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  1. #1
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    Brief Medical History Overview

    Age: 35, Male, Presenting Problem Since: 6 years, Symptom Behaviour: somewhat better, Symptoms Worse (24hr Behaviour): worse during day in activities, Aggravating Factors:: arm movements, when i move my head, both together, sitting and working on tables, Easing Factors:: lying down with my head not on a pillow and my arms straight out at side. serratus activation on right side., Investigations: MRIs showed C6-C7 disc bulge but no clear answer. XRays showed some kyphosis and straightened cervical curve, No Diabetes, No history of High Blood Pressure, No Medications, No Osteoporosis, No Hx of Cancer, No Unexplained Weight Loss, No Bowel/Bladder issues, Other Info: Have been told Fibro and CRPS. All my issues started post accident.

    Major problem / Symptomatic Areas

    Head, Neck - Posterior

    Head, Neck - Anterior

    Thoracic Spine

    Lumbar, Spine - Posterior

    Shoulder - Posterior - Left

    Shoulder - Posterior - Right

    Shoulder - Anterior - Left

    Shoulder - Anterior - Right

    Upper Arm, Triceps - Posterior - Left

    Upper Arm, Triceps - Posterior - Right

    Upper Arm, Biceps - Anterior - Left

    Upper Arm, Biceps - Anterior - Right

    Elbow, Forearm - Posterior - Left

    Elbow, Forearm - Posterior - Right

    Elbow, Forearm - Anterior - Left

    Elbow, Forearm - Anterior - Right

    Wrist, Hand - Posterior - Right

    Wrist, Hand - Anterior - Left

    Wrist, Hand - Anterior - Right

    Foot - Posterior - Left

    Foot - Posterior - Right

    Help needed - Thoracic Outlet Syndrome and Neck/UpperBack/Arm issues

    Hi all, I am 35 years old based out of India and am facing an uphill struggle in managing my Thoracic Outlet Syndrome and other issues. Your input would be invaluable.

    Around 6 years back, I was going through an intense time, was tired. Got on a bike with a rash acquaintance who said he'd drop me. I ended up face down having fallen off the bike (it was around 30-40 mph), on the left side & I had severe facial lacerations on the left side. Long story short, I ended up in the hospital and they sent me back after some basic work saying MRIs/spine x rays checked out ok. In hindsight, I think I fell on the left side of my face but injured both my shoulders and also my right arm/shoulder.

    A few days later, I immediately developed chronic pain in both my fingers/hands/tinglin, started from ulnar distribution (which got worse through the years and extended to all fingers on right and was all fingers on left side) & my right trapezius/back/shoulder would seize up with terrible spasms in good posture.

    Basically when i sat at a table, my right arm would seize up if i shrugged, and reached out low with my arm. I couldn't abduct my right arm at "low angles" ie with my elbows in extension and arm away from my midline. If I hunched over like a zombie, it would help.

    Six years and many doctors later, I have been told its not a cervical disc issue (I have a cervical disc bulge at C6-C7 and some doctors initially diagnosed my issue as spondylitis/disc bulge others disagreed). I have neck pain when I flex my neck. Not much/nothing significant when i extend it upwards. My MRI (I need to get a new one) at time of accident said moderate impression on thecal sac but no foraminal narrowing or nerve compression.

    Now, a doctor has said my issues are TOS & has asked me to undergo myofascial therapy & put me on Neurontin, Amytripyline. But both gave me side effects. Lyrica worked for a while but stopped being as effective. Myotherapy has not been very effective. My symptoms/trigger points keep reappearing.

    What has worked to some degree. Manual therapy (thoracic mobilization) which seems to have freed up my Long Thoracic Nerve on my right side and I began to be able to use my right arm a bit. But same PT also aggressively mobilized my lower spine and I developed a lumbar disc bulge (I developed a lateral pelvic shift) and a lot of pain, so unfortunately, wasn't able to return to him for further treatment.

    Exercises, I do heavy serratus type activations and it seems to have improved me some.But my upper back spasms when I have to use my neck and arms together.

    It seems, its next to impossible to manage this complex condition & I am hitting a brick wall each time I try to figure out possible approaches.

    Work is computer heavy & very stressful because of the pain - and I need to figure out how to actually live my life as at times the pain and challenges get very daunting.

    Symptoms

    Right side:

    Arms: Nerve pain in arms, blue veins in hands, very tight clawed fingers from time to time
    Back: tight upper back muscles and burning pain, spams in right upper trap, levator, rhomboid area and occasionally parasthesia on the spine of teh scapula and right side of shoulder blade.
    Additional details: My humerus is unstable forwards and upwards /anterior superior instability when I raise my arms high or move them backward forward (motions flapping like a bird)


    Upper trap/Levator/Rhomboid pain Symptoms (especially on right) worsen if i sit down and attempt to abduct my arms slightly with them held away from the side

    Based on my image analysis from a knowledgeable person and my symptoms, it was surmised that I seem to have injured my Long Thoracic Nerve in the fall from bike on my right side and have been working on reactivating my right serratus. In my original picture, I couldn't raise my right arm as high as my left and my shoulder blade on right couldn't rotate properly.

    I can feel a muscle contracting beneath my armpit even if i move my right arm up.

    Does that mean I can rehab the muscle? Any idea of teh time I'd take and the specific exercises and other muscles to focus on along with it?

    As I have constant pain in my right shoulder/neck area, I think overstressed levator and upper trap and also a supraspinatus injury probably. I might have fallen with my arm outstretched as a protective impulse.

    The Levator and Rhomboid are overdominant on the right side because of the serratus issue and I have nerve pain and compression in my right arm and hand.

    Research on whiplash shows deep cervical flexor, serratus and Upper trap dysfunction for whiplash injuries.


    When I raise my arm above 90 degrees, the humerus (seems to) pop out of the socket a bit on the right and i get pinching feeling of my tendons or a deep muscle.


    Left side:
    Arms: Nerve pain in my arms, hands, blue hands
    Also: sharp stabbing pain in my anterior shoulder (front deltoid)

    I dont have a contracting feeling in my armpit when i do scaption so i think serratus is fine.

    Left is (i surmise) due to injured longus colli which is not stabilizing my cervical spine. I read an article about the deep cervical neck flexors and how to gently tuck the chin and move it up and down to activate them. When I did that my head seemed to wobble on the left side.
    I have been doing capital flexion (activate deep cervical flexors) and it seems to have helped. My nerve pain in my left hand reduced!!

    Neck

    Very weak, when I look down the pain is worse, I get cramping in my upper back muscles and tingling. I read a book extract from Sahrmann's book and I seem to have "Flexion Syndrome". I cut my sleeping on pillows with neck propped up in flexion, and boom immediate results (reduction in arm nerve pain)

    Posture/Additional details:


    1. I have a kyphotic lordotic, forward head posture (much worsened after my accident) and a probable disc bulge/disc issue in my lower lumbar area (picked up late last year).

    2. I have been told I have a flat thoracic spine as well and my right side scapula wings more than the left.

    3. My clavicles droop downwards, so likely strong upper traps, weaker rotator cuff (esp given impingement type symptoms on both arms) which would be worsening the pull of the Upper Traps and Levator on the neck and also very weak Serratus on right

    4. Have been told my scapulae are slightly higher than normal (right dominant side lower than left) and more protracted. Fits with "computer posture".

    Any advice welcome as I am literally at my wits end managing my symptoms.

    My current plans/exercises are:

    1. Aim: Neck stabilization - activate deep cervical flexors, extensors

    Capital flexion and extension from prone position (30 degrees up and down) to strengthen/activate my deep neck flexors and extensors. These had a good effect. I started with aggressive chin tucks and my hands turned bluer and more clawed, I realized/thought I had overrecruited my neck flexors (scalenes and SCMs) and did more extension work plus gentler chin tucks. Things are better since then. When I shrug my shoulders I no longer get tingling zaps down my arms as much as I did before.

    2. Shoulder Work

    1.Pec Minor stretches
    2.Wall Angels for better posture (not overdoing them as the rhomboids may already be overactive)
    3.Scaption (tons) for activating Serratus and LT (I feel my muscles below my armpit - I guess my Serratus contract like anything when I do this on the right side and it seems to be helping in allowing me to sit with my arms abducted for a while)
    4. Wall angels but with arms forward for strengthening upward rotators and developing scapular synch (muscles below my armpit contract when I do this)
    Flexion with arms in front
    5.Blackburns exercises for rotator cuff ( These should address my lower mid traps too as they are pretty similar/same as Y,T,W)

    Thinking of adding thoracic mobilization - but don't know which particular exercise to do.

    So if the Serratus is contracting each time I raise my hand, is that a good sign (that its weak) and not that the nerve is overfiring (as it doesn't mostly pain/contract otherwise) and I can rehab it? Any idea of any additional exercises and time it'd take?

    Are my constant tight muscles in upper back due to weak rotator cuff and serratus forcing my Upper traps, levator and rhomboid to compensate and those spasm up?

    On TOS forums, people just refer to all these as nerve issues. I am wondering whether it is simply simpler, that injuiries may shut off nerve, muscle connections and then the cycle of pain and lack of activity makes things worse.

    3. Posture, Lower back

    Additional details:
    When I looked down, I would get mid back/thoracic pain- severe spasm. This has reduced after I tried strengthening my neck extensors. I assumed they were weak after my whiplash injury and sedentary lifestyle and hence looking down stressed my thoracic area.

    I get severe pain/numbness in my feet (bottom of feet, near toes) when i flex my lower back. I have been told this could be due to either a bad sitting position (flexed spine) or tight calf muscles. I have constant pain in my left lower back, either an injured Quadratus Lumborum or a disc issue (I intend to get a MRI done) per a PT.

    I am also doing Mc Kenzie extensions (lie on tummy look up) like the Pilates Sphinx (And these are helping me stand up straighter and also helping my disc bulge lumbar symptoms) and also prone cobras.

    4. Additional - weak core

    I also (as can be imagined) have a very weak core. I am planning on doing bridges, hip extensions, and Sahrmann's core exercises once I get the hang of them.

    My next plans are diaphraghmatic breathing (to take pressure off my scalenes and pec minors and SCM muscles) and also integrate neck movements with flexion so that I get used to activities of daily living.

    Also more computer style abduction (ie sit with a weight in a hand position similar to when I'd reach for a mouse). My biggest question is whether that "Feel" i get of my right serratus contracting means its weak and if ican strengthen it and how long would it take.

    Any advice very welcome.

    I am wondering if I have cervical cord issues (positional compression in flexion) and need a MRI or any further work ups/details.

    I am basically in a situation wherein after having seen many doctors, I am doing all I can to get better and exercise seems to help. There is a wealth of knowledge on this forum and your advice would be invaluable.

    Please help. I would value your advice and any tips, ideas.

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  2. #2
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    Re: Help needed - Thoracic Outlet Syndrome and Neck/UpperBack/Arm issues

    Serratus cramp: Also when i massage the side of my neck, where the scalenes are on the right side, my serratus no longer contracts heavily when i raise my arms.


  3. #3
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    Re: Help needed - Thoracic Outlet Syndrome and Neck/UpperBack/Arm issues

    Please could someone give me advice on thoracic outlet syndrome



 
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