I am wondering if anyone out there with a lot of knowledge or interest in the physical mechanisms and anatomy involved in TOS could theorize on what might have happened (and be happening still) to be causing my TOS? It is one of those weird mysteries I'd like to see solved if I can (like being a patient on an episode of "House" and getting to the right answer). I think poor posture (I had 1st ribs that were stuck/elevated) and a sudden loss of upper body muscle mass led to my TOS, but here is the exact event that pushed it over the edge, and I'm wondering if anyone has a guess to what happened anatomically that day ("LAUNDRY DAY"!):

I lifted a very light laundry basket under my right arm, right out in front of my body, and walked to the laundry room with it, something I had done now and then throughout my life without incident. After a few steps... sproing!! A jolting electric shock sensation went through my right arm. Now, I had, for weeks, been doing a daily exercise involving standing on a rubber tubing (like holding a skipping rope and standing on it) and gripping the two loops on either side (fingers/wrists facing inward) and pulling simultaneously up and out to the sides. In retrospect, I think I was doing this exercise wrong and it was meant to be done with fingers/wrists turned out front. Anyway, after the laundry incident, every time I performed this exercise, I would hear a snap (a 'click') in my right arm (or on my right side somewhere) before my arms even got to shoulder height. This was consistent and reproducible every single time. It seemed like the snapping was occuring on the outer side of my arm or shoulder somewhere, but I wasn't really sure where. It was very odd, and although I had an intermittent dull ache in my arm, that was about all. This went on for 3 months and I didn't think much about it.

3 months later, I wasn't too smart. I held the exact same light laundry basket in the exact way under the same arm and walked to the laundry room. Once again - surprise - I was jolted with an electric shock going down my arm. This time the shock was stronger and may have gone into both arms, but if so, it was definitely more on the right side. After that, it was a fast and steady decline over days and weeks, starting with tingling arms and progressing to extreme tingling in both hands, 4th and 5th fingers being the worst usually, numbness, weakness, and initially a general aching around the shoulder area (not like a joint aching, but more general), especially behind the shoulder (the outer edge, more like the shoulder blade area, perhaps, and ending at the armpit?) It got even worse from there, but I won't go on about that.

I have had an MRI done of my neck and there is no anatomical problem at the C8 nerve root to explain my symptoms, and EMG showed no ulnar entrapment (in fact it showed nothing at all). My neck does not 'feel' like it has ever been the problem, especially as I don't have neck muscle spasms... whatever the problem is, I think it is happening closer to my shoulders and involves bones or whatever other anatomical things might make clicking sounds. My question is: does anyone have any idea of what might have happened with the laundry basket incident and where the entrapment might be happening and *what* might be causing it? My physical therapist did not diagnose TOS but noted a bilateral first ribs issue ("inferior glide") and said that my ribs were stiff and not moving (they are moving fine now, apparently), and put as the diagnosis, "Bilateral C8 compression 2 degrees due to hypermobility of C6/7 and C7/T1 segments" -- but I believe she was wrong about this diagnosis, especially as I've gradually gotten worse despite stabilizing those segments (btw, anyone know what "2 degrees" means?) I am thinking that something *subluxated* that day, and that this is the REAL root of the problem -- but what?? Could my shoulder be hitting something? (my shoulder xrays are normal and I have no history of shoulder problems and have good range of motion, though come to think of it, if anything, I suppose I could be too mobile, and definitely weak in the shoulder area). Could my shoulder blade be hitting something? That is probably where I have felt the most pain... on the outside/back of the shoulder area, whatever that is (scapula). What can these things hit or tug at? What was the snapping sound? (needless to say, I don't do that exercise anymore!!!) My nerves are being tethered or choked somewhere along the thoracic outlet. Can my collarbone be involved? I am aware of the space between collarbone and first rib being an issue for people, but I don't know that it's really the actual root of my problem or full picture of my problem, especially as I am suspecting some possible shoulder involvement somehow.

Again, I have never had a previous known problem with my neck, shoulders, or upper body. The two laundry incidents were just the 'final straw' in something obviously ready to go. However, I *do* have a mild to moderate scoliosis (non-progressive) since puberty, so this probably helps predispose me to this condition somehow (it makes one shoulder higher than the other and gives my thoracic spine a rotational curve... lovely, huh!) and I am also tall/thin on top.

Thanks for any insights anyone has! And if anyone has any similar stories... please share!!! Maybe we can learn from each other!!!

Kat

For the life of me I can't follow your question.

With pain, comes less patience, and with the neurological limitations of full-blown TOS, one has even less patience.

I'll patch in my regular list of things to do to try to find out if one has TOS. The main thrust of which is to check out doctors' list and get to a GREAT TOS doc, as 99% of docs do NOT understand or greatly misunderstand (which can be dangerous) all of the types of TOS.

I do wish you the best on your healing path. The people here do care.

TOS is a diagnosis when ALL other testing does not show an obvious orthopedic or other reason for all of your symptoms. TOS is a diagnosis when you have ruled out all other problems, because if you do not do the foundational TOS to rule these out, then you might have missed an obvious tumor, etc., but it does not mean that TOS is merely what you call it when you are done with testing. Testing is extremely important. Normal results in all, can still conclude TOS, if the proper symptoms are present. There is no single, one-shot test for TOS. You can't usually "see" it.

I am not a doctor, and this description of tests is just "laymens' terms."

1. You should have ruled out any rheumatological or immunological conditions by seeing a rheumatologist and having these blood tests run. Sometimes they will run a brain MRI.

2. Neuro / ortho / vascular doctors do MRIs of the neck, brachial plexus, shoulder, hand, etc., looking for any obstruction or strucural abnormality. These MRIs can be run with fluid, and may or may not have your arms in differing positions. Mostly, these are for finding any arterial or vein blockages.

3. Xrays are also ordered of the spine, usually in the beginning, and a few TOSers will have additional cervical ribs, but many do not. "Extra cervical ribs" or "protruding cervical ribs", etc., are the terms to listen for.

4. Neuro docs do EMGs and nerve testing, including SSEPs, each one believing that only their way is the right way. Usually, it is not always going to show anything. You want to ask if they test up by the neck for the C-8, because if this is slow, the C-8, it tends to show TOS rather than cervical radiculopathy.

5. Doppler tests are like sonograms of the arm to see if there are any blockages of blood flow. You can have neurogenic TOS and still have vascular / circulation type symptoms, but these may not show up on this test. Blockages must be treated usually by surgeries, ASAP.

6. MRAs or MRIs with fluid can involve cut-downs along the arm to track blood flow or in an I.V., as you sit or stand. In my case, my nerves were wrapped around my double veins, so we were unable to cut-down all the way up.

7. 3d MRAs and C.Ts. give another vision. CTs have very high radiation, and should not be repeated except for good reason. MRAs by Dr. Collins and Dr. Brantigan are considered the best and shows different angles of the brachial plexus at such a high resolution that doctor is able to "see" compressions, impingements, etc. However, most of us do not get this luxury. (I think the cost is $10,000 right now and some insurance cover.)

8. Scalene block - if you feel relief for a brief period of time, this is the MOST positive for surgery.

9. Thyroid issues - many TOSers are hypothyroid. Some show up easily on a blood test. Others, are not shown on a blood test. Some are called "Hashimoto's thyroid" such as mine. Mine were based upon symptoms, rather than numbers on a blood test. They incuded: dry hair, or slow growing hair, depression with no real situation or depression that has gone on a long time, nails that don't grow or are brittle, dry or flakey skin, sleeping 10 or 12 hours or a whole weekend like I was and still tired, not being able to sleep at night, tired when forced to wake up, (once I started the thyroid, I slept from 11 AM to 7 AM without problem), slow bowels, like not moving for a week, (not really weight gain or weight loss, though, this wasn't about being fat, but about not good body metabolism.) So anyways, this is a subject for you and your doc.

If all of these tests come out basically normal, this leads to discussion of TOS as the culprit. It is especially hard to tell the difference between cervical ortho causes and TOS, and sometimes shoulder and TOS. But you must go through time-consuming testing to find out all of the results, because if you simply proceed with an ortho surgery, your TOS pain can go through the roof and you can have unexpected complications, so it's rather serious to proceed now with great caution, whereas the work comp ortho surgeons love to "cut and run!"

We have a ton of articles post on the upper left hand corner.

There are also a couple of “usual” conditions which go hand-in-hand with TOS; they include R.S.D. or C.R.P.S., fibromyalgia and autonomic neuropathy, as well as treatment for depression to handle the differing phases of ones’ life if TOS is determined to be present.

We also have listed some of our docs we have seen, on the upper left hand corner. In my opinion, most doctors ho say they know TOS can NOT diagnose TOS, and I went through over 10 orthos / neuros / vascular surgeons who did not diagnose me, and it wasn't until I flew to Denver and saw Dr. Annest that I got a diagnosis, and then most of these docs said "oh, that's what I thought, too, but didn't want to be the one to make the diagnosis."

Pain control is another big fight.

Be very wary of chiropractors who say they can "cure" TOS. Do NOT do any physical therapy or treatment that hurts you, or tries to strengthen you. TOSers (for the most part) cannot do strengthening exercises, cuz that causes swelling, which is already a problem.

The best physical therapy that I know of is the "Edgelow" system, he is listed in our doctors list in Berkeley CA. Many P/Ts do his system. You can get it via mail, too.

Getting a FREE work comp consultation is of the highest importance because if one considers what one does the most, it is usually working. Unless you KNOW your TOS was caused by an accident, or impinging rib that has been bothering you since birth, and if you have a good work history, as you try to figure out how you got TOS, even if you are not yet get diagnosed, you must cover your bases by filing a work comp claim form after a good free consultation. Were you in an accident to the collar bone area? Or, were you doing a job that had a lot of repetitive hand / arm movements over an extended period of time? IF you can't say why you got TOS and you're working, presume it caused the TOS, and make sure to get an attorney consult and proceed with a claim. Do not wait, no doctor will take care of this aspect for you. The onus is on you to pursue your work comp benefits, which, sometimes TOS is 100% disabling condition.

If you are sick or going to be sick through one year, you should also have a free Social Security consult and follow through with those filings.

I also suggest that after six months of absence from work, sending a certified mail receipt requested letter demanding identifications of any / all benefits for anyone disabled fully or partially from your company and to take any response to a licensed disability or insurance attorney.
Copyright 02-08

Well Kat-1,

That rubber tubing exercise is a Killer! It could be the damage was done in that fashion and the laundry thing is sort of a red herring. I doubt the basket is the cause, but rather the trigger.

I also have scoliosis, but it is progressive and quite severe...don't know if hyper-mobility is related to that or not. At the time of my cervical injury, I was tall and 'thin' too. I doubt that is an issue. My genetic propensity for developing scar tissue is most likely my issue and maybe yours.

PLEASE don't do any more of the rubber hose exercising. THAT is a serious attack on your Thoracic Outlet...I would think especially if your ribs are elevated and one shoulder is higher than the other.

Tam always posts that great resource on how to approach diagnosis.

Warmly,
Anne

Are you still going to PT? - they should be able to locate and explain the snapping and if the shoulder blade is rubbing or hitting anything.
If they can't help you with that then request another PT or PT place with advanced therapists.

Do your PT sessions mainly consist of you doing exercises , or do they do hands on therapies - ultrasound, various massage techniques, rib mobilizations, trigger point, Electric stim etc?

We also have some really good diagrams and anatomy links in our useful sticky thread - http://neurotalk.psychcentral.com/thread84.html

Hi Kat
I bumped up a couple post for you to help in TOS 101.
Often tos folks just have an anomolie that sets up a TOS injury to happen. It is noting one can predict, often not see in an exray, on an MRI and certainly until progressed on an EMG.

The brachial nerve bundle that is affected in tos runs ascross the trapizis of shoulder, from the cervical spine, nerves C5/6/7/8 qnd T1. THe nerve cell is three feet long running into the shoulder, arm and into the hand. all the way to branch into the radial-mediam- ulnar nerves to the finger tips. ANywhere along that three feet there is a hinge a compression can incite pain; including if you are holding a basket stretching the nerve to its limits of comfort it will send a zinger. Continual assults, like if you had a job in that position would leave a horrific world of hurt flaring.

The other thing is that as Tshadow said its diagx is through ruling out other orthopedic or medical problems, then the whats left is brachial injury. Why, until the nerves are so damaged or there is a problem as you said with your upper ribs it cannot be seen and therefore ruled disputed TOS. Only about 5% of TOS cases are diagx as "real:" TOS.

One half of society has short fiborus bands from the collar bone to the neck to support it. NOt half have TOS but an inciting incident as yours could develope a tos injury. Especially I bet it is not just the laundry basket zing, where a nerve may be entangled in scar matter or fiborus bands resticting it, but also the brachial bundle is hyper pain signals all activities.

I remember my daughter had hypermobility and this issue developed; If she yawned, or reached outward, her hands clawed/locked and arms against her chesst. Dr. Fried discribed it as a anomolie of shirp position. Arms agains the chest and hands curled. I had to press several trigger points for the spasms to release. One in the armpit, one in the inner side of the elbow, another in the trapizis area. This could relief the spasms,

Nerves do not heal, they develope scar matter entagling it, like adhisions, the muscles try to wrap around a sick nerve to protect it like a splint making a spasm.
For laundry you may want to stop the basket use and brain storm, me I have net bags and throw them down the steps, I get anyone around to take out of the dryer and carry up or do small arm load no basket to my chest.
I hate to fold, that makes my zings and tings,
I do a lot of kicking of laundry, especially towels or bedding. And if anyone is missing something, look in the dryer!

It is frustrating that there is no test to really rule tos on or out, added to most doctors never see a case in their career, or misdiagx until a lot of damage is done by not recognizing it.

You are so correct it is a House episode, it does a lot of detective work by a TOS expert to explain it to you, do an examin, take a detailed history and medical background, testing to check for other things too.

Also as Tshadow mention about the Thyroid, so very many of us on the forum have thyroid issues, this whether the tos first or thyroid of age, etc, does have a dual effect.
Read, read and read about TOS, A good thing to is a PAIN DIARY,
There are some if we serach the forum that have a persons body and key markers or terms to use to wtch your symptoms, including weather.

This was so helpful going to the doctors and IME's for me.I did them often, not daily unless a flare up.
Another thing, for painful flares a shot of toradol, a non opiate, anti inflamatory works great for ER level flares. I could avoid ER trips for my daughter by getting to the doctors for a shot, for spasms Valium . Best anti spasms med in the world, used knowledgably.

For your arm, I wonder did you try trigger point injections? Press the area over the shoulder, above the wing, I get a feeling of a knife in it often and that is where my flares trigger from. I get marcain in there and wonderful help.
We should start a weekly brainstorm session of HOUSE TOS style for the forum to challange us in and educate in the vast differences in our TOS and where the triggers are and how to accomadate our life style to limit them.
dianne

Thanks for the cut & pasted thing, tshadow -- really appreciate it! I know my post was hard to read -- I was amazed (and a little embarrassed, lol) that I wrote that much when I looked at it afterward.

Bi-Coastal -- it was only after I just posted that, believe it or not, that I came to the same conclusion about the damage potentially being *caused* by the rubber tubing exercise. I can't believe it... I was trying so earnestly to help improve my body, not make it worse with new problems. Cruel fate!!! Sorry to hear that you have a progressive and severe scoliosis. I have no idea what the treatment for that is like, but I certainly hope it is better and more effective than the options available to TOS sufferers right now!!

Jo55 -- thanks for the anatomy links! My latest PT has just gone on maternity leave, so I am currently looking for someone new. I have mostly been given home exercises (they did do rib mobilizations initially, nerve mobilization, some manual neck traction). I wonder if there is such a thing as 'collarbone traction', hmmm...

I have demonstrated my shoulders to 3 people. I was told it's the glenohumeral joint, but still haven't been told what the joint is actually doing, how to improve it (other than adjusting my arm positions to put less strain on it), and especially how it could potentially relate to the troublesome nerve issues affecting my entire hand and arm!! They might not have been too good at their explanations, but truthfully, I think they just don't know. It may take some kind of expert to figure it out.

Kat

Di Marie,

Thanks for explaining so much. Half of society has fibrous bands??? Gosh, I didn't realize that. I thought it was mostly people with cervical ribs (of which made up 1% of the population!!) I wonder why they can't just remove the fibrous bands and leave the ribs intact, at least as a first line of treatment, and then do the more aggressive forms of surgery if it's not enough to make a difference. I guess who would want to be cut into twice, and maybe it has been shown that it doesn't make enough difference on its own anyway.

I would be more than happy to join in on "House -- TOS style" and do detective work to help figure out people's triggers and the solutions. Yeah! Bring it on!

I haven't had trigger point injections yet, but the spot you speak of, yep, when I'm at my worst, that's my main spot. I just haven't gotten to the point where I've tried that kind of therapy yet.

Kat

So, my chiro says that the heart attack like chest pain, and the strangling feeling that changes, and weakens your voice and swallowing is all muscle spasm. (wow long sentenceed LOL)
If those are muscle spasms, what do you do for them?

trix,
my chiro did NIMMO - it's a mix of deep tissue, trigger point & active release.
more info-
http://www.theamericanchiropractor.c...481&category=3
http://www.chirotherapy.com/blog.aspx?n=31
[Nimmo Technique: {from above link}

Application of simple pressure to tender areas to release muscles from localized spasm. Also called the Nimmo Receptor-Tonus Method, this technique was discovered by Raymond L. Nimmo, D.C. Seminars on this technique are now given in most chiropractic colleges. A normal muscle has normal tonus. Accident, insult, and injury may cause too many impulses to fire into the cord producing hypertonus or hypermyotonia. If this situation exists for a sufficient time, it can change the position of bones, producing subluxations, body distortions, low hips, etc. Later a trigger point may form in the muscle which sends a barrage of noxious impulses into an area producing vasoconstriction with consequent ischemia. Since tonus is controlled by the sympathetics, and is not under conscious control, we can not correct our own distortions. However, it was discovered that pressure applied in proper degree, at proper intervals, will release both trigger and hypermyotonia. Wooden "T-Bars" with rubber tips are used to reach between ribs and transverse processes in order to eliminate trigger points and segmental neuropathy, the latter usually being referred from viscera. Post adjustment procedures are used. Palpation is the only means of diagnoses. X-rays are not used. Most conditions that are encountered in general chiropractic practice including neuromuscular disorders and the cause of practically all pain can be successfully treated using the Nimmo technique. Receptor-Tonus relieves most pain immediately.]