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And Thoracic Outlet Syndrome

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And Thoracic Outlet Syndrome • Palpatory diagnosis and manipulative management of carpal tunnel syndrome: Part 2. 'Double crush' and thoracic outlet syndrome BENJAMIN M. SUCHER, DO 1( The physician treating carpal nificant. Ultimately, palpatory assessment was tunnel syndrome needs to be aware of the instrumental in guiding the author with initial or possible concomitant occurrence of thoracic subsequent methods (or both) of effective treat­ outlet syndrome, the so-called double crush syn­ ment. Palpatory monitoring was the key to clinical drome. Palpation is used to differentiate carpal management in all cases. tunnel syndrome from thoracic outlet syn­ drome. Such palpatory examination assists Methods the physician in planning the initial treat­ Patients with CTS were assessed as previously described.? ment, including osteopathic manipulation They all underwent electrodiagnostic testing, which and self-stretching maneuvers, targeted specif­ included a minimum of median and ulnar distal motor ically at the most clinically significant patho­ and sensory conduction studies. Needle electromyograms logic region. Supplemental physical medicine and more extensive conduction studies were also per­ formed if not done previously, or as clinically indicated. modalities such as ultrasound may enhance They were treated according to the outlined protocols the treatment response. Some illustrative for osteopathic manipulation and self-stretching exer­ cases are reported. cises.B,9 Palpatory assessment routinely included axial rota­ (Key words: Carpal tunnel syndrome, osteo­ tion. When restriction was noted for this motion, treat­ pathic manipulation, thoracic outlet syn­ ment included the "opponens roll"? technique. As a drome, double crush syndrome) self-stretch maneuver, the thumb is abducted with slight extension and rotated laterally (Figure 1). The primary The initial presentation of carpal tunnel syn­ limitations or precautions to this new self-stretch involve advanced degenerative changes in the first carpometacarpal drome (CTS) often is a diagnostic challenge, espe­ joint and bilateral CTS. With bilateral disease, place­ cially when nerve conduction abnormalities are ment ofthe opposite hand (performing the stretch) in a very mild and symptoms include the fifth digit. position that challenges the carpal canal could aggra­ Thoracic outlet syndrome (TOS) presents a similar vate the CTS on that side. To accommodate such cases, challenge, but in addition has been controversial,l a modified one-arm technique was developed (Figure 2). even when findings are obviously related to a prox­ Several of the patients with CTS (cases 1,3, and 5) imal, plexus location. In short, CTS and TOS often underwent the application of ultrasound (Figure 3), occa­ have a similar presentation, which not only con­ sionally with phonophore sis. Therapeutic ultrasound fuses the clinician but also may lead to incorrect or increases the extensibility of "tight structures,"lO,ll and ineffective treatment. When these entities occur thereby augments various forms of treatment, includ­ ing stretching and range of motion. Maximal effect occurs together, the result is commonly known as double within 10 to 15 minutes after the application, so stretch­ crush syndrome,2.6 which may complicate not only ing and manipulation were performed immediately after diagnosis but treatment as well. 3 ultrasound. It is important to avoid the center of the This study examines several cases of pain, carpal canal, because direct heating of the median nerve numbness, or tingling in the hand that were diag­ could lead to increased inflammation and aggravate the nosed initially as CTS. In some cases, the patient condition. 1o Instead, the ultrasound was directed "around" also had TOS, and those cases could have been the canal, along the edges, to include the thenar muscle labeled double crush syndrome, but either the CTS mass and the medial and lateral sections of the transverse or the TOS was determined to be clinically more sig- carpal ligament (Fig ure 3). Patients with TOS were assessed by visual inspec­ Correspondence to Benjamin M. Sucher, DO, Medical Direc­ tion and palpation for restricted motion.1 Diagnostic tor, Center for Carpal Tunnel Studies, 10555 N Tatum, Suite tests, as necessary, were obtained to rule out other dis­ A-104, Paradise Valley, AZ 85253. orders. In addition, they all underwent electrodiagnos- Original contribution· Sucher JAOA • Vol 95 • No 8 · August 1995·471 Figure 1. The "opponens roll" self-stretch technique of lateral axial rotation stretches the opponens pollicis muscle. Relaxed position (left) and maximum stretch (rotation position (right). Figure 2. One-arm technique for carpal tunnel syndrome stretch. Patient slowly leans forward at the hip to increase intensity of stretch (left). For optimal effectiveness and tolerance, positioning is fine-tuned by moving the hand and forearm up or down, right or left, or rotated (pronation-supination). Close- up (right) illustrates maximum stretch. Figure 3. Application of therapeutic ultrasound for the treatment of carpal tunnel syndrome. Central (median nerve) portion of the canal is avoided by treating hypothenar mass ( medial portion of transverse carpal ligament (left) and thenar mass ( lateral portion of the ligament (right). 472 · JAOA • Vol 95 • No 8 · August 1995 Original contribution · Sucher Figure 4. Scalene regional (left) and focal (right) stress tests for thoracic outlet syndrome. Both tests can be easily combined to enhance the "stress" effect (may be helpful in mild cases). Figure 5. Pectoral regional (left) and fo cal (right) stress tests for thoracic outlet syndrome. tic tests, which included more proximal conduction stud­ sidered as "regional," in contrast to an alternative "focal" ies than necessary for CTS evaluation. Primary confir­ stress test (Figures 4, right and 5, right), which involves mation of diagnosis, however, involved direct palpation applying direct pressure over the scalene or pectoral site of the scalene and pectoral regions, or stress testing for 10 to 15 seconds in an attempt to reproduce symptoms. (Figures 4 and 5). The assessments were performed with Regional stress testing would include the Adson's, cos­ the patient seated, supine, or in the lateral decubitus toclavicular, and hyperabduction maneuvers. position. Direct palpation over the anterior and middle Patients with positive results on any of the motion scalene muscles identifies muscle tone and tension in tests were treated for the restrictions noted as well as for the static position initially. Then, motion is introduced postural and structural abnormalities.12,13 Treatment by the clinician's sidebending and extending the patient's included physical medicine modalities such as ultra­ head to assess for local restriction during the maneu­ sound, hydrocollator packs, and electric muscle stimulation. ver. The same was done for the smaller pectoral muscle, Some patients were also instructed in posture correc­ by the clinician's palpating under the greater pectoral mus­ tion and shoulder girdle strengthening exercise with use cle, or using direct anterior palpation through the more of elastic bands (Thera-Band, Hygenic Corp, Akron, superficial muscle. 12 Motion testing was carried out by Ohio).l3 retracting the shoulder girdle or extending and abduct­ ing the arm (or both). Stress testing for each site involved Reports of cases taking the motion testing to the maximum limit of tol­ Case 1 erance and holding for 30 to 60 seconds, or until symp­ A 43-year-old woman was first seen with right upper toms developed that reproduced the primary complaint. extremity pain and paresthesia consistent with CTS and This stress test (Figures 4, left and 5, left ) could be con- TOS, apparently caused or aggravated by keyboard activ- Original contribution • Sucher JAOA • Vol 95 • No 8 · August 1995·473 Table 1 Results of Nerve Conduction Studies Before and After Treatment: Case 1 Nerve Distal motor Amplitude, Distal sensory Amplitude, and date latency,* ms mV latency,t ms fLV • Median 1/18/94 3.6 14 2.3 70 3/9/94 3.1 16 2.2 100 • Uluar 1/18/94 2.6 11 1.7 50 *Distal motor latencies were all recorded at 8 cm (to Ule abductor pollicis brevis muscle). t Distal sensory latencies are all mixed nerve palm-to-wrist responses at 8 Clll. ity at work. Symptoms were rated 3 to 7 (on a scale of 0 exercise included the thoracic outlet and carpal canal. As to 10). symptoms decreased, restriction at each site also dimin­ The regional stress test results were positive for ished. Because of residual restriction and mild symp­ TOS. The carpal compression test as well as Phalen's toms, treatment continued on both regions, and the flexion test (at 10 seconds) yielded positive results. Pal­ patient was encouraged to stretch the wrist (carpal canal) patory assessment revealed moderate to marked restric­ and thoracic outlet. Physical medicine modalities were tion on transverse extension, thenar abduction/exten­ discontinued after 6 weeks, whereupon the patient pro­ sion, and lateral axial rotation at the right wrist. Restriction gressed to independent exercise. was also noted about the pectoral muscles and scalene region. Electrodiagnostic tests showed mild CTS (Table 1). Case 3 Treatment was directed at both the wrist and tho­ A 76-year-old woman was first seen with paresthesia, racic outlet regions with physical medicine modalities, numbness of the hands, and tightness with discomfort in stretching exercise, and manipulation. As symptoms the neck and shoulders. Hand symptoms, which
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