Topic: Wright’s Hyper-abduction Syndrome
The history of Thoracic Outlet Syndrome ( T.O.S) dates back to the 1700s when discovered that the first rib was a causative factor in T.O.S. Medical management was discussed in the early 1800s and again in the twentieth century. Adson revealed how the scalene muscles could be implicated in T.O.S. In 1935 Wright demonstrated how shoulder hyper-abduction could result in neurovascular compromise in T.O.S behind the tendon of the pectoralis minor. In 1956, Peet first coined the term T.O.S and in the 1960s Roos claimed the first rib, and its musculo-ligamnetous attachments as the direct cause and/or contributor to said neurovascular compromise AKA T.O.S. Along with surgeon Green, they developed the Roos-Green transaxillary resection of the first rib, still performed to this day.
A review of the literature discloses five patterns of T.O.S primarily based on the anatomic location and type of neurovascular compromise and are as follows:
- Upper Plexus Compression: Characterized by pain in the anterolateral neck, shoulder, jaw, with radiating paresthesia to the upper chest (pecs) and the C5-7 dermatome of the lateral arm
- Lower Plexus Compression: pain located in the supra and/or infra-clavicular fossa, posterior neck, rhomboids, axilla and radiates along the ulnar nerve distribution (C8-T1 Dermatome)
- Arterial Compromise: ischemic avascular processes characterized by coolness, and exertional fatigue
- Venous Compromise: includes swelling of the arm, non-pitting edema, characteristic bluish discoloration with venous collateralization in the chest and shoulder
- Mixed Neurovascular Compromise: a combination of above patterns of compromises, previously described.
Up to 75% of these T.O.S patients have a history of an acute or repetitive trauma associated with the onset of T.O.S. A detailed subjective history will often reveal a slip, fall, or incident of FOOSH (fall on outstretched hand) as the precipitating insult. This fact is often over-looked and disclosure is likely to predict the pattern and result in more accurate treatment related to the otherwise recalcitrant patient. Moreover, I have seen many cases with multiple failed attempts to eradicate the neurovascular compromise and failed clinical outcomes often due to lack of precise knowledge of the biomechanics of the injury that resulted in the T.O.S.
The following case study presented to me in the mid1980s traveling to the USA from Copenhagen, DK for my specialized treatment of her failed T.O.S. During administered case history she mentioned no-one asked her the depth of questioning that I did relative to the specific onset thereby correlating a potential injury causing her T.O.S. The interrogatory spawned her recall of a few minor falls when learning how to ride a bicycle at 48years of age just 1-2years prior to her conditional onset.
At the time in Denmark, the patient went through all conventional allopathic and alternative treatments from her subjective remarks to advanced diagnostic exams including angiograms and subsequent blood thinners attempting to eradicate what they assumed was intrinsic blockage (blood clot). To no avail, she underwent the Roos-Green transaxillary resection of her first rib. She failed surgical decompression of her T.O.S and was left with the same pre-op diagnosis.
Stumped at her chronification and lack of improvement medically and through failed multiple chiropractic and acupuncture treatments she was referred to me. Based on my new patient interview, it became immediately obvious to me that she suffered a FOOSH injury that resulted in the biomechanics of scapula and clavicular subluxations. It was not the first rib involvement as it was removed surgically.
The pectoralis minor neurovascular compromise as explained in the Lower Plexus Compression pattern of Wright’s Hyper-abduction Syndrome was the “extrinsic” compromise that prior physician testing failed to clearly demonstrate. You see, the subluxing scapula (protracted, antetilted) and resultant clavicular compensation (medial and inferior) caused the contracting pec minor to compromise the brachial plexus emitted through the retro-pec minor space, as well as decreasing the supra and infraclavicular fossa.
The result of The Mally Method treatment of her scapula and clavicle manipulation was immediate restoration in neurovascular flow through her arm. Dumbfounded the patient agreed to be televised on Channel 8 by Paul Lewis Investigative Reporter. Her story resulted in 39 new patients referred from one two minute educational segment and testimony to the accuracy of treatment contingent on the accuracy of the details provided by the patient and a clear use of the biomechanics. You too can help your patients using biomechanics and treatment of this type of injury. Visit ExtremityExperts.com.
