Thoracic Outlet Syndrome–TOS, for short
When it first began with shoulder and upper back, I thought it was just muscular tension from leaning over the computer or patients as I’m doing acupuncture. But as the initial pain resolved and the throbbing pain moved to my forearm, I knew what it was. Thoracic outlet syndrome.
Unfortunately, I was on my way to a week long yoga/surf retreat, so there was little I could do to address it immediately. The forearm pain progressed to tingling and numbness in my fingers, so sitting still in meditation or savasana (corpse pose–lying down on back and remaining still) was really a struggle. I one-handed some of the yoga poses and skipped out on others. Surfing and paddle boarding were a bit of a challenge, but workable. Perhaps it aggravated my TOS since the numbness persists, but at least now the pain is gone.
Isn’t it interesting though that once you experience something yourself, you seem to draw in others experiencing the same? Such is the case for me in my practice, so I thought I would blog about thoracic outlet syndrome, so you can know if maybe you or someone you know has the same.
What is thoracic outlet syndrome?
TOS is a condition caused by compression of the nerves, blood vessels, or both as they pass through a narrow area between the base of the neck and the armpit, called the thoracic outlet (makes sense). It’s kind of like the more commonly recognized carpal tunnel syndrome, except where the arm meets the torso instead of at the wrist.
How it thoracic outlet syndrome diagnosed?
First, symptoms are considered. Do you have:
- neck, shoulder, or arm pain
- numbness or tingling in the fingers
- weakness in the hand
- impaired circulation to your hands and fingers
- redness or swelling in your arm
- hands or arms that are easily fatigued
If you have those, you can try out this the Roos test. Raise your arms by your sides and bend at your elbows 90 degrees, hands facing front. Quickly open and close your hands for up to two minutes. If the affected side feels worse than the non-affected side, reproducing your symptoms, then you may have TOS.
You can also get electrical and radiological tests.
What causes thoracic outlet syndrome?
The thoracic outlet really doesn’t leave much space for the blood vessels and nerves to pass through, so anything that causes compression on them can result in TOS. I mentioned that mine is predominantly tight pecs minor muscle. But it could also be tightness or inflammation in the scalene muscles (along the side of the neck) or an extra rib called a cervical rib.
My thoracic outlet syndrome was from carrying one dog in a front body carrier while walking my other dog who sometimes pulls me forward (my first and only time doing that). I wish I could say it was from doing something amazing like a one-handed handstand or saving someone’s life, but sadly, it wasn’t.
You might also get it from an imbalance of strong chest muscles to upper back muscles, improper weight lifting, impact injury, repetitive movements, poor posture, obesity, or just that you happen to be born with a cervical rib.
What can you do about thoracic outlet syndrome?
Stretching is helpful. Check out this video for a few stretching options. Stretching the neck and the chest helps open up more space for the structures to pass through the thoracic outlet. Balancing that with strengthening exercises to help pull the shoulders back and position the head better over the torso are also helpful.
I use a rolled up yoga mat to lie on (place it between your shoulder blades and stretch your arms out to your sides or over your head), but you can also use a rolled up towel, blanket, or sheets. Or, another option might be to do a Zipline and stretch out this way! Not exactly practical, but definitely more fun! 😉
What I find most helpful is acupuncture. While I was at the retreat, I was unable to get someone to acupuncture me and I was unable to acupuncture my own shoulder, pecs, and back, so I did a very simple forearm treatment (shown partially completed above) that helped. Oh, and kinesiotaping to support the muscles. That really helped in between the acupuncture sessions.
Pain, fatigue, depression, anxiety, disabilities, injuries, and chronic illness. Every day I work with people who are suffering. And the question that sometimes comes up is, “Will I get better?”
I believe that our bodies are designed to heal, so yes, I do reply that things will get better. Does that mean 100%? Sometimes, against all odds, yes. Sometimes not 100%, but better.
Courage to Come Back
I was recently honoured to get to watch someone I know well received a prestigious award, the Courage to Come Back Award. Tom is a man who doesn’t do things for awards or accolades. In fact, in this video, you can see that he says he doesn’t know if he was a good social worker (I’m sure he was!), but that he felt he could do his best to do little things to help others.
He has many major health challenges—legally blind, kidney transplant (twice), chronic pain, and more—but despite them, is one of the more active people I know. He curls, does yoga, and walks everywhere. He travels, he volunteers, he writes articles, he advocates for people in need, and his home is a regular gathering place for parties.
So, what does Tom have to say about overcoming and dealing with challenges? I interviewed him for his perspective a week after receiving the Courage to Come Back Award.
Support of others
Tom was born with severe vision problems. Nearly blind, he could see the blackboard at school, but couldn’t see the words on it. He asked his teachers to read aloud what they wrote on the board. In university, his friends read his textbooks to him.
So, it’s no surprise that when I asked Tom to name some of the things that have helped him through his life, despite his health challenges, he said that support is the most important. Find people you trust, respect, and can rely upon. And know that it’s a two-way street, so be trustworthy, respectful, and reliable to them.
But then I asked him how to ask for help. Because sometimes it’s hard to ask. He said that his experience is that most people want to help. And that when people care for you, they don’t want to worry about you. It’s more of an impediment to worry than to be able to help. And sometimes people don’t simply offer to help without you asking because they don’t want to intrude.
Sometimes pain continues. Sometimes things don’t get better or more challenges arise. So, how do you manage? What do you do?
Tom’s suggestions? “Pain is something you may not always be able to get rid of, but you can work on reducing it. Your body and mind can adjust to pain. If you can just get better bit by bit, even chronic pain can feel less painful. And remember, it usually took a long time to get to where you are now, so it takes effort, commitment, conviction, and hope to make changes for the better.”
Though this phrase may not work for all, Tom remembers with a chuckle, a time that he was really struggling and a friend said to him, “It’s better to be above ground than below.” For him, that was motivation to push forward.
If you get to meet Tom, you’ll find out he has a great sense of humour. He says he’s always perceived things in a “zany way,” and that has helped.
One of the main messages he’d like to share is that it takes courage. It’s no surprise that the award is called Courage to Come Back. “Everyone suffers some type of adversity, struggles in their life. And the most important thing is to take steps forward, one at a time, and keep trying. Don’t give up. Stay positive, even when it’s hard.”
What you can do to help someone in need
What if you’re on the other side of the equation? You may know someone with chronic health issues, and perhaps you want to help, but you don’t want to mistakenly offend. Tom told me that a simple question to ask is, “Can I help?” That way a person can say yes or no to assistance.
Also, try to avoid saying, “you should…” as that can come across as overbearing. But, Tom says that it’s important for all of us to remember not to take things too personally. Most of us are well-meaning and are just trying to help.
Additionally, sometimes it’s better to just listen instead of offering soothing words, suggestions, or a pep talk. “Silence is very important. It shows you are listening and thinking,” Tom says.
And, when you do talk, Tom told me of advice he received from one of his mentors, “It’s not always what you say, but how you say it.”
One more quote
One more bit from Tom, “Healing is not a sprint; it’s a marathon.” And he would know. Tom has been beating the odds for more than 70 years.
For more about the winners of the Courage to Come Back Award, check out their site here.
Still on my monthly habit building, last month I completed #jokeadayJuly. I committed to share a joke (at least one, sometimes more) every day for 31 days. I shared it on my Facebook page (Dr.Melissa Carr) and told it to various people around me throughout the day.
It’s harder than you might think to find 31 decent (with both meanings of “not dirty” and also “okay”) jokes. But it was fun to search for jokes, and even to laugh at the ones that were truly bad (again, in both senses of the word). And, my favourite part was that friends also shared their jokes with me.
Purposefully seeking humour every day is a powerful medicine, even if it only produces a small smile or groaning giggle. Trying to tickle your funny bone means you are intentionally bringing positive into your life, and that bounces into the lives of others around you, and continuously comes back to you. It’s kind of like that paddle ball on an elastic band that you might have played with when you were a kid–but with the plus of not actually whacking you in the face when you miss.
Laughter has been shown to:
- Reduce feelings of stress
- Stimulate your heart, lungs, and muscles
- Burn calories
- Stimulate blood circulation
- Relax tight muscles
- Ease pain
- Improve immune function
- Boost mood (duh)
- Release endorphins
* Acupuncture does a lot of these too, by the way.
No joke, look up laughter on PubMed (a reputable source of research), and you’ll find a number of articles citing the value of laughter as medicine.
These are some of what I thought were my best jokes of the month. Send me your best jokes!
Mahatma Gandhi, as you know, walked barefoot most of the time, which produced an impressive set of calluses on his feet. He also ate very little, which made him rather frail, and with his odd diet, he suffered from bad breath. This made him…(oh, man, this is so bad, it’s good)…a super calloused fragile mystic hexed by halitosis.
What’s Orange and sounds like a Parrot? ……………..A Carrot.
Why did the hipster burn his mouth on a slice of pizza? He ate it before it was cool.
Two bass drums and a cymbal roll down a hill. Ba dum tssh.
I don’t have much of a green thumb.
I’m thankful that I’m a Dr. of Traditional Chinese Medicine in the 21st century because if I were doing this in the earlier days of TCM, I would have had to grow and collect my own herbs–and that would not have been great for my patients.
What I can do is help you gardeners get back to your plants if pain, injury, or other health issue are interfering with your fun in the dirt. Click here to check out my article in 24 Hours Vancouver, “Kneeling gardeners face growing pains.”
Anyone following the NFL—and many who don’t—know that Peyton Manning is one of the best quarterbacks in history. Last year he set single-season records for touchdowns and passing yards, and of course this year his team is playing in the Superbowl against Seattle.
I am a Peyton Manning fan. But the reason that I am writing about him is because of his recovery—a resurrection, really—from a neck condition that resulted in four surgeries and would have ended the career of most professional athletes.
So, what did Peyton do to have one of his best years yet, at age 37, following such physical trauma? I don’t know the details of his rehabilitation, but there are some pieces that we do know.
- Peyton sought help from the experts and his athlete friends. He found out what he could about his condition, though he recognized that every individual heals differently.
- He rested. For almost three months after his fourth surgery (a second vertebral fusion) he did not pick up a football.
- He started slow and built himself up patiently. He was forced to listen to his body, and with the guidance of his trainers he started with minimal movement and minimal weight, throwing darts instead of footballs, lifting only five-pound weights, and sitting in front of a mirror practicing his throwing action.
- He changed the way he plays. His right arm is still weaker than his left, so he had to relearn and alter his game to match his new body.
- He put it all into perspective. His older brother Cooper was a promising wide-receiver who had to quit football at a young age because of spinal stenosis (a narrowing of the spaces within the spine, putting pressure on the spinal cord). At age 16 Peyton was told by his doctor that his neck curvature was a potential problem, but he was fortunate to be able to play without major injury for 20 years, and he didn’t take his talent for granted. He also became a proud father of twins and said that though it was hard to be fighting for the return of his physical gift, the gain of having his kids was an equalizer. “I would take that trade any day of the week,” he said.
I don’t know if Peyton received acupuncture or biopuncture, but I do know that these therapies would have helped improve local blood flow to support the healing of the injured tissues. They can also reduce inflammation, release tight muscles, and relieve pain. But you know that already, right? 😉
This past weekend I did the Tough Mudder in Whistler. My last race prior to this was a Terry Fox run when I was in grade 6. When I started getting ready for this, a few months ago, I was concerned that my knees wouldn’t make it. I’ve mentioned in the past that I don’t like running. A large part of that is that it used to really hurt my knees to run. So, just as I avoid poking myself in my eye with my finger in order to avoid stabbing pain to my eye, I avoided running. But the Tough Mudder was almost a half marathon distance, plus obstacles, so I needed to make running a major part of my training.
How do you practice running when running hurts?
I started by choosing my terrain. I knew that running on pavement, particularly on sidewalks, is the worst for painful shock impact. So, I chose to run mostly on a chip trail circuit.
I also started with a run/walk combo. I have a hard time allowing myself to slow down or stop, but I knew that if I pushed too hard, my knees would give out.
I tried to listen to my body. At the beginning, I paid attention to pain. But, I also discovered that certain kinds of pain would go away. They were not actually true pains, but more like discomforts. I could push through those, keep running, and be fine.
But, a couple of times I misread pain/discomfort and suffered afterward. As a result, I made sure to ice my knees following my runs, so as to take down the inflammation I was causing.
Since I knew that running was the most injurious, I did other forms of training that didn’t involve running, but would continue to build strength and endurance. Snowshoeing, climbing the Grouse Grind, and yoga were my choices.
I also made sure to get treatments. I had massage, chiro, and acupuncture. I did my own biopuncture in my knees, using a combo of Traumeel, Zeel, Lympdiaral, and procaine once a week to build up my knees and take down the inflammation. This was definitely a huge part of my healing and strengthening!
Most Tough Mudders I spoke with were worried about one obstacle or another–overcoming fears of heights, electrocution, water, etc. I was most worried about the running. At the beginning I was afraid I wouldn’t be able to get past 5K of running. Because at the beginning my knees hurt at just 3-4K. I also had problems with anything downhill.
But, I love reading about the power of the mind. So, one day I did the snowshoe grind and decided to run down the mountain with the thought of strong knees that would carry me down with ease. Indeed they were strong that day and I suffered no pain. Unfortunately, not every training after that meant no pain. But some did, so that was encouraging.
It was those “some” moments that allowed me to believe that no knee pain would be possible.
Now, just 2 days after Tough Mudder, I’m happy to have happy knees. They didn’t hurt at all on event day. They didn’t hurt the day after. And they don’t hurt today. Well, except for the bruises.
So, if you have pain, perhaps there is a way around, to do the things that you strive to do.
Have you ever hit your shin so hard that the moment it happened you knew it would be a doozie, but you get to wait a few seconds after the hit while you hold your breath and wait for the pain to arrive? You have enough time to figure out what exclamation you are going to make. Are there innocent little kid ears around? Will “shoot!” help or does this hit require something a bit more expletive?
I did this a little while ago. You can see the cut that happened immediately. But what you don’t see in this picture is the bruise that should have appeared. Should have appeared, but never did. Why? Because I immediately started a routine of applying Traumeel cream to the area. Then reapplied every 3-6 waking hours for a couple of days. No bruise. Pain went away quickly. This picture was taken 2 days after the hit, when my shin should have been a lovely shade of blue or maybe yellow.
I love colourful, but prefer my skin not display a rainbow. Thank you Traumeel! Oh, and I should mention that I do injections of Traumeel for those who have deeper pain than just a bruise.
While pain means suffering and misery to most, it is also a sign that your body is alerting you to pay attention! If your house smoke alarm starts beeping, do you turn it off without addressing the cause of the alarm–the fire? Of course not! Yet many people try to cover up pain by taking drugs or simply ignoring it. While this may temporarily dull the pain, your body will continue to remind you that something is still wrong, and the pain can become more intense and chronic.
It is important to treat pain as pain can slow recovery, interfere with sleep and eating, and worsen fear, anxiety, frustration, and depression. However, “quick fix” drugs have negative possibilities and they often do not treat chronic pain effectively over the long-term.
“Today, adverse drug reactions and drug interactions are directly responsible for thousands of deaths annually and for more than 20 per cent of all hospitalizations for adults over the age of 65.”
— Statistics Canada, 1998
Since drugs do not take care of the source of the problem and they can be associated with many side effects, what can you do?
Traditional Chinese Medicine can address both the branch (the symptom) as well as the root (the cause) of the pain. Acupuncture is a natural, time-tested, safe, and effective way to treat pain. It is acknowledged by the World Health Organization (WHO), the National Institute of Health (NIH), the Arthritis Society, and many pain management centres and institutes.
Chinese herbs, supplements, and food cures can be used alone or to support acupuncture treatments.
How does TCM treat pain?
TCM doctors have used acupuncture and herbs to treat warriors, martial artists, emperors and empresses, farmers, children, and more for over 5000 years.
The basic premise is that pain is a result of a blockage of the normally smooth flow of Qi through the meridians. Qi is the energy that nourishes every cell, tissue, organ, and system in the body. When it is obstructed, it accumulates on one side of the blockage and is deficient on the other side. One of the symptoms associated with this problem is pain. This pathology can be compared to a hose through which flows water to feed a plant. If there is an obstruction in the hose, the water will not flow smoothly and the plant will wilt. And remember, if any area is damaged, tight, or restricted, it also does not receive proper blood flow, and that impedes full healing.
“If there is free flow, there is no pain;
If there is no free flow, there is pain.”
– Classical Chinese medical text, Nan-Ching,
2nd Century A.D.
Acupuncture relieves pain by moving the Qi. While this is not understood at present by western science, medical research has shown acupuncture to be a safe and effective treatment method for pain.
Acupuncture has been shown to stimulate the production of endorphins (chemicals that block pain), neutralize trigger points, relax muscles, and block the transmission of pain signals to the brain by stimulating competing nerves.
One major benefit to acupuncture as a complementary therapy, is that it can be used safely with other therapies, including pharmaceutical drugs.
Many herbs have been shown to be anti-inflammatory and pain-relieving. A TCM herbalist will choose herbs that move Qi and Blood to relieve pain, and also add herbs to treat the underlying imbalances.
Without proper nutrition our bodies do not heal well. In order to replace and repair damaged cells, specific nutrients need to be available. When they are not, recovery is impaired. In addition, as with the herbal remedies, some foods have medicinal properties, and food recommendations can be made to suit the individual.
What kinds of pain can TCM treat?
Both acute and chronic pain can benefit from TCM treatments.
Acute pain begins suddenly, is short-term, and is usually the result of a specific injury. An example of acute pain is seen in someone who has just sprained his or her ankle. In the event of a recent injury, x-rays can be used to determine if there is a fracture, and ice is usually applied during the first 24 hours to relieve swelling.
Acupuncture and/or herbs can be used to bring down the swelling, relieve pain, and speed healing. The earlier an injury is treated, the faster the recovery.
Chronic pain is generally defined as pain that lasts longer than three months. It can have significant psychological and emotional effects as it may limit a person’s ability to function well.
Chronic pain occurs in about 11-54% (depending on age) of people, and a conventional search for treatment is unsuccessful for many, thus leading to frustration.
Because TCM treats the source of the symptoms, as well as the pain itself, chronic pain is well-treated by TCM’s holistic system.
When I was 12 I was figure skating 4 days a week and taking dance lessons once a week, in addition to the usual play and activities that kids do both within and outside of school. I also occasionally had swimming lessons, diving lessons, and gymnastics lessons. In other words, I was very active. But at that time my knees started to hurt.
They hurt when I ran. They hurt when I skated. They hurt when I rode my bike. And sometimes they hurt just because. So my mom took me to the doctor and then to the physiotherapist. I was diagnosed with bilateral chondromalacia patellae. Simply put, both knees did not have enough cartilage, the cushioning material, underneath my kneecap. That meant that the bones in my knees experienced more friction, resulting in pain.
I went to physio treatment every week for close to a year. The physio used ultrasound and a TENS machine, instructed me to ice my knees regularly, and gave me quad strengthening exercises. He also had me fitted for knee braces and shoe orthotics. I hated it all. Icing my knees for 10 minutes felt like an hour of torture. I regularly left in more pain after physio. The quad strengthening was fine, but actually, as a figure skater, my quads were pretty strong. Shoe orthotics in those days were not nearly as common as they are now. The only running shoes we could find that fit them were Brooks. Big, ugly Brooks. We did the best we could to find regular shoes to fit the orthotics, but I was a pre-teen and definitely NOT going to wear orthopaedic-looking shoes.
The knee braces. Those were the worst part. They were neoprene, supposedly breathable. But the rash at the back of my knees that occurred when I exercised and sweated proved otherwise. Plus, their “skin” coloured tone did not make them invisible.
Through high school and university I kept up my sports and added in more athletic activities, including volleyball, squash, and step classes. I kept wearing the shoe orthotics and the despised knee braces.
When I moved to Japan for a couple of years, I told myself that I didn’t have space to take the knee braces–poor excuse. Ha! I did still suffer knee pain. My main mode of transportation was a bicycle and the pain got so bad one time that I went to the hospital to have them take a look. The doctor there, without even touching or testing my knees, told me to stop riding my bike. That was how I got to work, so I bore through the pain and managed.
Time and again, I rediscovered my “Achilles heel.” I cried in pain most of my way down Mount Kinabalu in Malaysia (walking downhill is very hard on knees), I gave up after just one painful session of road running training for the Vancouver Sun Run, and my knees gave way when I stepped of the bike after my first (and for a long time, only) spin class.
Shortly after returning to Canada I discovered a “new” medicine, Traditional Chinese Medicine. Before even trying out acupuncture, Chinese herbs, or any of the other therapies I now offer, I decided that I would change my path from sports medicine to TCM. In TCM school I received acupuncture and Chinese herbs. I started investigating other ways to help my knees and found that I had very tight hamstrings, so stretched and stretched.
During my 4th year of TCM school I sold my knee braces. Darn. I wish I would have kept them. But not because I want to wear them ever again. Because I’d like to have them as a reminder of where I was and were I am. I will not run distances on the road. But I can run on trail and treadmill and soft surfaces. I can ride my bike. Recently, I even ran down–the dreaded downhill!–Grouse Mountain on my snowshoes. I’m still careful. But, I’m now training to be able to run 10-12 miles on soft terrain for the Tough Mudder this year (2013).
Am I exaggerating? Sadly, no. But many people are taking this class of medications…NSAIDs (Non-Steroidal Anti-Inflammatory Drugs). You might recognize the names as ibuprofen, naproxen, indomethacin, or celexocib.
“Since the mid-80s, more than 300,000 Americans have died of NSAID complications, and 1.7 million were hospitalized.”
NSAIDs can cause gastrointestinal bleeds, actually destroy your joints (though they are often taken for joint pain!), increase cardiovascular risk, and even contribute to erectile dysfunction.
The article details: Healing the NSAID Nation
There are many natural supplements, foods, and treatment alternatives for managing inflammation and pain! Inflammation and pain are major causes of many of the health issues I treat daily. So, if you are taking an NSAID, consider that there are other options!