TOS Questions with my Responses

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Hand Tingling: What Should I Do?

Question: I'm 3 weeks post FRR and PM release. My hand tingles all the time, especially my middle finger to my pinky, worse than before surgery.

  • What are good exercises to gain grip strength again? Writing strength too.
  • Are there any pool exercises with like, a small weight, a water bottle perhaps that you would recommend as well?  
  • My shoulder blade hurts all the time. The pain between my shoulder blade and my spine....its so distracting and painful. Its constant. Any recommendations?

Answer: I had the pain in the shoulder blade to spine area for a while too. Strengthening the Serratus and Middle traps + improving my middle back mobility were key to reducing this pain. Additionally, addressing this area first helped my nerve tension and arm weakness. I do several different ulnar and median and radial glides with clients, but they are pretty standard ones as it is a secondary focus to improving the positioning of the shoulder blade and middle back region.

Getting a Massage?

Question: Will massages help me? I’m having my 2nd flare up and if I put pressure on the knots the aching and tingling go away, until I release it!

Answer: From my experiences, massages can go both ways. Since the numbness and tingling is a nerve related issues, sometimes massaging directly over the nerve can cause further irritation. However, light pressure over the nerve area entrapped can help 'desensitize' or calm down the symptoms. I have found that massage along the nerve pathway (but not directly over the area that feels inflamed), is usually beneficial. For example, I will occasionally get R elbow itchiness/numbness (I have diagnosed this myself as radial nerve irritation. Massaging the elbow often hurts and makes it worse. Massaging the upper shoulders typically reduces symptoms. --Since you mentioned it helps symptoms, I believe it is a good thing for you! However, keep is the back of your mind this question, "why is it constantly flaring up? what is continually getting over stressed or under worked to cause the flare-up?"

Weights or No Weights?

Question: Do you have your clients do weight machines? I can't do anything that will make the triceps muscle expand or do any weights for the triceps or I will have a really big problem.

Answer: To start, I do believe people should eventually be able to lift as much weight as prior to TOS. For me, I have certain weight training movements that will always be more sensitive. For example, bench press and deadlifts are tough (because of the missing first rib and pull on my shoulder respectively). To answer your other questions: In general, I have clients do both types of weights. I typically start with machine weights because the machine provides feedback about body positioning. However, if it causes symptoms, then I would stop, reassess, and likely not have them do it again if symptoms return. While the triceps muscle can cramp or spasm for a number of reasons, I always go back to the nerve that activates the triceps muscle. It is the radial nerve that runs from your neck through the thoracic outlet down the back of the arm, and into the back of the thumb. However, based on the post, I cant say this is your issue OR is not your issue. Im really sorry to hear that you are struggling to return to lifting. As I mentioned in a prior post, I personally would assess shoulder blade muscle strength and positioning as well as how well the middle back is moving.

Muscle Spasms: Find the Pattern!

Question: Have you seen anyone who has arm spasms after the FRRS, scalene removal, and PMR. Our daughter had symptoms for 2.5 years, and starting 3 months before surgery her arm spasmed constantly. Since surgery, she has spasmed several times, but it does stop. She is still on muscle relaxants and is not drawing (she’s an artist). Naturally, she is concerned that as she is released to draw more the spasms will become more frequent and more severe - just as it was before surgery... She is in PT - mostly massages, nerve glides, stretches.

Answer: If I were working with your daughter, I would be most curious about the factors that trigger the muscle spasms (when do they happen, how long do they last, where are they specifically located, etc…). I have worked with people with intermittent localized muscle spasms, but they would often subside with certain arm and shoulder blade positions. Additionally, I would try to determine which muscles are in spasm and specifically do these muscles relate to each other in any way? Finally, the return to drawing will need to be slow and gradual. If she has had symptoms for 2.5 years, each time she goes into the drawing posture, her brain and body are anticipating a spasm. I would try drawing in different positions (standing vs. sitting; changing the neck and shoulder posture, etc…).

Persistent/Chronic Pain and TOS?

Question: Do most people have persistent pain after the rib resection or before?

Answer: Most of my clients have not had a first rib resection. Many of them have persistent pain from neurogenic TOS that has been treated conservatively on and off for a period of time. The main difference with persistent pain is how the brain changes after being in pain for a long period of time. The change is called neuroplasticity OR cortical smudging. Fortunately, just as the brain can become too sensitive to pain, it can also adapt for the positive as well! On this website, I have compiled a list of resources about pain!

Surgery Soon: Tips and Advice!

Question: I have my surgery scheduled. This surgeon does a VATs thorascopic approach for the first rib removal. Any experiences, tips, success stories with this would be appreciated?

Answer: Something that surprised me was that my subclavian vein closed off after surgery. This is more common than not, but I did not know this would happen. Since it closed, I had more post-surgery swelling longer than I anticipated. I often use the analogy that the subclavian vein (my major highway) closed, so now my collateral veins (the smaller roads) needed to work harder. They backed up for a little while (more traffic on the roads), but are getting stronger and stronger each day. Today my smaller veins are much more visible and stronger and I only have swelling with heavy lifting.

(see my video in the

Neurogenic TOS: What Helps the Most?

Question: I have been diagnosed with TOS but haven’t seen a specialist bc I am not interested in surgery yet.  It’s really been quite a journey, from MRIs to EMGs to this and that MD. Of course I’ve been to a couple different manual and orthopedic certified PTs, also have a seen soft tissue specialists in bodywork. I’ve had some relief but would certainly love to discuss my case with you. What do you see helps most often with neurogenic TOS?  I’ve been unable to determine if mine is scalene driven or pec minor or both. Personally I believe it’s more of a whole body issue, having R SI/ lumbar issues with radiculopathy also changed my movement patterns.

Answer: Having gone through the vTOS process and worked with multiple TOS clients, I have found that addressing the shoulder blade strength, CT junction mobility, and prolonged/repetitive daily postures is key.

1) scapular positioning is hugely important-- one thing to consider with yourself: I often give people upper trapezius strengthening exercises in an overhead position because TOS clients are frequently downwardly rotated and depressed on the involved side.

2) CT junction mobility has been very important for me and many clients

3) I have found that prolonged postures, stress, and lack of sleep recreate my symptoms more than anything else. My prolonged postures include computer work, playing on the floor with my young daughter, and heavy deadlifting movements.

The Pec Minor Muscle & Stretching

Question: I get nerve pain in my armpit and just below the coracoid. It seems to suggest pec minor syndrome, but I don’t have a tight pec minor or round shoulders. My shoulders in a neutral position and there’s not much of a stretch when I try a pec minor stretch. A few Pec minor stretches actually sets off bad flare ups. If I don’t have a tight pec minor can it still be the pec minor causing the issue? The pain areas match up with the pec minor and I have such bad flare ups when I stretch it. I’m totally confused! Thanks for any advice.

Answer: Often times, nerve pain is caused by either excessive tension or compression on the nerves as they go down the arm. While the pec minor is often blamed for the problem, it may be due to other prolonged postures or positions that you are doing. For example, prolonged computer work causes some nerve irritation into my elbow. With that being said, I would also look into serratus anterior strengthening exercises (this is the opposing muscle to the pec minor). Additionally, think about the shoulder blade posture from a head to toe standpoint too. Often times, my TOS clients are conscious of a forward shoulder position, but are constantly drawing 'down and back,' which can place tension along the thoracic outlet region. I have them work on a neutral posture that does NOT involve pulling the shoulder blades down and away.