ATTENTION!!! The physician responsible for the patient’s treatment must be informed of the medical massage protocols that will be used in manual therapy, and the practitioner must obtain the physician’s permission prior to the initiation of such therapy. 

This video is a presentation of the medical massage protocol in cases of Anterior Scalene Muscle Syndrome/Thoracic Outlet Syndrome. It is based on scientific publications reviewed in Medical Massage, Volume I. Please refer to pp. 195-209 of the Medical Massage, Vol. I textbook to learn more about pathology, clinical symptoms and diagnostic evaluation of tissue in cases of Anterior Scalene Muscle Syndrome/Thoracic Outlet Syndrome.

In the videos, we will repeat each technique and approach only two or three times to save time and space. Follow the time guidelines shown at the beginning of each step.

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EVALUATION OF THE PATIENT WITH ANTERIOR SCALENE MUSCLE SYNDROME (ASMS)/THORACIC OUTLET SYNDROME
 

The anterior scalene muscle (ASM) is the key to the upper extremity. Even mild tension in this muscle may irritate the brachial plexus, and in such cases the patient may exhibit symptoms of ANY abnormality on the upper extremity.

These symptoms are a direct consequence of the irritation of the brachial plexus, e.g. numbness on the thumb (Radial Nerve Neuralgia) or pain on the lateral surface of the shoulder joint (Deltoid Muscle Syndrome). They can also mimic the exact clinical picture of other abnormalities e.g. numbness of the palm (Carpal Tunnel Syndrome) or pain on the lateral surface of the elbow joint (Tennis Elbow).

This is why patients frequently undergo long and expensive local treatments, and even surgeries, without success as the initial problem was in a completely different area. This is a very important issue, because at the beginning the patient with ASMS never complains about pain, tension, or any other symptoms in the anterior neck. He or she will always feel uncomfortable sensations in the areas where the nerves from the irritated part of the brachial plexus end. This is a very confusing clinical phenomenon. This is the reason why the ASM is nicknamed ‘the silent killer’.

Every patient with any abnormality on the upper extremity should be evaluated for the possibility of tension in the anterior scalene muscle. There are four very easy ways to conduct tests that are 100% informative and help to detect even the slightest tension in the ASM.

Each nerve carries sensory (conducts the sensation of touch, temperature, etc. to the spinal cord) and motor (conducts impulses from the spinal cord to the muscles and other tissue) fibers. The practitioner should evaluate both components. Usually the sensory component is affected first, while abnormalities in the motor component mean more profound changes in the affected area.

Examination the Sensory Deficit
 

Each spinal nerve which forms the brachial plexus enters the space between the anterior and middle scalene muscles on a different level. This is why tension in the different parts of the ASM will irritate a different part of the brachial plexus with the resulting development of a clinical picture down the arm, forearm and hand.

If we split the ASM into three parts we find that under the upper third of the ASM, just below the mastoid process, the C5-C6 spinal nerves (main contributor to the radial nerve) are located. The middle part of the ASM covers the C7 spinal nerve (main contributor to the medial nerve). The lower third of the ASM covers the C8-T1 spinal nerves (main contributors to the ulnar nerve). Please see video below.


The examination of sensory deficit has two steps: 

 

1. Questioning

The hand has a very precise pattern of innervation by the radial, median and ulnar nerve, which originates from different parts of the brachial plexus. If we correlate the patient’s hand with his or her anterior neck, we will find that the thumb and dorsal surfaces of the second and third fingers, except distal phalanges, are associated with the upper third of the ASM (i.e., radial nerve). The index, middle finger and half of the fourth fingers on the palmar hand are associated with the middle third of ASM (i.e. median nerve, and half the of the fourth and entire fifth fingers are associated with the lower third of ASM (i.e., ulnar nerve).

The practitioner should ask about any current or previous sensory symptoms (e,g., pain, tingling, numbness, etc.) and match them with the innervation of the hand we have just discussed. For example, the patient has a clinical picture of Carpal Tunnel Syndrome with numbness of the palmar surface of the index and middle fingers. If the patient has Carpal Tunnel Syndrome as a result of ASMS, the middle third of the ASM will exhibit the greatest tension.

Thus, even before application of Wartenberg’s Test and Trigger Point Test, the practitioner may predict which part of the brachial plexus may be affected by a tensed ASM just by asking the right questions.

2. Sensory Test (ST)

When the ASM slightly irritates any part of the brachial plexus, the patient may not complain about any sensory abnormalities yet. However, they can be detected using the ST. The examination of each finger will detect even the earliest stages of sensory deficit. Ask the patient to close eyes and to compare the sensations from both sides while the practitioner simultaneously strokes the same finger on the affected and unaffected side using the fingernails.

The video shows application of the ST and correlation of the examination of each part of the hand with the appropriate part of the ASM.

The ST gives exact information of which peripheral nerve is affected and to what degree. Thus, without examining the ASM itself, you any predict what part of it is more likely, under the tension, in case that the clinical symptoms are caused by irritation of the brachial plexus by ASM.

Examination of Motor Deficit

Motor Test (MT)

MT allows the practitioner to detect the earliest stages of muscle weakness. Of course this test is very general, but it is simple and really helps examine muscle strength.

First, ask the patient if he or she is right or left handed. Stand in front of the patient, cross your forearms and grasp the patients’ right hand with your right hand and his or her left hand with your left hand. Now ask the patient to slowly squeeze your hands with the same force until you tell him or her to stop and maintain the same pressure.

Concentrate on your sensations. You are examining three parameters: 

1. General strength:

First, compare the general muscle strength or how the squeeze feels on the unaffected side as compared to the normal side. Remember that the patients primary hand is always stronger.

2. Correct grip:

Normally when an individual squeezes one’s hand, he or she applies more pressure using the thumb-index fingers, while the rest of the fingers support the hands compression. Let us consider that the patient has initial stages of the weakness of the thumb and thenar eminence of the hand. In such cases the practitioner will feel more pressure elicited by the 3rd-5th fingers instead of the thumb-index fingers. In another scenario, the weakness of the hypothenar muscles (5th finger eminence) the practitioner will feel as a soft, weak attempt of compression by the 3rd-5th fingers as compared to the unaffected hand. The white arrows indicate areas of muscle weakness during the hand squeeze.

3. Muscle Resistance to the Isometric Contraction:

The isometric contraction is much more energy demanding compared to the isotonic contraction. This is why you will feel that the grip on the affected side may get weaker despite that initial 5 – 10 seconds of hand squeezes that felt the same on both sides.

MT allows the practitioner to evaluate the intensity of the clinical picture because motor abnormalities, muscle weakness, atrophy, trigger points, etc. appear later, after the sensory abnormalities have already formed and exhibited themselves.

Wartenberg’s Test

This test was proposed by Dr. P. Wartenberg in the 1930’s. It gives very accurate information if tension developed in the middle and lower thirds of the anterior scalene muscle.

The first part of the video shows the initial placement of the thumb for the execution of the test. Notice that the thumb must be placed flat just above the clavicle. The second part of the video shows the application of the pressure in the right spot. Notice how the thumb rotates and pushes down behind the clavicle.

When applying pressure on the right spot, the tendinous part of the ASM is felt as a cord, and the practitioner feels pulsation of the subclavian artery under the finger.

WTis considered positive if the patient feels acute pain while the practitioner applies even moderate pressure in this area or an already existing symptoms get worse, e;g. pain shoots to the thumb, or paraesthesia (i.e sensation of tingling) becomes numbness, etc.

WT give 100% accurate information if the anterior scalene muscle (especially the middle and lower thirds associated with the median and ulnar nerves) irritates the brachial plexus.

Trigger Point Test (TPT)

Wartenberg’s Test is very accurate, but sometimes it does not give all of the information if tension is formed in the upper third of the scalene muscle. Thus, the practitioner should also use the TPT along with Wartenberg’s Test.

TPT is also easy to perform. Find the area of the main trigger point in the anterior scalene muscle, which is located half the distance between the mastoid process and the clavicle.

The first part of the video shows the anatomical arrangement of the anterior neck when the patients’ head is turned to the opposite, unaffected side (left side in the video). In the video, the black dot indicates the mastoid process; the dashed line indicates the posterior edge of the sternocleidomastoid muscle; the solid lines indicate the edges of the ASM after it emerges from under the sternocleidomastoid muscle; the waved line indicates the upper edge of the clavicle.

The trigger point is located in the middle of the ASM, between the clavicle and mastoid process, underneath the posterior edge of the sternocleidomastoid muscle. Thus, to access the trigger point, the practitioner should push the posterior edge of the sternocleidomastoid muscle forward.

The second part of the video shows the application of the TPT in the patient position on their back. In the video the index finger indicates the area of the trigger point, and the thumb shows the mobilization of the sternocleidomastoid muscle. As you can see, the pressure is directed horizontally and the bulged tissue in front of the thumb is the sternocleidomastoid muscle which has been pushed medially.

After pushing the posterior edge of the sternocleidomastoid muscle medially, carefully re-direct pressure to the vertebral column. This area is sensitive in general, so use a moderate pressure. If the patient feels acute pain which radiates up to the mastoid process and/or sensory abnormalities down the arm, forearm and hand, the TPT is considered positive.

The TPT allows us to examine the tension in the upper third of the anterior scalene muscle associated with the radial nerve.

 

If Wartenberg’s Test and/or Trigger Point Test are positive, the practitioner should always start the treatment of any abnormality of the upper extremity with the application of the medical massage protocol for the ASMS, which is presented below. Only after the tension in the ASMS is eliminated and the threat brachial plexus irritation is gone, the local part of the treatment should be applied (e.g., medical massage protocol for the Carpal Tunnel or Golfer’s Elbow, etc.)

 

MEDICAL MASSAGE PROTOCOL IN CASES OF ANTERIOR SCALENE MUSCLE SYNDROME / THORACIC OUTLET SYNDROME

Duration: 40 min to one hour 

Step 1. Work on the posterior neck and shoulders. The patient is positioned on his or her stomach.
a. Effleurage and kneading in the inhibitory regime on the posterior neck and shoulders 
Duration: 3 min

Begin with effleurage strokes in the direction of drainage, starting them from the upper back and neck.

For the first 2 to 3 strokes use superficial effleurage, and later switch to deep effleurage maintaining a fold of skin in front of the fingertips during the stroke. Pay attention to the direction of effleurage strokes shown in the video.

Apply kneading of the upper shoulder muscles on the unaffected side first, then switch to the affected side and concentrate there.

End this part of the protocol with several effleurage strokes.


b. Friction at the insertion of the trapezius muscle into the scapula 
Duration: 2 min

Begin with longitudinal friction along the medial edge of the scapula, and later apply friction across the fibers at their insertion into the edge of the scapula. Be sure to apply friction strictly next to the bone, and do not slide the thumb over the skin. The bulging tissue seen in the video behind the thumb is the lower portion of the trapezius muscle.

Concentrate along the insertion of the trapezius muscle into the spine of the scapula. Again, begin with friction along, and later across, the fibers at their insertion into the spine of the scapula. The bulging tissue behind the thumb seen in the video is the upper portion of the trapezius muscle.


Step 2. Work on the posterior neck concentrating on the C5 to C7 level (being where the anterior scalene muscle’s innervation originates).
a. Relaxation of the cervical paravertebral muscles 
Duration: 3 min 

Begin with application of the technique on the unaffected side. Apply 2 to 3 repetitions. Work longer and slower on the affected side. To review the step-by-step application of this technique, click here.


b. Friction on the lateral surface of the spinous processes, or Sherbak’s friction 
Duration: 2 min 

Apply repetitive friction on the lateral surfaces of the spinous processes of the C5, C6 and C7 cervical vertebrae. To review the step-by-step application of this technique, click here.


c. Friction in the area of the cutaneous branches of the spinal nerves 
Duration: 2 min 

The three black dots at the beginning of the video indicate the spinous processes of the C5, C6 and C7 cervical vertebrae.

First, employ intense circular friction and moderate compression of tissue in the paravertebral area between the spinous processes of the C5 and C6 vertebrae. This is the location of the cutaneous branch of the C6 spinal nerve.

Move to the next segment between the C6 and C7 spinous processes to address the cutaneous branch of the C7 spinal nerve with the same combination of techniques. This part is shown in the video.

Before applying friction, be sure to stretch the skin over the area addressed here. Also, at the end apply electric vibration in the permanent, fixed mode to these two areas.

If cutaneous reflex zones and/or connective tissue zones are detected, it is the application of their treatment (see below) that should constitute the end of this step.


Step 3. Work on the anterior neck. The patient is positioned on the back.

The practitioner must be very careful on the anterior neck. An already inflamed brachial plexus finds itself just underneath the fingertips. Thus, any technique on the anterior neck must be applied within a short time frame and efficiently, so as to minimize potential irritation of the brachial plexus. This relates as well to the amount of pressure applied, which has to be within the comfort level of the patient.

To address the anterior neck, the practitioner must be familiar with this important area and its complex anatomy. Video shows the anatomical landmarks on the anterior neck for Anterior Scalene Muscle Syndrome/Thoracic Outlet Syndrome: the black dot indicates the mastoid process; the dashed line indicates the posterior edge of the sternomastoid muscle; the solid lines indicate the edges of the anterior scalene muscle; the waved line indicates the upper edge of the clavicle.

Pay attention to the location of the trigger point in the anterior scalene muscle. This area is very important for upcoming steps. The trigger point is located in the middle of the anterior scalene muscle, between the clavicle and mastoid process, underneath the posterior edge of the sternocleidomastoid muscle. Thus, to access the trigger point, the practitioner should push the posterior edge of the sternocleidomastoid muscle forward.

In the video, the index finger indicates the area of the trigger point and the thumb shows the mobilization of the sternocleidomastoid muscle. As you can see, the pressure directed horizontally and the bulged tissue in front of the thumb is the sternocleidomastoid muscle which has been pushed forward.

After turning the patient onto his or her back, and before addressing the anterior neck, work on the posterior neck and shoulders for one minute employing effleurage and moderate friction. This will afford the patient time to adapt to the new position.


a. Effleurage on the anterior neck in cases of very intense clinical symptoms 
Duration: 1 min 

Please notice the position of the right hand. The hand must be placed all the way behind the neck for the thumb to apply stokes flatly along the anterior scalene muscle.

Also, notice that the tip of the thumb ALWAYS stays behind the posterior edge of the sternocleidomastoid muscle. Very light pressure is applied only when the thumb moves down along the anterior scalene muscle. Therefore, pressure must be directed horizontally. Each stroke begins under the mastoid process and ends just above the clavicle.


b. Effleurage on the anterior neck in cases of mild to moderate clinical symptoms 
Duration: 2 min 

Employ the same strokes observing the same principles of application, except that in this case the head is turned to the opposite side. This position renders accessible the anterior scalene muscle, however puts additional pressure on the brachial plexus. For this reason, it is best to use the previous variant if the brachial plexus is exerted strong pressure by the anterior scalene muscle.

Please notice the flat positioning of the thumb, the horizontal direction of the pressure, and the tip of the thumb which pushes the sternocleidomastoid muscle forward during each stroke.


c. Friction along the anterior scalene muscle 
Duration: 1-2 minutes

Apply very light and gentle circular friction along the anterior scalene muscle using the fingertips brought together.

Switch to circular friction using the thumb, but keep it flat. Begin the strokes below the mastoid process and end them above the clavicle.

The final part is the application of circular friction in the supraclavicular fossa just behind the clavicle. This is the area of the insertion of the anterior scalene muscle into the first rib.

Be careful with the amount of pressure applied, as the subclavian artery and vein are underneath the thumb.


Step 4. Local stretching of the anterior scalene muscle 
Duration: 5 repetitions from each position (2 min)

Begin with local stretching of the entire anterior scalene muscle during the patient’s prolonged exhalation. To execute this technique correctly, control the patient’s head and neck at the mastoid process using the left hand.

Apply the right thumb below the mastoid process and direct the pressure horizontally, carefully sliding the thumb along the anterior scalene muscle and getting the thumb ONTO the clavicle. At this moment apply a gentle stretch, pulling both hands in opposite directions.

Please pay attention to the movement of the wrist during the stroke; the efficacy of the stroke depends on this. Notice that the initial position of the palm is perpendicular to the axis of the spine. While the practitioner executes the stroke and moves the hand forward, the wrist comes to be extended in such a way that at the end of the stroke the palm is parallel to the axis of the spine. Only in this way will you be able to get the thumb easily on the clavicle. Repeat this technique 5 times.

Now, apply local stretching of the lower half of the anterior scalene muscle. Place the 2nd to 5th fingers of the left hand (brought together) on the trigger point area in the anterior scalene muscle. The trigger point area is in the middle of the anterior scalene muscle, between the clavicle and mastoid process, just underneath the posterior edge of the sternocleidomastoid muscle.

The right thumb slides down from the level of the left fingertips; when it arrives onto the clavicle, the practitioner should gently pull both hands in opposite directions such as to stretch the lower half of the anterior scalene muscle. The pressure of both hands is directed horizontally. Repeat this technique 5 times.


Step 5. Passive stretching of the cervical muscles
a. Passive stretching along the neck’s axis 
Duration: 3 to 5 repetitions (half a minute)

Place one hand under the patient’s occipital ridge and place the 4th and 5th fingers of the other hand (brought together) under the chin. Be sure that your hand does not apply uncomfortable pressure on the trachea.

Ask the patient to quickly inhale and exhale slowly through the mouth. As soon as exhalation begins, start to slowly pull the head EQUALLY with both hands toward yourself (using your hold of the occipital ridge and the chin).

Observe the patient’s facial expressions. He or she should inform you about any uncomfortable sensations during the stretch. Decrease the intensity of the pull if the patient is uncomfortable. The white arrows in the video indicate the direction of this passive stretch.


b. Passive stretching incorporating rotation to the opposite side 
Duration: 3 to 5 repetitions (half a minute)

Turn the patient’s head to the opposite side (left side in the video). Be sure that the patient’s head is rotated without lateral flexion, i.e., the chin must remain parallel to the shoulder (left shoulder in the video).

Place your left hand behind the right mastoid process and your right hand on the right shoulder with your thumb on the clavicle. Ask the patient to inhale, and as he or she slowly exhales carefully stretch the neck by pulling the hands in opposite directions.

Observe the patient’s reactions and decrease the intensity of the stretch as soon as the patient manifests any signs of experiencing any uncomfortable sensations.


Step 6. Circular friction and manual vibration in the trigger point area in the anterior scalene muscle 
Duration: up to a minute

The trigger point area is in the middle of the anterior scalene muscle between the clavicle and mastoid process, just underneath the posterior edge of the sternocleidomastoid muscle.

Do not employ strong vertical pressure during friction and manual vibration. However, the pressure applied should be strong enough to hold the skin during the application of these techniques. Otherwise, friction will irritate the already inflamed brachial plexus.

End the protocol with one minute of effleurage on the posterior shoulder and neck while the patient is on his or her back.

Cutaneous Reflex Zones 

Duration: 3 min

Cutaneous reflex zones may be found on the posterior neck along the paravertebral line on the level of the C5 to C7 cervical vertebrae.

Apply superficial friction and skin kneading in this area. Add this treatment at the end of Step 2 of the previously discussed protocol.

Connective Tissue Zones 

Duration: 4 min

Connective tissue zones may form on the posterior and anterior neck. Connective tissue massage is the best way to eliminate them. Do not employ this therapy if there are no signs and symptoms of connective tissue zones.

The connective tissue massage (CTM) protocol is shown in the video. Be sure to apply minimal vertical pressure during strokes when working on the anterior neck.

CTM on the posterior neck should be added at the very end of Step 2 of the previously discussed protocol. CTM on the anterior neck should be added at the very end of Step 3.

Reflex Zones in the Skeletal Muscles
 

Add the treatment of reflex zones in the skeletal muscles at the end of Step 3, after the CTM strokes on the anterior neck.


a. Work in the area of the trigger point in the anterior scalene muscle 
Duration: 2 min

It is impossible to apply trigger point therapy on the anterior scalene muscle in the classic fashion as any vertical compression will also compress the already irritated brachial plexus against the transverse processes of the cervical vertebrae.

There is thus a special approach to working in the trigger point area of the anterior scalene muscle. Turn the patient’s head to the unaffected side (left side in the video) and place the right hand flat on the affected side of the head and the neck.

Locate the trigger point using the third finger and turn the patient’s head to the affected side so as to relax the cervical muscles on that side of the anterior neck.

While turning the head, keep the third finger in the same spot to secure the location of the trigger point. The practitioner’s right hand must be completely flat, however with the third finger bent so as to conduct the treatment while the patient’s head is lying comfortably on the palm of that hand.

The last part of the video shows the position of the hand and finger’s movement during therapy.


b. Postisometric Muscle Relaxation (PIR) for the anterior scalene muscle

In the instance that the patient exhibits an acute clinical picture of Thoracic Outlet Syndrome and/or also suffers from intervertebral disk abnormalities on the neck, the practitioner should employ the approach presented in this video.


Duration: two repetitions of isometric contraction-against-resistance alternated with two sets of three passive stretches (5 min).

Turn the patient’s head to the unaffected side within his or her comfort level. Place your right hand on the patient’s right shoulder and your left hand on his or her forehead.

Ask the patient to effect two consecutive movements against your resistance: first, to slowly turn his or her head to the right; and then, without either of you releasing pressure, to bend the head forward. The practitioner must resist each contraction and maintain the resistance for 15 to 20 seconds.

The next step is three passive stretches during the patient’s prolonged exhalation. Repeat this sequence one more time.

 

In the instance that the patient exhibits a mild to moderate clinical picture of the Anterior Scalene Muscle Syndrome, or that he or she does not have intervertebral disk pathology on the neck and has a wider range of motion, the practitioner may use the second variant of the PIR protocol.

Ask the patient to move up toward the head end of the table such that both of his or her shoulders are on the edge of the table. The practitioner must efficiently support the patient’s head so that the patient feels that his or her head and neck are secure. Otherwise, he or she will resist the treatment by guarding the neck.

At the beginning of the video, pay attention to the different body positions the practitioner adopts depending upon whether conducting PIR treatment on the right or the left side.

PIR ON THE FIRST LEVEL

Turn the patient’s head to the left (for right-side pathology) while supporting the head with your right hand. The elbow of your right arm should rest on your right thigh for additional stability.

Place your left hand on the patient’s forehead in a way such that your index finger is parallel to the patient’s brows and your thumb is on the right temporal area.

Now, ask the patient to slowly turn the head to the right while you resist this movement using your thumb. Without either the patient or you releasing pressure, ask the patient to bend the head forward while you resist this movement with your index finger. Maintain the resistance for 10 to 15 seconds before asking the patient to relax.

After the resistance part, apply three passive stretches during the patient’s prolonged exhalation. Each stretch must be conducted within the patient’s comfort level. The practitioner must interrupt any additional pulling as soon as the patient manifests any signs of experiencing ANY uncomfortable sensations. For this reason the practitioner should determine the comfort level of passive stretching before the treatment. Always adapt the intensity of the stretch to the patient’s sensation.

Each passive stretch is conducted from the middle (i.e., regular) position of the head and is a combination of three consecutive stretches: first, gently pull the patient’s head toward yourself; second, extend it backward; and finally rotate it to the left (for right-side pathology).

The passive stretch is initiated at the start of the patient’s long exhalation and the rotation to the left coincides with the end of the exhalation.

PIR ON THE SECOND LEVEL

The end of the third passive stretch is the beginning of the second resistance-against-contraction movement. From this new position, ask the patient to turn his or her head to the right and to flex it forward (approaching it thus to the shoulder) while you resist both movements in the same way as described above for the first step.

After 10 to 15 seconds, lift the patient’s head up to make him or her comfortable and again conduct three passive stretches. This is to be conducted in the same way as discussed above at the end of Step 1.

Periostal Reflex Zones

Duration: 3 min

Periostal reflex zones can be found on the anterior and posterior surface of the clavicle. The best way to address periostal reflex zones is through Periostal Massage.

Employ this treatment only if periostal reflex zones are detected. Add periostal massage at the end of Step 6.

Full Protocol: