• Palpatory diagnosis and manipulative management of : 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 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 conduction abnormalities are ment ofthe opposite (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- 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 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 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 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 , and tightness with discomfort in stretching exercise, and manipulation. As symptoms the neck and . Hand symptoms, which were decreased and restriction at the thoracic outlet area rated 7 (on a scale of 0 to 10), had been present for 6 resolved, manipulation was redirected to other involved months on the right and for years on the left. Wrist sites. Within 2 weeks, the patient was having minimal orthoses had been of no benefit. Chiropractic (high-veloc­ symptoms. Physical medicine modalities were discon­ ity) manipulation and physical medicine modalities tinued after 3 weeks. The patient rapidly progressed to helped only minimally. Phalen's test yielded positive independent exercises, including strengthening of the results bilaterally at 15 to 20 seconds. Palpatory restric­ shoulder girdle with elastic bands. tion was noted at the wrists/carpal canals, moderate on the left and mild to moderate on the right, for trans­ Case 2 verse extension, thenar abduction, and lateral axial rota­ A 36-year-old woman, seen in November 1993, had a tion. Cervical range of motion was moderately limited. history of right hand pain, paresthesia, and numbness. Regional stress testing was positive, and palpatory restric­ Symptoms, which were rated 4 to 7 (on a scale of 0 to 10), tion was noted about the scalene and pectoral muscles. had begun 10 years previously. Palpatory examination revealed marked restriction in the right pectoralis minor muscle with restricted Table 2 excursion of ribs 1 through 4 on exhalation, scalene mus­ Results of Nerve Conduction Studies cle restriction on the right, and reproduction of symp­ Before and After Treatment: Case 2 toms with deep palpation of both these muscles (posi­ tive focal stress test result). The regional stress test Nerve Distal motor Amplitude, result was negative. Phalen's flexion test, as well as the and date latency,* ms mV carpal compression test, yielded positive results. The wrist/carpal canal region showed moderate restriction • Median involving transverse extension, thenar abduction, and 1/7/94 3.7 9 (16)t lateral axial rotation. Electrodiagnostic tests showed mild CTS and lower 4113/94 3.4 12 (14)t trunk brachial plexopathy (TOS) (Table 2 ). The latter included mild neurogenic changes (polyphasic motor unit • Uluar potentials, increased firing rate and duration) within 1/7/94 3. 1 10 the right C7ITI myotomes.

Manipulative treatment was directed at both the "Distal motor latencies were all recorded at 8 Clll (to the abductor wrist and the thoracic outlet. Physical medicine modal­ pollicis brevis muscle). ities (with ultrasound) were directed to the cervicotho­ tValue in pru'entheses is for distal-palmru' response. racic region, including the pectoral muscles. Stretching

474 • JAOA • Vol 95 • No 8 • August 1995 Original contribution • Sucher the TOS, based on moni­ Table 3 toring with frequent and Results of Nerve Conduction Studies Before and After Treatment: Case 3 regular palpatory assess­ ment. Nerve Distal motor Amplitude, Distal sensory Amplitude, and date latency,'" ms mV latency,t ms fLV Case 4 When first seen, a 20-year­ • Median old woman had bilateral 12/14/93 3.2 17 2.3 100 upper extremity pain and 2/10/94 ...... 2.3 100 numbness of 2 to 3 months' duration. She had done • Ulnar excessive pottery work with 12/14/93 2.5 8 1.8 70 the wrists extended. Symp­ toms were rated 8 to 10 *DistaJ motor latencies were all recorded at 8 cm (to the abductor pollicis brevis muscle). (on a scale of 0 to 10). Pre­ t DistaJ sensory latencies are all mixed nelve palm-to-wrist responses at 8 cm. vious treatment with anti­ inflammatory medication and rest had been inef­ fective. Table 4 The initial physical Results of Nerve Conduction Studies Before and After Treatment: Case 5 examination revealed a positive Tinel's sign, Nerve Distal motor Amplitude, Distal sensory Amplitude, Phalen's and carpal com­ and date latency,* ms mV latency,t ms fLV pression tests, and decreased pin sensation • Median (RIL) within the median nerve 11126/93 3.3/2.5 1117 2.111.9 100/100 distribution distally. Wrists 3/8/94 3.0/. .. 13!' .. 1.9/1.8 95/150 were restricted mildly at the carpal canals. Palpa­ • Ulnar (RIL) tory restriction was also 11/26/93 .. .12.3 .../8 1.6/1.6 60/30 noted about the scalene 3/8/94 ...... 1.8/1. 7 30/30 and pectoral muscles. The regional TOS stress test *Disk'll motor latencies were all recorded at 8 em (to Ule abductor pollicis brevis muscle). yielded positive results. t DistaJ sensory latencies are all mixed nelve palm-to-wlist responses at 8 cm. In spite of an initial clinical impression of CTS (and TOS), electrodiag­ Focal stress testing results were positive on the left, nostic tests revealed no evidence of median neuropa­ and negative on the right. Electrodiagnostic tests showed thy at the wrists. However, increased insertional activ­ mild CTS on the left only (Table 3). ity and rare positive waves in hand muscles innervated Initially, treatment consisted of manipulation and by the were consistent with mild injury in physical medicine modalities directed to the thoracic the lower trunk of the brachial plexus and therefore outlet region and wrists/carpal canals. The patient supported the diagnosis of TOS. noticed marked improvement after only two manipula­ Treatment was directed solely toward the cervi­ tion sessions. She was stretching the carpal tunnel inde­ cothoracic region and thoracic outlet (especially the pendently, and restrictions at the wrist were decreasing. scalene and pectoral muscles). Marked improvement The carpal canal region was manipulated on only one occa­ was noted (after only one session of manipulation, two sion (the fourth manipulation session out of six) because sessions with physical medicine modalities, and self­ of slight recurrence of symptoms and mild residual stretching). restriction. Stretching exercise was also added for the thoracic outlet region, with subsequent inclusion of Case 5 strengthening (Thera-Band). Bilateral upper extremity pain, tingling, and numbness Nerve conduction studies performed 3 weeks after as well as neck and shoulder pain had been present for the manipulation to the wrist revealed no change. The 3 months in a 34-year-old woman. She had had inten­ primary component of her symptoms, I believe, were sive computer/keyboard activity at work. Primary symp­ due to TOS, with a very mild or minimal CTS component toms in the thumb and palm were rated between 5 and on the left, also accounting for slightly more pronounced 8 (on a scale of 0 to 10). symptoms on that side. In addition, both regional and Tinel's sign was positive, as were the results of focal TOS stress-testing results were positive on the Phalen's test. The carpal canals on transverse exten­ left. Treatment was guided by the primary palpatory sion, thenar abduction, supination, and lateral axial restriction (at the thoracic outlet), and the rapid response rotation showed restriction, moderate on the left and to manipulation and stretching of this region. In spite moderate to severe on the right. Segmental restriction of the confirmed diagnosis of CTS on electrodiagnostic was noted at C71T1 and T51T6 , as well as local restric­ testing, the primary focus of treatment therefore was tion of the scalene and pectoral muscles. The regional

Original contribution • Sucher JAOA • Vol 95 • No 8 · August 1995·475 TOS stress test yielded positive results. Electrodiagnostic tests showed CTS, very mild on the left and mild on the right. MILD" Treatment, begun December Thoracic outlet syndrome 13, 1993, consisted of manipula­ o Mild local palpatory restriction tion and physical medicine modal­ o Negative regional and focal ities, directed to the thoracic outlet stress test results and carpal canal regions (and asso­ o No electrodiagnostic abnormality ciated somatic dysfunction), and o Symptom severity < 4 (on scale included stretching exercise. Pro­ of 0 to 10) gressive improvement was noted, with complete resolution of hand numbness by February 14, 1994. MODERATE" SEVERE*t At that time, treatment to the carpal Thoracic outlet Thoracic outlet canal regions was discontinued syndrome syndrome because restriction had decreased Advanced palpatory to zero on the left and mild on the o Moderate local pal­ o right. Strengthening exercise (with patory restriction • Osteopathic restriction Positive regional the Thera-Band) and posture cor­ o Positive regional or manipulation o and focal stress rection were added subsequently. focal stress test • Self-stretch test results Slight return of hand numbness results o Possible mild I o Possible mild to prompted the limited nerve con­ I electrodiagnostic I moderate duction studies done on March 8, I abnormality I electrodiagnostic 1994, which revealed complete res­ I I o Symptom severity 4 I abnormality olution of CTS (Table 4). As a result, I to 6 (on scale of 0 I o Symptom severity all treatment was focused on the I to 10) I 7 to 9 (on scale of cervicothoracic and thoracic outlet I I I o to 10) regions, again successfully elimi­ I I nating numbness. I Discussion f Double crush syndrome is • Physical medicine • Postural/structural becoming more widely recog­ modalities ------.. correction nized and understood.5 The most • Strengthening exercise • Orthoses common presentation appears to be the combination of TOS and CTS,4-6 with an incidence of 6 Figure 6. Algorithm for treatment of nonprogressive thoracic outlet syndrome . .* Anti-inflam­ up to 45% in some studies. matory medication, muscle relaxers, activity modifications would be used as indicated and This high incidence is proba­ tolerated in all cases. t Values for very severe thoracic outlet syndrome would be greater than bly responsible for the frequent those for severe, and the patient probably would be referred for surgical evaluation. misdiagnosis of CTS and TOS.14,15 Confusion regarding which entity, CTS or TOS, to treat first, particularly regarding surgery, is preva­ sional or rare cases wher e the electro diagnostic test lent.5,6 Treating one site often aggravates the result is positive, as in cases 2 and 4 described other,16 or symptoms persist.17,18 Upton and McCo­ herein. Simply producing an electro diagnostic test mas2 recognized the importance of treating all result positive for CTS does not exclude TOS; in fact, "vulnerable points" along the nerve pathway. This TOS frequently exists concomitantly. view was confirmed subsequently by Nemoto and The cases reported illustrate how the treat­ coauthors,19 whose experimental model showed ing physician used palpation to determine the loca­ that both the distal and proximal compressions tion of most of the clinically significant dysfunction. need treatment. The clinician therefore could precisely target treat­ Most cases of CTS do not occur in isolation. ment, including not only osteopathic manipula­ There is usually some proximal dysfunction, at tion, but physical medicine modalities and exercises least in the upper extremity, if not the cervi­ as well. Case 4 is exemplary in demonstrating the cothoracic region. The presentation of TOS has additional value of palpatory diagnosis, which cor­ been previously described in detail.1 Unfortunately, roborated the electrodiagnostic findings: a rela­ thermography is not widely available for use as a tively unrestricted wrist correlated with the absence diagnostic test; therefore, TOS must be assessed of CTS. The clinician thereby was directed away solely by physical examination, except in occa- from the carpal canal to the site of maximum dys-

476· JAOA • Vol 95 • No 8 · August 1995 Original contribution · Sucher sum of impairment caused by individuallesions,6,19 because MILD' compression at one site renders Carpal tunnel syndrome the axon more susceptible to damage at another.2 D Distal motor latencyt < 4.0 ms Several cases of CTS report­ D Distal sensory latency:!: < 2.5 ms 20 D Palpatory restriction < 3 (on scale ed elsewhere have been treat­ of 0 to 5) ed adjunctively with ion­ D Symptom severity < 4 (on scale tophoresis, particularly when of 0 to 10) the condition is early or mild. In addition, the author has found iontophoresis very useful in sev­ MODERATE' SEVERE'§ eral unreported cases that are Carpal tunnel Carpal tunnel more acute, or severe. The deliv­ syndrome syndrome ery of steroid appears to decrease D Distal motor latency D Distal motor latency any associated inflammatory 4.0 to 5.0 ms 5.0 to 6.5 ms component and so would ren­ D Distal sensory D Distal sensory der the tissue more responsive latency 2.5 to 3.0 ms • Osteopathic latency 3.0 to 4.0 to the manipulative release. By D Palpatory restriction D Palpatory restriction ---.. manipulation decreasing the severity or irri­ 3.0 to 3.5 • Self-stretch 3.5 to 4.0 D Symptom severity tability, the patient may be able D Symptom severity to withstand the vigorous 4 to 6 (on scale of 7 to 9 (on scale of ,,'* stretching maneuvers that pre­ o to 10) , o to 10) ,, D Possible denerva­ viously could not be tolerated. ,, tion on needle elec- Subsequently, ultrasound can ,, tromyogram ,, be initiated in combination with ,, gradually more intense manip­ , ulation and self-stretching, as described in some of the report- ed cases. • Ultrasound treatment • Iontophoresis or In patients with more • Phonophoresis ------~ • Steroid injection advanced CTS, with restricted lateral axial rotation, it is advis- able to initiate the manipula­ tion at the opponens pollicis Figure 7. Algorithm for treatment of nonprogressive carpal tunnel syndrome. "Orthoses, component, because the oppo­ anti-inflammatory medication, activity modifications would be used as indicated and tolerated in all cases. tDistal motor latencies recorded at 8 cm (to the abductor pollicis brevis muscle). nens roll maneuver directly ele­ f Distal sensory latencies are mixed nerve palm-to-wrist responses at 8 cm. §Values for very vates the transverse carpallig­ severe carpal tunnel syndrome would be greater than those for severe, and the patient prob­ ament off the median nerve.7 ably would be referred for surgical treatment. Once this release has been accomplished, the other manip­ function, the thoracic outlet, for the most effec­ ulative maneuvers and stretching are tolerated tive treatment. more easily. Patients 1, 2, 3, and 5 all had level 2 In the patient with this type of double crush (moderate) or greater restriction of lateral axial syndrome (CTS and TOS), physical medicine modal­ rotation. Treatment in those patients included ities should be included routinely with manipulative manipulative release of the carpal canal through the treatment and directed to the thoracic outlet and the muscular attachment of the opponens pollicis to carpal canal. If restriction is mild at one of these the transverse carpal ligament. sites, treatment shoUld be emphasized at the other. Staging the severity of CTS and TOS presents Nonetheless, self-stretching exercise would still be a challenge, but it is especially useful as a treatment appropriate for the site of mild involvement. If guide. In my experience, the degree of TOS is based symptoms do not resolve, intensified treatments at on a combination of local restriction to palpation, mildly involved sites should be attempted. A mild symptom ratings, stress test responses, and elec­ restriction that would be insignificant in isolation trodiagnostic test results. The degree of palpato­ is often significant when it occurs in combination with ry restriction for TOS has not been measured as mild aT greater involvement at another site. This has it has for CTS, so the restriction should be evalu­ been recognized as a key factor in double crush syn­ ated more on a qualitative ("yes-or-no") basis. As the drome, where altered function is greater than the local restriction about the scalene and pectoral

Original contribution • Sucher JAOA • Vol 95 • No 8· August 1995·477 muscles becomes more substantial, it not only is palpable, but the severity becomes reflected in the stress tests. Treatment of TOS remains as explained in pre­ vious reports.1,12, 13 The flow chart in Figure 6 is offered as a supplemental guide for management of TOS. Advanced abnormality on electrodiagnos­ tic tests, severe unrelenting pain, or progressive objectively determined weakness places the case in the severe or very severe category, and suggests the need for surgical evaluation. On the basis of ratings in this chart, cases 2, 3, and 4 fall into the moderate to severe range. Cases 1 and 5 might be considered in the moderate to severe range on the basis of symptoms, but there are no severe objec­ tive TOS findings in these cases. The subjective symptoms most likely approach the severe range because of contribution from CTS. In such cases of double crush syndrome, more extensive treat­ ment may be indicated than would be suggested by the flow chart. Experience with various degrees of CTS using combinations of treatment including manipulation, stretching exercise, medication, orthoses, ultra­ sound, and iontophoresis resulted in the treatment flow chart in Figure 7. As with TOS, this algorithm is simply a suggested guide, based on a history of cases demonstrating rapid improvement of CTS, with or without concomitant TOS. The severity ratings and their use in the flow chart are most accurate when the CTS occurs in isolation with­ Figure 8. Pectoral muscle (greater and smaller) wall stretch out TOS. However, when TOS is also present, the for thoracic outlet syndrome. Patient leans forward at the hip (on addition of physical medicine modalities may be the bent knee) and the arm and shoulder girdle are pulled back ­ more useful with even mild involvement. ward. Caution is necessary to protect the lower back from hyper­ According to the rating system in Figure 7, on extension. the basis of nerve conduction studies only, all the cases, the patient will have to limit the amount of cases ofCTS (1, 2, 3, and 5) would be considered mild. body weight applied or use a more open and relaxed The more advanced palpatory restriction, howev­ grip. An alternative technique involves using a er, would place cases 1 and 5 into the mild to mod­ wall (Figure 8). This method stretches both the erate range. Symptoms could suggest the more greater and smaller pectoral muscles without requir­ severe categories for all of these cases, but TOS ing any grasping or flexion, thereby mini­ probably contributes to some symptoms. Cases of mizing stress to the carpal canal. CTS that are severe to very severe or progressive Another concern is that in cases of bilateral and unresponsive to treatment within 2 to 4 weeks CTS, patients may have little tolerance for stretch­ should be referred for surgical evaluation. ing one side with the other, symptomatic side. The These guidelines are similar to other recent one-arm technique described here (Figure 2 ) has suggestions by the American Academy of Neurol­ been developed to accommodate this situation. This ogy21 but are more aggressive with the nonsurgical method has the advantage of sparing the opposite approach. The Academy recommends noninvasive hand. treatment as long as there is no progression of Finally, it should be remembered that one or more motor or sensory deficits or severe electrodiagnos­ of several other potential sites of nerve injury may tic abnormality. The suggested duration of treatment 21 coexist with CTS or TOS (or both). Careful clinical is up to 6 months. examination and electrodiagnosis will help to iden­ Clinicians must also be aware of the patient tify such disorders.22 with combined CTS and TOS who will be unable to tolerate the overhead-bar technique for stretching Comment the smaller pectoral muscle, because of the grip­ Cases of upper extremity nerve compression may ping required with the CTS-involved hand. In these have a component of both CTS and TOS present.

478 ' JAOA • Vol 95 • No 8 ' August 1995 Original contribution' Sucher Therefore, it may be difficult, if not impossible, to nel syndrome: Documentation with magnetic resonance imag­ treat CTS if the clinician is unskilled at diagnosis ing. JAOA 1993;93:1273-1278. and treatment of TOS. Palpatory assessment has 10. Lehmann JF, DeLateur BJ: Therapeutic heat, in Lehmann a vital role in the clinical evaluation and manipu­ JF (ed): Therapeutic Heat and Cold, ed 3. Baltimore, Md, Williams & Wilkins, 1982, pp 404-562. lative management of patients with CTS and TOS. 11. Lee MHM, Itoh M, Yang GW, et al: Physical therapy and Awareness of the specific location and degree of rehabilitation medicine, in Bonica JJ: The Management of Pain, restriction noted on palpation helps to determine ed 2. Philadelphia, Pa, Lea & Febiger, 1990, vol 2, pp 1769- which site is responsible for producing upper extrem­ 1788. ity symptoms. Such awareness helps the clinician 12. Sucher BM: Thoracic outlet syndrome-A myofascial vari­ focus manipulative and other treatment on the pri­ ant: Part 2. Treatment. JAOA 1990;90:810-823. mary pathologic sites. 13. Sucher BM, Heath DM: Thoracic outlet syndrome-A myofas­ cia 1 variant: Part 3. Structural and postural considerations. JAOA 1993;93:334-345. Acknowledgment 14. Hirsh LF, Thanki A: The thoracic outlet syndrome: Meet­ Appreciation is expressed to Eugenia F. Sucher, Execu­ ing the diagnostic challenges. Postgrad Med 1985;77:197-207. tive Director, Center for Carpal Tunnel Studies, for edit­ 15. Wood VE, Twito R, Verska JM: Thoracic outlet syndrome: ing assistance. The results of first rib resection in 100 patients. Orthop Clin North Am 1988;19:131-146. 16. Carroll RE, Hurst LC: The relationship of thoracic outlet syn­ drome and carpal tunnel syndrome. Clin Orthop Rel R es References 1982;164: 149-153. 1. Sucher BM: Thoracic outlet syndrome-A myofascial vari­ 17. Golding DN: Brachial neuralgia and the carpal tunnel syn­ ant: Part 1. Pathology and diagnosis. JAOA 1990;90:686-704. drome. Br Med J 1968;3:803. 2. Upton ARM, McComas AJ: The double crush in nerve-entrap­ 18. Hurst LC, Weissberg D, Carroll RE: The relationship ofthe ment syndromes. Lancet 1973;2:359-362. double crush to carpal tunnel syndrome (an analysis of 1,000 cases 3. Leffert RD: Thoracic outlet syndromes. Hand Clin 1992;8:285- of carpal tunnel syndrome). J Hand Surg 1985;10-B:202-204. 297. 19. Nemoto K, Matsumoto N, Tazaki K, et al: An experimental 4. Osterman AL: The double crush syndrome. Orthop Clin North study on the "double crush" hypothesis. J Hand Surg 1987;12- Am 1988;19:147-155. A:552-559. 5. Wood YE, Biondi J: Double-crush nerve compression in tho­ 20. Banta CA: A prospective, nonrandomized study of ion­ racic-outlet syndrome. J Bone Joint Surg 1990;72-A:85-87. tophoresis, wrist splinting, and antiinflammatory medication in 6. Narakas AO: The role of thoracic outlet syndrome in the the treatment of early-mild carpal tunnel syndrome. J Occup Med double crush syndrome. Ann Hand Surg 1990;9:331- 1994;36:166-168. 340. 21. American Academy of Neurology, Quality Standards Sub­ 7. Sucher BM: Palpatory diagnosis and manipulative manage­ committee: Practice parameter for carpal tunnel syndrome ment of carpal tunnel syndrome. JAOA 1994;94:647-663. (summary statements). Neurology 1993;43:2406-2409. 8. Sucher BM: Myofascial release of carpal tunnel syndrome. JAOA 22. Mackinnon SE: Double and multiple 'crush' syndromes: 1993;93:92-101. Double and multiple entrapment neuropathies. Hand Clin 9. Sucher BM: Myofascial manipulative release of carpal tun- 1992;8:369-390.

Original contribution • Sucher JAOA • Vol 95 • No 8· August 1995 • 479