.

Currently, my PT is having me work on lowering my rib cage for certain things/movements. It surprised me that it was contributing (not necessarily causing) certain sx. But as I get more and more familiar with my own anatomy, it make sense. Of course isolating certain muscles to achieve this is more work. Dang.

The Brachial Plexus (BP), as I understand it from reading and looking at photos, pictures, drawings etc. passes a large territory and beneath and inbetween and over certain other anatomical structures. In some people it varies the "typical route" and sometimes there are issues and sometimes there are no issues. These detours are common with many nerves.

In my situation (which I assume others share to some extent) the BP is compromised/compressed in the vicinity of the first rib/clavicle. This is usually referred to as costoclavicular syndrome. Not only is the BP compromised, but my subclavian artery and vein is compressed there causing some circulation issues as well. Part of the compromise is aggravated by forward head position (which I have from time to time but am correcting) which tightens the scalenes and causes them to pull UP on the first rib (where one or more scalene is attached). The BP also passes in between or around (depending on each of our unique routes for the BP) the scalenes...so having tight scalenes adds to the compression and irritation...again the circular cycle of irritation, tightness compression that never seems to get relieved. Rounded shoulders also adds to this because of the forward/anterior tilt of the upper body and rib cage. It contributes to the creation of tight pecs including the pec minor. Resulting in what I describe as a sort of concave chest vs. the open chest. Now you have compromise of the BP at the coracoid process which is where the pec minor attaches...surprise surprise. Yes, it is well known that compression here will be yet another TOS offshoot...pec minor syndrome which is the other area in MY case of compression and compromise...both areas are helped/relieved when I engage in trunctal strengthening or what I understand as strengthening back muscles to overwhelm the pull of tight pec minors...correcting posture to open the chest and eliminatte the concaveness...correcting head forward to relieve the stress on the neck muscles including but not limited to the scalenes...and finally (or recently) lowering my ribcage to further assist in the decompression on the first rib/clavicle area.

Oooh...lots of good questions. Compromise behind pec minor...typically (not always)..bad posture..rounded shoulders...weak or tight pec minor muscles...concave chest. Look at the anatomy and you will see a rounded shoulder or it rolling forward REDUCES the space of the BP to pass...thus you increase the likelihood it will get pinched/irritated/injured/compressed. Voila...pain. Muscle imbalance is over time...sit or stand or walk etc...with bad posture and you increase the likelihood. Some are predisposed to this. My PT told me that I was predisposed that I want to take too much responsibility for having bad posture. She said it's bad but not as bad as others who have no issues. I also had huge breasts until 17 and had them reduced...this compounded my poor posture which really never got corrected. All that dragging down. One group vulnerable to TOS are women with huge breasts because of the weight pulling down and forward their upper body posture. Check it out. I'm not sure about why the serratus anterior is weak...but probably the same reason that the upper back muscles rhomboids and mid traps are weak too...they give up trying to hold up the body in the correct upright position and thus become weak...the pecs don't become strong but they tighten in response and almost cause the structure to be permanently bent in this bad position. My back muscles were weak...they are stronger now...not strong enough consistently but it takes time and I have to be patient and keep working at it. I am seeing and feeling the difference. It is one reason I am screaming for people to really work at this. I understand that it may not work for everyone, but it may work more often than is being tried.

To each his own I guess. I don't know your situation well enough to comment about the forward head etc. All literature and common sense says that the head should not be held forward. I recognize there are exceptions. Is it possible though that you are comfortable with forward head because your structure has adapted to this? I forget the explanation but ultimately it is still not good. It was and is a bit of a strain for me to correct my head but ultimately it is not painful and I can almost feel the improved circulation. Though in case the forward head doesn't appear to be the biggest culprit ...but over all upper body posture...thus when I correct shoulders and chest the head almost naturally will go back. I would resort to medication only when all other efforts fail. The one thing I picked up in your many posts that I couldn't relate to or comment on its impact was the compromise of your LTN. You seem to have an element that I did not have. Other than that many of your self help remedies seemed similar to mine...i.e. open the chest...get the body/shoulders to go back etc. I'm surprised that you feel that forward head is good for you...but if it works for you...great.

I agree about a mobile upper body/thoracic as well as lumbar spine. PT started with me with certain moves I was already doing with my Yoga...hence she did not have to teach me that...again..NOT ALL YOGA is good for TOS but many poses are. PT was reduced down to a few things specific to my TOS because of the other therapeutic modalities I was engaged in. We are still tweaking my therapy with the addition of exercises to lower my ribcage...(I belly breath naturally always have) but my rib cage could be lower or brought down more often so as not to compress...sort of like helping me to keep it down while I perform certain tasks...same thing with keeping my shoudlers down and back during these same tasks..with time and effort they will hold this position more naturally without me even thinking and I will not (should not) have any compression or flare ups. I hope.

my point is, that without a "soft" ribcage, it is impossible to get yourself into the correct position for "good posture" because the ribs just won't go to the proper place. Also, the forward head goes along with this. It just gets stuck there until you can find someone who understands and can help you get it unstuck.

also, oft times if the lats or quadratus muscles are too tight, then either or both will work to push the ribcage up. In which case, no amount of working on the scalenes or shoulder muscles will get the rib cage to come down.

Hellerwork and/or myofascial release is extremely useful in these cases to loosen the muscles, THEN one can work to keep them loose on their own. They are almost impossible to really stretch out on your own, much like some of the upper shoulder/neck muscles.

I agree that flexible muscles and body are key to so many things including getting relief.

I suppose what you call soft ribcage, I'd call flexible. No biggie, I just thought you were referring to something different and I wanted to understand.

I think I need to re-learn HOW to activate certain muscles and not others to accomplish certain movements..hence the need to go back to the PT at this point...that and she has indicated that with the work I've done in the past my body is more responsive to things she can do to help me.

Keep up the good work.