1:1 m m I I m

Scalene entrapment syndrome m CD by James 0. Royder, DO, FAA() m

ver the years, a continuing diagnostic and thera- When the Tinel's Sign and the Phalen's Test are both peutic dilemma is presented by the large number negative, one can usually rule out a mononeuropathy of 0 0 of patients who present with cervical the ulnar or radial nerve, such as Carpal Tunnel, Guyon radiculopathy without positive neurological findings and Tunnel or Tardy Ulnar Palsy syndromes. When the a negative MRI. Muscle spasms, rigidity, restriction of Scalene-cramp Test' evokes a pattern of referred pain range of motion are the presenting objective findings, down the upper extremity, it suggests entrapment of the while neck pain, headaches, light headedness. along with brachial plexus by the scalene muscles. In performing this pain and "tingling" in the shoulder, arm and hand are the test, the patient rotates the head toward the painful ex- initial subjective complaints. tremity and then pulls his chin down into the supraclav- The patient's history will usually reveal some type of icular fossa..this causes the scalene muscles on that side traumatic event preceding the onset of these symptoms. to contract and will exaggerate the referred pain if the In some cases, the symptoms develop insidiously over a scalenes are involved. period of time. A series of continuous, repetitive traumas The Scalene-relief Test' is a quick way to check to see can produce the same damage. Initially, we must rule out if the scalene muscles are involved. With the patient in cervical disc disease. Without a history of trauma, a tradi- the supine position, the affected forearm is brought up tional 7 view study of the cervical spine is in order. With and laid across the forehead. If the scalene muscles are a history of a rear end motor vehicle accident, a Davis x- involved this will quickly relieve the pain. In this posi- ray study should be ordered to include an AP, three lateral tion. the tightness of the scalene muscles are relieved be- views: in the neutral position, with the neck hyperflexed. cause the clavicles and first rib are elevated, thereby re- and with the neck hyperextended. The study is completed lieving the pull of the scalene muscles. with a right oblique, left oblique and open mouth view of The Finger-Flexion Testa is another helpful test. In this the odontoid. test the fingers are fully extended at the metacarpopha- Cervical ribs are occasionally found that greatly com- langeal joint. The patient is asked to actively flex the fin- plicate the picture. Elongated transverse processes of C-7 gers at the proximal phalangeal joint in order to press the often can signify the presence of a ligamentous structure pads of his fingers to his palm. The test is positive for capable of entrapment of the Subclavian Artery and Vein involvement of the scalene muscles if all of the fingers along with the Brachial Plexus. Both the cervical rib and are unable to completely flex. A positive test is indicated the atypical ligament can produce a Thoracic Outlet Syn- by incomplete flexion of all fingers indicating a more gen- drome. eral involvement of the extensor digitorum muscles, which The classic symptoms that gives one a clinical indica- occurs when scalene trigger points are active on the same tion that the Scalene muscles might be entrapping the Bra- side. chial Plexus is pain radiating into the forearm and hand, In taking a history of a rear end automobile injury (whip- along with dysesthesia. Pain can be on both the radial and lash), it is my custom to make every effort to determine: ulnar side of the hand. More often the pain is on the radial the axis of the force vector hitting the automobile; what side of the forearm with dysesthesia on the ulnar side. If was the posture of the patient at time of impact; were seat the situation has been long standing there is usually edema belts on; and the position of the head at the moment of of the ulnar side as well as motor involvement. The edema impact. In this way, one can begin to conceptualize the and swelling is due to venous congestion and lymphe- direction of the energy force that went through the body dema due to the entrapment. -4

Fall 1998 AAO Journal/25 in order to understand the dynamics of poral bones which would suggest a the forces on the anatomical structures cause for tinnitus, vertigo, hearing dis- injured. turbance, balance disturbances, TMJ Extreme tenderness in the Scalene dysfunction, ear pain, light headedness, triangle is a strong indication of swallowing hesitation. and other trou- myotascial pain involving the scalene bling symptoms related to the Tempo- muscles. The scalene triangle is the V ral bone malalignment. shaped space between the anterior and Usually the base of the skull is most medial scalene muscles and their at- often affected with cervical trauma be- tachment to the clavicle interiorly. cause all of the strap muscle of the neck Careful palpation of the scalene originate on the Occipital, Temporal, muscles will reveal trigger points in and anteriorly, on the Mandible. The these structures with radiations of pain ligamentous structures of the jaw are into the shoulder arm and hand. Vari- particularly vulnerable. The Spheno- ous referral patterns are found depend- mandibular ligament, Stylo-mandibu- ing on the muscles involved. Scalene Tr lar ligament. Tempero-mandibular liga- The initial exam includes a careful ment. Lateral Ptergoid muscle, Stylo- palpatory examination of all of the cervical and upper tho- hyoid muscle and Digastric muscle are structures which racic structures including the Scalene Triangle Thoracic are integral to the integrity of the Cranio-cervical region. Outlet and Thoracic Inlet, supraclavicular spaces, in- The Masseter and Temporal muscles will be involved as cluding Sibsons Fascia ( the floor of the supraclavicular well. This explains the frequent involvement of the TMJ fossal, distortions of the clavicle, carotid pulses, thyroid dysfunction in whiplash- type injuries. gland. lymph glands and an y tightness or imbalance of An MM or CT is not indicated if there are no positive the muscles attaching to the Hyoid hone. neurological findings. A course of conservative therapy is The Thoracic Outlet is a slit like opening whose bound- initiated with ice massage. ice packs. gentle massage, Jones aries are: the clavicle superiorly. the first rib inferiorly, Counter Strain OMT to the affected muscles. Physio- medially is the junction of the first rib that goes under the therapy will include Ultra sound and gentle stretching to clavicle. The Lateral boundary is the head of the humerus the affected areas. Immobilization with a cervical collar and proximal end of the scapula. The Thoracic Inlet is will assist in reminding the patient to keep correct pos- described as the space bordered by the clavicles and manu- brium anteriorly and the scapula and trapezius posteri- orly. The Sibsons fascia occupies the space in the supras- capular fossa. It is through the Thoracic Inlet that all of the venous blood and lymphatic drainage from the face, neck and cranium into the thorax takes place, thus the term Inlet is used. The Thoracic Outlet Syndrome needs to be tested for by using the Adson maneuver. The Coasclavicular Syn- drome is next checked for to rule out compression of the neurovascular bundle between the clavicle and the first rib by having the patient assume an exaggerated military "attention: or "brace" position with his shoulders pulled back and downward. Next one must check for shortening Thoracic Outlet of the Pectoralis minor muscle which can also produce compression of the neurovascular bundle to upper extrem- ity as in the Hyperabduction Syndrome. Neural entrapments of th y upper extremities to be evalu- ated for are: the Cubital tunnel, Carpal tunnel, Guyon tunnel, and at the mid-forearm. the Pronator Syndrome. All of these entrapment syndromes produce quite a mix- ture of similar and related symptoms with radiculopathy traveling both distally and proximately. Thoracic Inlet Cranial exam must search for any restriction of the tern- 26/AAO Journal Fall 1998 ture. Traditionally we prescribe an anti-inflammatory and anterio-lateral cervical musculature. All of the muscles agent, either an NSAIDs or a Medrol Dosepak. Analge- work in an orchestrated harmony. Agonist fibers contract- sics and muscle relaxants tend to be helpful early on. They ing as antagonist fibers relax, each with an equal speed are seldom necessary after 2-4 weeks. Some muscle re- and intensity to give a smooth action. Following a trauma, laxants such as carispridol, have a tranquilizing and eu- this smooth orchestration is totally disrupted...so the com- phoric effect, thus, have a tendency to be abused, so I puter freezes up. In a protective response. the muscles never use this one. We have several others to use that do surrounding the injured muscles splint up to brace and not have this abuse potential. All medication refills should protect the injured muscles from further injury. This splint- be closely monitored and changed often. If a patient ing can be neurologically maintained for an overly exces- "likes" a medication, change it, so that they do not be- sively period of time, longer than the time it is actually come accustom to it. A patient is not supposed to "like" a needed. medicine...thats why "medicine should taste bad: Cervical trauma reflexsively involves all of the mus- culature. Posteriorly: the Trapezius. Semispinalis capi- tier one week of conservative therapy, some salu- tis, Splenius capitis, Splenius cervicis. Longissimus capi- tary benefits should be clinically obvious. The tis, the Rotatores, Cervical multifidi, Thoracic multifidi. A patients neurological status must be followed the Occipital and Suboccipital are all involved to varying closely and repeated on each follow-up visit. If no im- degrees. Anteriolaterally: the Scalenus anterior, medius, provement is seen and/or new neurological sign develop. minimus and posterior muscle masses along with the Ster- then an MRI would be indicated. An EMG should not be nocleidomastoid muscles are injured and react accordingly done for 6-8 weeks followin g an injury to be useful. to the trauma sustained by each group. Anteriorly: the When the MRI fails to reveal a HNP, fracture, or dislo- Omohyoid, Stereo-hyoid, Sterno-thyroid. My lolivoid, cation. then we can be certain of the diagnosis of soft tis- Thyrohyoid, Hypoglossus. the Digastric muscles. Genio- sue injury producing myositis caused by the sprain and hyoid. and the Longus colli muscles are all involved. strain and a resulting Somatic Dysfunction. With the neu- Travel has given us an excellent description of this rological exam remaining negative and a negative MRI, troublesome malady. Once the causative etiology is rec- we can be confident that a conservative regimen of therapy ognized it is not difficult to design an effective treatment should be continued. plan. First a ruptured cervical disc, Spinal Stenosis. Fora- One should strive to develop the linguistic skill to un- men Stenosis and Facet disease must be excluded in the derstand the descriptive terms the patient uses in describ- differential diagnosis process. Perhaps a Therapeutic Epi- ing their symptoms. In the patients vernacular, the pa- dural Steroid Instillation (TES) or a direct referral to a tient may call a radiculopathy a "shooting pain" or a neurosurgeon would be indicated. "numbness" of the hand or arm. When the word "numb" The diagnosis of Scalene Entrapment Syndrome can is often used, they never seem to mean "the absence of usually be made during a careful history and physical ex- feeling: On the contrary. the meaning they are trying to amination. As Travel has stated, entrapment of the lower convey is an abnormal and uncomfortable, strange sensa- trunk of the brachial plexus affects nearly all fibers of the tion or feeling. What they are describing is a dysesthesia ulnar nerve and some fibers of the median nerve. As the and not an anesthesia where there is an absence of sensa- brachial plexus is formed by the cervical spinal nerves of tion... which the word "numb - would indicate. C-5, 6, 7. 8, T-l. it emerges between the anterior and When the patient is questioned more carefully . they middle scalene muscles. Any tightening, shortening or usually reply... "a tingling feeling, or stinging feeling...like spasm of the scalene muscle groups can produce entrap- the arm has been asleep (with the blood cut oft) and is ment of the brachial plexus. The symptoms produced by waking up again." So we must carefully question the pa- this impingement is tingling, numbness, and dysesthesias tient to make sure we understand the meaning the patient of the ulnar distribution of the hand. In addition patients is trying to convey because the colloquial meaning of cer- may demonstrate sonic hypoesthesia to light touch, pin tain words and terms and words can vary widely. prick, and temperature changes in the little finger. Sonic With cervical sprain and strain, the entire cervical re- edema of the hand may be present as due to reflex sup- gion sustains the trauma. Seldom is only a singular muscle pression of the peristaltic contractions of the lymph ducts group involved. All of the cervical musculature respond produced by the impingement." in a reflexive manner through a complex network of neu- A chronic impingement on the scalene muscle group rological interrelationships shared through reciprocal in- can cause elevation of the first rib producing compres- nervation, interneuronal innervation and internuncial sion of the space between the clavicle and the first rib. connections. This unique and complex agonist-antagonist This produces compression of the Subclavian Artery. relationship exists between the anterior, lateral, posterior

Fall 1998 AAO Journal/27 Venous stasis can also become a part of the problem as slumping his upper back, neck, and shoulders producing well. The autonomic nerves are entrapped as well and can the equivalent chronic strain. produce a Reflex Sympathetic Dystrophy (RSD), such as The main reason I felt a pressing and urgent necessity Shoulder Hand Syndrome. to develop extra expertise in this area, is because I re- cently had three patients with chronic scalene entrapment. he anatomy of the Scalene muscles is very inter I had worked diligently on them with physical therapy, esting and deserves attention in order to understand counterstrain OMT, medications, facet blocks, TESIS, T these confusing, overlapping and closely related orthopedic consultations and neurosurgical consultations. syndromes. The anatomy is: The neurosurgeon confirmed the diagnosis and referred two of the patients to a plastic surgeon who performed an 1. The Scalene Anterior: originates from the anterior innovative surgical procedure which consisted of tubercles of the transverse processes of C-3-6. It inserts dissecetion of the brachial plexus and translocating fat pads onto the scalene tubercle on the inner boarder of the first in between the trunks of the brachial plexus. Six weeks rib. Nerve supply is the anterior branches of C-5.6. 8 after the surgery no noticeable improvement was gained. mainly. Arterial supply to the scalene muscles are branches I was determined that the outcome of third patient would of the Ascending cervical artery that comes off the infe- he better. The following is the treatment regimen I devel- rior thyroid artery. oped for the third patient. no surgery was necessary after his pain improved. 2. Scalene Ali:dins: originates from the posterior as- pect of the transverse processes of C-2-7 and inserts onto reatment Plan for the Scalene Entrapment Syn the upper surface of I st rib posteriorly. Nerve supply pos- drome consists of a varying combination of the terior branches of the anterior primary rami of 3rd 4th T following: Jones Counter Strain (muscle shorten- cervical and lateral muscular branches of 3rd and 4th cer- ing, balancing. holding until release). Myofascial release, vical. Arterial supply is branches of ascending cervical Ultrasonic sound with electro-muscle stimulation and hot artery. packs, postural correction. Fluro-methane Spray and stretch, trigger point injection. anti-inflammatory medi- 3. Scalene Posterior: originates from the posterior tu- cations. massage therapy, postural management. EMG bercles on the transverse processes of the C-4, 5. 6. It biofeedback, home stretching exercises, and when pos- inserts onto the outer surface of the second rib behind and sible an ergonomic inspection and evaluation of his/her some times the third rib. All of the scalene muscles are work place. innervated by branches of the anterior primary division Counter Strain treatment of the Scalenus Medius of the spinal nerves C-2 through C-7. The arterial supply Muscle consist of sidebending the neck to the affected is branches of the ascending cervical artery as above. side while palpating the S. medius muscle. At usually 35- 45 degrees, the palpating finger will feel the muscle be- 4. Scalene Mimimus: originates from the anterior tu- ginning to relax and gently begin to perceive a happy, bercle of the transverse process of C-7 and sometimes C- warm. pulsatile feeling. Next the head and neck are gen- 6, passing behind and beneath the subclavian artery and tl y rotated toward from the side 10-15 degrees at which before it attaches to the inner hoarder of the first rib. In- point the operator \\ ill perceive an even greater feeling of sertion onto the pleural dome or cupola, which is muscle relaxation, quiet pulsation which the operator rec- strengthened by the Sibsons fascia which is anchored by ognizes as the balance point. The position is held in this this fascia to the anterior tubercle of C-7 and the inner position of balance for at least 90 seconds. Then the head boarder of the first rih. This muscle further reinforces this and neck can gently be returned to their normal anatomic fascia. position. The Scalenus Anterior Muscle can he balanced in There are several causes of chronic strain of the a similar manner by first flexing the head and neck for- scalene musculature that contribute to the Scalene Entrap- ward 40-45 degrees until muscle relaxation and pulsation ment. Postural considerations must be considered. One is perceived. Then rotate the head and neck away from who always lets his shoulders roll forward and head jut the side of involvement. Again arriving at the position of forward will have a continuous strain on his cervical strap optimum muscle balance as identified by the quality of muscles. One who reads, studies, or watches TV in im- muscle relaxation and "happy pulsating" feeling. proper positions can produce the same chronic strains The patient is carefully coached and instructed on pattern. Tall people (64") who work in an ergonomic en- how he can perform self treatment at his home and at work. vironment meant for a 58" person will continuously be The patient is instructed to monitor his posture on a hourly 28/AAO Journal Fall 1998 basis, at a minimum. The patient must be continuously tional types of Osteopathic Manipulation. In the subacute seeking the position of comfort by a continuing an on- phase, passive motion is initiated. Counterstrain Osteo- going process of postural assessment and adjusting his pathic Manipulation, reduction in analgesics. spray and posture. Passive stretching exercise areas are also taught stretch, postural instructions, self-treatment and self- as another home self help tactic. Through this behavioral stretching is taught. Teaching proper breathing. self-re- modification, the patient's old maladaptive posture is re- laxation, and meditation are helpful at this point. If the placed by proper posture. The patients symptoms just fade treatment plan is started early and assertively, there is a into the past. good chance that the condition will not progress to the The third patient referred to previously, never had his chronic stage. We often do not get the patient at the on surgery and his disabling symptoms faded away. In his set of his/her injury because they pursue self-help or from case, it was fortunate in that the psychologist on his case other health care providers before we see them. Often they had been trained in EMG biofeedback. He went to his are already in the chronic stage when we first see them. In work place, placed EMG electrodes on his scalene and this case we must first win their confidence and trust. Here trapezius muscles and demonstrated on the computer is certainly a place for functional OMT. High Velocity/ screen how the muscles reacted adversely when he per- Low amplitude (HVLA) thrusting often startles and alarms formed certain tasks. They were able to refine the manner the patient who is unaccustomed to it or unprepared for it. in which he performed certain tasks so that he would not Often they have already had that form of treatment from cause the muscle excitation he usually experienced while their local Chiropractor and seek something more. performing the same tasks. The computerized monitor provided graphic and immediate display on the monitor, n the chronic phase, it is unwise to use analgesics giving the patient immediate feedback of the benefit of other than NSAIDs, ASA, or acetaminophen. Darvon using the improved methods at work. This patient was / and Fiorinal type products do have mind altering af- able to apply this newly gained postural knowledge and fects that can and do become habituating. Muscle relax- apply it to his daily activities of living. ants such as Soma (carisoprodol) is very habit forming and commonly abused. Do not get caught in that trap. Summary Document the over the counter drugs (OTC) the patient is In the comprehensive management of the patient with taking. Be sure to inform the patient that 2000 mg/d of chronic pain, a careful history and thorough physical ex- Tylenol is toxic to the kidneys and liver over a period of amination is paramount to effective diagnosis. Only with time. an accurate diagnosis can an appropriate treatment regi- Ibuprofen can also be toxic. Ask any Nephrologist, and men be designed. A structural exam along with a gait analy- he will tell you that 75 percent of the patients on kidney sis is necessary to identify any biomechanical problems. dialysis is due to the toxic effects of Tylenol or NSAIDs. Biomechanical problems such as sacral base unleveling, The chronic stage patient is already deconditioned from short leg, small hemi-pelvis, flat feet, pronation of foot, long periods of inactivity, so a reconditioning program other foot problems. and gait dysfunctions must be cor- has to be instituted, postural instruction, along with be- rected initially for the other body corrections to hold. Oth- havioral modification, relaxation therapy, meditation train- erwise these dysfunctions will negate any positive progress ing, home exercise program. no narcotics, withdrawal of and disappointing results will follow. all OTC analgesics, caffeine, nicotine, alcohol, fast foods. Ideally, a treatment regimen anticipates that the re- colas, and high sugar convenience foods. If they do not sults of the treatment will last or hold until the next treat- have the will power to do these things, they will fail and ment so that each succeeding treatment builds upon the you will be blamed. preceding one. The patient's condition should progres- sively improve with each treatment until no further treat- References: ments are necessary. In order for this to occur, a portion I. Travel JG Simons DG: Myofascial Pain and Dysfunction. The of each treatment must hold in order for the stepwise heal- Trigger Point Manual. Williams Wilkins: (pg 344-366).

ing process to be possible. Dysfunctional gait. bad body 2. IBID: (pg 351) biomechanics and poor posture can destroy the most bril- liantly conceived treatment plan. 3. IBID: (pg 351-2) In the acute phase, pain, inflammation and muscle 4. spasm must be ameolated as rapidly as possible, utilizing IBID: (pg 353) immobilization, ice, triggerpoint injection, analgesics, anti- 5. IBID: (pg 357) inflammatories, muscle relaxants. and gentle. finesse func- 5. IBID: (pg 357).0 Fall 1998 AAO Journal/29