Manipulation of the dysfunctional upper thoracic segments may reliev Selmonosky CA, Byrd R, Blood C, Blanc JS. Hi, thanks for your extensive review. Recoverable with the right protocol. Signs of neurogenic TOS are as follows: Pain or aches in your neck, back of the head or shoulder. Extreme muscular inhibition will cause severe abrasiveness and tightening, greatly increasing its potential of irritating / compressing nearby structures such as nerves and blood vessels. A typical TOS patient will often present with similar scapular resting position, as many studies (cited below) also show. Compression of the superficial C8 to T1 cutaneous afferent fibers elicits stimuli that are transmitted to the brain and are recognized as integumentary pain or paresthesias in the ulnar nerve distribution. They have minimal work capacity, which is why they severely tighten and irritate the surrounding nervous structures. Each patient showed an anomaly of the vertebral artery system which allowed intermittent compression of either the origin or cervical course of the artery. Is it possible that the external rotators are pressing on a vein or artery? When I do the exercises, not only I feel that my mouth dry up but also my sinus, making breathing trough the nose very hard. Again, a strong pressure will usually be required. Pain can be present on an intermittent or permanent basis. I have been trying to follow some of your programs and it seems to be affecting my vagus nerve and causing a lot of anxiety. Povlsen et al., 2014, Thoracic outlet syndrome (TOS) is controversial in terms of definition, anatomy, aetiology and treatment. 3. The somatic nervous system and autonomic nervous system is interconnected through something called gray rami communicans. The symptoms that you experience as a result of thoracic outlet syndrome will depend on whether the nerves or the blood vessels are affected. Read below. Compression of the sympathetic nerves in the thoracic outlet may occur alone or in combination with peripheral nerve and blood vessels. However, musculoskeletally induced hyperperfusion may also occur, as stated, if the inlet to the arm is obstructed (Larsen et al. The role of the autonomic influences should be taken into consideration every time conventional antiarrhythmic treatment is insufficient. Ganz toll. TOS exceeds the competence of PT. I got back to work but these symptoms making my life harder than ever. i have the botox scheduled for in a few weeks. Advertising revenue supports our not-for-profit mission. Thoracic Outlet Syndrome (TOS) causes dizziness because of positional compression of the vertebral artery with resultant symptoms of vertebrobasilary insufficiency. Symptoms . Treatment for thoracic outlet syndrome usually involves physical therapy and pain relief measures. Breaking your neck certainly didnt make your neck muscles stronger. A pinched or compressed nerve can trigger numbness, tingling or other sensations at That is, the resolution of dizzyness when rotsting and tilting the head away of the compressed part. fingers turn white when in the cold. 1988;11:571575. If any relevant symptoms appear after the provocation, that is a strong indication that there are vascular implications in the given case of thoracic outlet syndrome. The ulnar nerve is often just a side effect from the compression in the thoracic outlet. Parasympathetic stimulation has long been associated with increased propensity to AF (40,41). 1983 Mar;83(3):461-3. doi: 10.1378/chest.83.3.461. Weakness in . Daily stretches focusing on the chest, neck and shoulders can help improve shoulder muscle strength and prevent thoracic outlet syndrome. Vanti C, Natalini L, Romeo A, Tosarelli D, Pillastrini P. Conservative treatment of thoracic outlet syndrome. They elevate the ribs during inspiration (inhalation), ipsilaterally rotate, cause lateral translation, laterally flex and forward flex (bend) the neck. Youll have to book a session. NeuroTalk Support Groups > Health Conditions M - Z > Thoracic Outlet Syndrome > dizziness related to tos? As we have already seen, SBP will affect our breathing strategy. There are a lot of 5-minute-experts out there that insist on a lot of things, interetingly without any genuine results with patients. Usually the median nerve is not affected (weakness of the 1st finger). Left scalenectomy and rib resection confirmed the MRI and MRA findings; the scalene triangle contents were decompressed, and migraine symptoms subsequently resolved. other information we have about you. of electrodiagnosis in thoracic outlet syndrome. PMID: 25427003. Thats not because they are not intelligent, but perhaps had a slight lack of attention to detail, and of course because the body was working against them rather than with them. This article and your scapular dyskinesis article have helped me immensely. Its important to work on both the cause and the symptoms in order to resolve thoracic outlet syndrome as swiftly as possible. Agri. The site of obstruction occurred at the origin of the vertebralartery or cephalad to the level of C5. Neurogenic thoracic outlet syndrome Arm/hand fatigue, numbness, tingling. A relatively common symptom is chronic cough, but Ive also seen chronic hiccups, increased heart rate upon cervical rotation, dry throat syndrome, clogged ears, tinnitus, burning tongue and even pseudoangina symptoms occur in some of these patients. Dyspnea (difficulty breathing) and pnealgia (painful respiration) is also relatively common in this patient group, as bilateral brachial plexopathy may impair the function of the phrenic nerve, although this is not well known. PMID: 21072145; PMCID: PMC2966747. The main point of TOS surgery is to make space between the first rib and the collar bone. Thoracic outlet syndrome. Thoracic outlet syndrome (TOS) is a group of disorders that occur when blood vessels or nerves in the space between your collarbone and your first rib (thoracic outlet) are compressed. Thoracic outlet syndrome. TOS occurs when the blood vessels or nerves in the thoracic outlet area become compressed, irritated or injured. Hold it for at least 30 seconds, and look for tingling or frank pain in your arm, hand, chest, neck or scapula. ATOS can decrease your blood circulation. I dont recommend PT after surgery, as most PTs have no clue how to treat this problem. That the muscles causing the entrapment are usually, 2nd finger opposition Median nerve Superior trunk, Biceps Musculocutaneous nerve Middle trunk, Lateral deltoid Axillary nerve Inferior trunk, middle trunk, Suboccipital, or mastoidal pain and pressure, Feeling heavy-headed or as if wearing a tight helmet, Thoracic outlet syndrome is usually caused by extremely weak scalenes and posturallydepressed clavicle, Underlying causes for the above are often swayback posture, belly-breathing,poor scapular control, Pressure tests can be performed to identify the exact areas of compression, The muscles that surround the irritated nerves are almost always weak, and need strengthening, Atasoy E. Thoracic outlet compression syndrome. Your email address will not be published. If the posture, breathing, and neurogenic pressure-testing all have indications of dysfunction, and of course that the patient presents with additional vascular symptoms, they may very well be caused by vascular thoracic outlet compression. Regarding the exercises part, If its hard for the patient to start right away working on these muscles, would swimming 2/3 times a week be an alternative to strengthen the neck, shoulders and back? For something this specific youd have to book a session. Wearing heavy gloves can help also. Typically, neurogenic TOS is well addressed with a combination of physical therapy, muscle relaxants . So far, the key points that we have talked about are: Itis absolutely critical to establish proper breathing habits, clavicular resting position and cervical posture, in order to resolve thoracic outlet syndrome. Do you think there is non-surgical hope for me (I have EDS and POTS too) or is this going to be something that will need the right specialist to truly resolve? Garrick and Webb1in their excellent book, Sports Injuries: Diagnosis and Management, state that a weak muscle is a tight muscle. The compression can cause various symptoms, including: Pain. https://youtu.be/HezNZkdt4Ug. Try to sleep on one side and not have a pillow. without contrast , MSKT agiography with contrast)) URL https://drive.google.com/drive/folders/180G0B9Ev6UWbGuFIdXjjcgFiqFmJggud . This article is concerned with thoracic outlet compression syndrome (TOCS), one of the most controversial subjects in medicine. Sometimes, a congenital (from birth) abnormality can cause thoracic outlet syndrome, but it is more likely to occur after injury or bodybuilding. Its virtually always appropriate to initiate a strengthening protocol on these structures. In addition to usual migraine triggers, symptoms were triggered by neck extension and by arm abduction and external rotation; paresthesias and pain preceded migraine triggered by arm and neck movement. Im still quite active (weight lifting, drumming, yoga). Boezaart AP, Haller A, Laduzenski S, Koyyalamudi VB, Ihnatsenka B, Wright T. Neurogenic thoracic outlet syndrome: A case report and review of the literature. to repetitive work tasks. Numbness. She also exhibited other less severe brainstem symptoms. Thank you! Pain, paresthesia, decreased sensation, and weakness are the major symptoms. Many forms of scapula asymmetry may well exist in TOS populations, but in the limited research that has been done, scapula or shoulder girdle depression or drooping has been consistently observed (Kenny et al., 1993; Walsh, 1994; Pascarelli and Hsu, 2001; Skandalakis and Mirilas, 2001). Thank you and congratulations! Even after surgery, this will either compress the plexus toward the 1st rib stump, or toward the 2nd rib. Physical therapyis typically the first treatment. Similar discomforts can occur in other parts of the upper body including the chest, To provide you with the most relevant and helpful information, and understand which neck pain, shoulder pain, arm pain, numbness and tingling of the fingers, and. On MRI verbal spine neck where i see wide (big) anterior scalene muscles and vertebral artery located nearby at a distance of 1-1.5 mm. 16-17 Supinator MMT (left), Teres minor MMT (right). The compression was usually aggravated by rotation or hyperextension of the neck. Demondion et al., 2006. I decided to try to fix this on my own (shoulders back and down) and as such I developed an upper extremity DVT (effort thrombosis) of the subclavian vein recently. About 95% of TOS are neurogenic -- i.e. Thank you! . Accessed July 6, 2021. Whenever a weak muscle is forced to work beyond its capacity, it will tighten and, therefore, be more subject to stress and strain. Neck and shoulder pain or tingling. Some may argue that pressure directly into a muscle that lies on top of a nerve, always will cause nervous symptoms, but this is NOT true. The SCJ dislocation is a separate issue. This is called a positive Tinels sign. They synapse in the dorsal gray matter of the spinal cord, and the axons of the second-order neurons ascend in the spinal cord up to the brain. Continued bracing / severe psychological distress. AJR Am J Roentgenol. We have to force the body to re-engage those scalenes. J Thorac Dis. The hypertrophy isnt real muscle tissue. Thanks. I want to know more about exercises for strengthening Scalen and SCM muscles. If they do, you can MMT the teres major and minor, or just initiate a strengthening protocol right away as theyll test weak anyway. Thoracic outlet syndrome is caused by continuous compression of the nerves and vascular structures. Sympathetic system may promote arrhythmia by increasing Ca2+transient. Annals of Surgery. https://www.youtube.com/watch?v=dCI-Qa6Fu-Y. The medial tricep can be tested by having the patient resist elbow flexion while in slight lateral humeral rotation. This period of exacerbation of symptoms can last all from 2 weeks to 6 months depending on the severity of the situation, and presuming everything is performed correctly (exercises, posture, breathing, etc), and this may of course become a difficult period for the client. Dorsal sympathectomy is helpful for patients with sympathetic maintained pain syndrome or causalgia and patients with recurrent TOS symptoms who need a second procedure. Gentle strengthening once to twice per week of the offending muscle is the appropriate treatment. To evaluate compression between the biceps, squeeze into the distal biceps. always botox first and see the response. I have to assume this is from what you said, that it further compresses the thoracic outlet. If the shoulders appear relatively symmetrical in resting height after surgery, this suggests that an inadequate amount of rib was removed. Useful triad for diagnosing the cause of chest pain. Arterial thoracic outlet syndrome is a rare cause of shoulder pain due to compression of the subclavian or axillary artery within the thoracic outlet. None of them seem to understand. If this reproduces the pain, test the muscle. For me, this has been caused by the alignment of my head and neck, and the way the skull sits on the spine. Thoracic expansion is normal, and abdominal expansion is normal. Only two patients showed unequivocal poststenotic dilatation as evidence of severe anterior scalene muscle compression. Of course, time was starting to take its toll. See my reps and sets video on youtube. They may be used to quantify the problem, once already implicated, however. Our heart health checklist can help you determine when to seek care. Contact, Terms & conditions So the thickness and hardness in the scalenes is because of fatty tissue, correct? Nerve compression neuropathy may lead to muscle weakness. July 1963;158(1):133-137, Alcocer F, David M, Goodman R, Jain SK, David S. A forgotten vascular disease with important clinical implications. you might call your own sanity into question. 1., and mainly, because the collar bone is too low during articulation of the arm. Contact Information. PMID: 4000441. It should get a little worse as the scalenes are worked, but not cause excruciating pain. Ribs (the top ones), scar tissue, and bands of muscle can all play a role in compressing the nerves or blood vessels. The only way (that I know of) to deal with this, is slowly rehabbing the muscles by strengthening them steadily and easily over time. Thoracic outlet syndrome can lead to a wide range of symptoms. lumbar plexus compression syndrome article, David Weinstocks book Neurokinetic Therapy, Vestibular impairment and its association to the neck and TMJ, https://www.youtube.com/watch?v=dCI-Qa6Fu-Y, https://drive.google.com/drive/folders/180G0B9Ev6UWbGuFIdXjjcgFiqFmJggud, Do you really have atlantoaxial and craniocervical instability? Many patients also feel tightness of of, or a lump in the throat (globus hystericus), which is often misdiagnosed as a psychiatric symptom. This can cause shoulder and neck pain and numbness in your fingers. Patients with migraines and concomitant swelling and/or paresthesias, especially related to provocative arm maneuvers, should be considered a possible atypical presentation of TOS and evaluated in more detail. I Have a 10 year old with EDS, POTS and more. When there is numbness in the fingers, there may be some coldness as well. See some interesting evidence below. 2017 Feb;39:285.e5-285.e8. No absolutes, though. I have seen several patients with severe pain upon pressure to the interscalene triangle, positive myotome tests etc., who still did not have any findings upon EMG. Due to continuous compression within spaces that the nerves and vessels pass through. Dear Kjetil I believe I got TOS after a rotator cuff tear/possible brachial plexus injury. Tolson TD. Deep venous thrombosis usually begins in venous valve cusps. The concept is simple: Push into the entrapment point and see if it reproduces the pain. Does thoracic outlet syndrome cause cerebrovascular hyperperfusion? Your email address will not be published. Treatment for Venous Thoracic Outlet Syndrome, Masks are required inside all of our care facilities, COVID-19 testing locations on Maryland.gov. Symptoms of thoracic outlet syndrome differ depending on the type of TOS someone has. I started psychotherapy, no exercises just massage ultrasound therapy, neck traction, and heat therapy. A Sympathetic Ear Thoracic outlet syndrome (TOS) may affect neurologic or vascular structures, or both, depending on the component of the neurovascular bundle predominantly compressed. i appear to be having arteial tos symptoms, just had one of my worse cold and white hand episodes. The patient can also pull their shoulders back and down. January 2012. Are there any possible ligaments implications that mighr further compress the structures. Here are the exercises for scalene strengthening. PM R. 2015;7(7):746-761. doi:10.1016/j.pmrj.2015.01.024. privacy practices. 2). For most people experiencing symptoms of TOS, the recommended treatments are: Surgery might be recommended for patients who are diagnosed with an anatomical abnormality Pain in the hand and arm, especially during overhead motions of the arm, Embolism (blockage) of an artery in the hand or arm. Connolly JF, Dehne R. Nonunion of the clavicle and thoracic outlet syndrome. Reading your article really shed light on that as I assume its because I was doing a lot of back and down motions trying to fix it, which compresses the thoracic outlet even more. Symptoms of thoracic outlet syndrome include pain and paraesthesias. Visible veins in one shoulder, arm or on one side of your chest. The anterior scalene is a muscle located in the neck that attaches to the first rib in the area known as the thoracic . Patients with hypermobility disorders are also, empirically, quite susceptible to the acquisition of TOS. Innormal breathing patterns, the ribs and clavicle should elevate slightly during inspiration, and this is done in syncronization by the scalenes, trapezius and several other muscles. Urschel & Kourlis, 2007, Cough attacks elicited by movement of the neck and right arm are reported in a patient who had sustained several shoulder injuries and who had an anterior scalenectomy. Komanetsky et al., 1996. To explain chest pain from TOS compression, it is important to remember there are at least two types of pain pathways in the arm: the commonly acknowledged (C5 to T1) somatic fibers, which transmit more superficial pain, and the afferent sympathetic nerve fibers, which transmit deeper painful stimuli. Wow this article has brought so much light to something my dr and I have been searching for! Learn more about the tranaxillary first rib resection surgical approach to treat TOS from the Johns Hopkins Thoracic Outlet Syndrome Clinic. Thanks for your helpful artikle about TOS. If pain is reproduced, you can evaluate the muscles that surround the nerves function by using palpation and MMT. Please read this article if you've just started practicing Clinical Somatics exercises and are experiencing any of the following sensations: Nausea, dizziness, feeling off-balance. Occlusion of the right vertebral artery occurred at the narrowed scalenovertebral angle with this rotational head movement. When there is compression, injury, or irritation of the nerves and blood vessels in the lower neck and upper chest area, it's called Thoracic Outlet Syndrome. 2005;92:25-7. doi: 10.1007/3-211-27458-8_6. Doctors think my operation was succesfull the advised to start exercises even tho it makes the symptoms worse for a while should keep doing it for some results. Manual Therapy 15 (2010) 305e314. The compression can happen between the muscles of your neck and shoulder or between the first rib and collarbone. The sensitivity of these tests are simply inadequate and should not be used to exclude pathology. So, not really. I live in South Africa and wish that our doctors had more knowledge on this syndrome. Learn more: Vaccines, Boosters & Additional Doses | Testing | Patient Care | Visitor Guidelines | Coronavirus. Thoracic outlet syndrome symptoms include. Compression of C7,C8,and T1 nerves fibers is responsible for the neck pain. Goshima K. Overview of thoracic outlet syndromes. thank you for your time. Having a cervical rib (an extra rib extending from the neck) increases your chance of developing thoracic outlet syndrome. This animation illustrates how physicians at the Johns Hopkins Thoracic Outlet Syndrome Clinic perform interscalene brachial plexus blocks using botulinum toxin type A injections to provide temporary pain relief for patients. in relation to surgical intervention of atherosclerosis. Headaches in the back of the head. Anaesth pain intensive care 2020;24(1). Result of this one was post op horners syndrome and lower trunk damage. Weight gain: As with extra muscle mass, extra fat in the neck may compress nerves or subclavian vessels. In your general opinion, do you think subclavian vein compression upon abduction should be surgically decompressed even in the absence of a clot? After reading some of your material I believe rhinitis, hard time breathing trough the nose and also sinuses problems might be muscle skeletal and neurological related. The stretching makes the client feel better! Coronavirus (COVID-19): Latest Updates | Visitation PoliciesVisitation PoliciesVisitation PoliciesVisitation PoliciesVisitation Policies | COVID-19 Testing | Vaccine InformationVaccine InformationVaccine Information. Blue discoloration. Strong, healthy muscles are rarely responsible for neuralgia. The cervical plexus is comprised of C1-4 nerve roots, and mainly carry sensory functions. What youll likely come to notice is that carpal tunnel syndrome and similar issues are often just a secondary TOS-symptom. What is venous thoracic outlet syndrome? No significant loss of power with my arm but this back pain was not allowing to use arm comfortably upwards above certain angles. No shock there. Can you please email me. Do you recommend any specific exercises of those you have made available on Youtube for people suffering mainly with facial and ear pain? Sell et al., 1994. Thoracic outlet syndrome: a review. If this is too difficult for you, either find a coach or work solely on thoracic vertical expansion, as this is most important element for resolvingTOS. (tos symptoms are on the right). The cause of the compression varies and can include: There are several factors that seem to increase the risk of thoracic outlet syndrome, including: Complications from this condition stem from the type of presentation (neurogenic, venous or arterial). 2) I wasnt surely clear about this after reading the article: Could Scapular problems (scapular dyskinesis) be the cause of TOS with neck and head symptoms? or variation, or who have experienced a physical injury or trauma that is found to Thanks again. Fishman LM, Dombi GW, Michaelsen C, Ringel S, Rozbruch J, Rosner B, et al. Thanks in advance! I have several suggestive symptoms for TOS and one is I cant brush my childrens teeth in the evenings because the trapezius muscle gets tired quickly on the symptomatic side. It has potential to cause numerous types and areas of pain, such as neuralgia in the arms, chest, between the shoulder blades and in the back (figure 1), dizziness, brain fog, migraine, headaches, a feeling of being "heavy-headed", etc. Your SCM would not affect your arm, only to some extent the subclavian vein. Chilean J of Surg. However, vagal stimulation or perfusion of ACh in experiments contributes to development of AF by heterogeneous shortening of action potential duration and refractory period. But, how reliable is this estimate? Check the full list of possible causes and conditions now! In neurogenic thoracic outlet syndrome, nerve compromise can lead to . What about sinuses problems from TOS? KL TRENING & REHAB Tightness (due to weakness) of the scalenus muscles will compress the subclavian artery, especially during ipsilateral rotation and extension of the neck. Radiculopathy refers to the whole complex of symptoms that can be caused by irritation or compression of a nerve root in the spine. Accessed July 6, 2021. PMID: 7266064. Schenardi C. Whiplash injury. My scap is usually in pain and my shoulder feels numb and whole arm feels heavy and dead. Tell the patient to relax and to resistyour pressure naturally, without engaging all the muscles of the neck. doi: 10.1016/s0749-0712(03)00089-1. Muscle Nerve. Schade das die Videos nicht in deutsch sind. The carpal tunnel is a little different than the rest of the compression points in this article. Although I am more than confident that my protocol thats written in this article works, it is important to emphasize that treating TOS is not simple, nor easy. Symptoms of thoracic outlet syndrome include: Cold feeling or other signs of poor circulation in the forearm or hand. Aug. 18, 2021. When nerves are compressed, signs and symptoms of neurogenic thoracic outlet syndrome include: Signs and symptoms of venous thoracic outlet syndrome can include: Signs and symptoms of arterial thoracic outlet syndrome can include: See your doctor if you consistently experience any of the signs and symptoms of thoracic outlet syndrome. Specifically: Cervical rib: A cervical rib is an extra rib that grows from the cervical spine the neck part of the spine. 2015;44:376. My coracoclavicular ligament was severed in my right shoulder and I had to have surgery. How could thoracic outlet cause face pain? PMID: 15005382. Summary. Yamagami T, Handa H, Higashi K, Kaji R. Brachial plexus injury with cough attack: case report. Unfortunately, none of the physicians can explain my strange symptoms. Posterior scalene muscle Bodybuilding: Built-up muscles in the neck may grow too large and compress nerves or the subclavian vessels. This is called the Morleys test (Sanders 2007, Laulan 2011). When strengthening the upper traps, can this worsen nerve pain? I am in the process of trying to figure out if I have vascular TOS. Holding teeth together, chin tucking or simply saying that people breath trough mouth due to laziness is non sense. This generally means that the compression is stemming from another structure, and that the area thatyoure working on is not that important. Many thanks your articles have taught me more than any NHS nurse or doctor or physio i have seen in my 32 years so far. My scalene I believe the middle one sticks out and is hard to the touch does they mean its weak and hypertrophied? Thats fine, youre just doing too many reps or the frequency is too high. neck, head and ears. Neurogenic TOS more often affects women, while arterial TOS and venous TOS affect people of all genders. Fig. Many breathing experts claim that diaphragmatic (belly)-breathing is the ultimate cure to virtually anything. You might be called a malingerer, and The two most useful MMTs are provided here, for the teres minor and supinator muscles. Taking the research above into account, the reader can probably start to understand that its often very difficult to be properly diagnosed and treated if one has thoracic outlet syndrome. (4 months after surgery). Many people with a cervical rib never know it, because the bone is often tiny and isnt noticed, even in X-rays. 2010;18(2):74-83. doi:10.1179/106698110X12640740712734. And of course, big time neck pain. Somatosensory evoked potentials: lack of value for diagnosis of thoracic outlet syndrome. J Trauma 1989;29:112733. TOS commonly shows itself as Other symptoms include headaches, vertigo, and memory loss. Would you push for first rib resection for release, or attempt these exercises first? Hello, The underlying reasons are often postural and breathing abnormalities that need to be corrected. It may also be the most underrated, overlooked, misdiagnosed, and probably the most important and difficult to manage peripheral nerve compression in the upper extremity. This condition also has an altered sensation and temperature in the arm and hand. Thoracic Outlet Syndrome (TOS) refers to an ill-defined assortment of disorders originating Thoracic outlet syndrome usually affects the arm or hand with a combination of: Coldness in the upper arm or chest. This can be rooted in habits alone, or triggered by injuries such as a clavicular fracture (Moon Jib Yoo et al., 2009; Ishimaru et a., 2012; Connolly & Dehne, 1989), whiplash injury (Schenardi, 2005) or similar. You are the man!!! Correlation of cerebral blood flow and electroencephalographic changes during carotid endarterectomy: with results of surgery and hemodynamics of cerebral ischemia. There are potential entrapment points all the way down the arms, in the route of the nervous branches. This can be hyperventilation, heavy carrying and working overhead, or especially horizontal pushing. Thoracic Outlet Syndrome Symptoms You're most likely to feel them in your arms and hands. 6 days post surgery i had terrible pain all over the place with shortage of breath and it came out to be hematoma. Pathways of pain in angina pectoris and afferent stimuli originating from brachial plexus compression at the thoracic outlet stimulate the same autonomic and somatic spinal centers that induce referred pain to the chest wall and arm. Whenscalenes arevery very tight, they also elevate the first rib, furtherly reducing the space between the rib and the clavicle, increasingthe potential for compression within the costoclavicular passage. To test for affection, squeeze your thumb into the interval in the posterior armpit, and/or into the supinator muscle. This is my files of diagnostics in the format dicom and jpeg (MRI verbal spine neck and MRA agiography But some patients suffer from legitimate neurogenic suboccipital symptoms in TOS, and these will respond favorably to a nerve block, whereas the vasculogenic one will not.