When the Pathology Book is Scary and You’re Afraid to Massage

written by Robert Truax, DO

“Sam, I'm referring a patient to you with Thoracic Outlet Syndrome (TOS) for myofascial release.”

As I sat down at the community desk, Sam reached for her medical massage pathophysiology textbook to read up on TOS.

When I glanced back at her, she looked scared.

She read aloud that "TOS was a condition that involves either an obstructed subclavian vein often causing a blood clot or a compressed nerve, both treated through surgery."

She looked back at me like . . . "you want me to massage someone with this?"

Ah . . . fear of the surgical condition.

While surgical TOS fits that definition, 98% of TOS isn't that severe and is amenable to massage therapy.

It's typically a combination of tight:

• scalenes,
• upper trapezius,
• sternocleidomastoid, and
• pectoralis minor

that wrap (a bit more tightly than it should) around the brachial plexus, causing non-specific nerve symptoms (numbness, tingling) and neck-shoulder discomfort.

This type of TOS doesn't cause nerve pinching or blood clots.

 

Formal Diagnoses Can Cause Fear and Confusion

It's unfortunate that the way TOS was described in Sam's own resource book caused more confusion and fear, not more clarity and confidence.

This can lead to feeling unqualified to care for clients that I, as a physician, believe could benefit from your massage.

I don't want that for you.

As a medical school professor, with each new student class, I'm reminded how I felt as a young, new medical student. I had similar feelings at the beginning of medical school.

Colleen and I created Mentor Connect for this reason. I want you to have a better understanding of the medical world so that you can work confidently within it. 

Let's get to it. 

Determining Severity

(First and foremost: Do not provide massage to someone if you feel uncomfortable and something doesn’t seem right in light of what you know and in light of the type of massage you do.)

As a Primary Care Osteopathic Sports Medicine physician, I see musculoskeletal (MSK) problems as my main patient complaint.

The first thing I do is determine:

• Is this an anatomical problem that needs surgical intervention (injection or surgery) or
• is this primarily functional, so I can manage this conservatively?

The first time I diagnosed a surgical TOS was during my Sports Medicine fellowship - over the telephone!

The athletic trainer for the high school called me and said one of his basketball players had sudden pain, swelling, and discoloration in her right arm. I instructed him to send her to the Emergency Room to get an ultrasound of her brachial vein.

The next day she had her first rib removed.

How was I so accurate over the phone?

I made an educated guess. There were several sudden concurring changes that made me worry enough to send this teenager to the Emergency Room.

To be clear, most MSK issues never need surgery, so 90% of the time I recommend a conservative management plan.

A condition is surgical when:

• a clear and precise anatomical problem,
• causes clear symptoms and reduced function,
• that requires precise surgical intervention to resolve.

Surgery is about fixing something wrong with the patient's anatomy.

I tell my osteopathic medical students to ask these questions:

• Is the MSK issue of such severity that they will need surgical intervention now, for instance a femur fracture, a tumor pressing on the spinal cord?
• Is this a surgical issue but not urgent, for instance, anterior cruciate ligament injury, rotator cuff tear?
• Is the MSK issue non-surgical/no anatomical problem but functional/muscular so it requires conservative care?

As a massage therapist, if your client is so severe they urgently need surgery; most likely, they won't come to you.

If they do, they will be so ill-appearing and uncomfortable on your massage table, you will be frightened to treat them.

This high school athlete had sudden onset focal swelling (her right upper extremity) with neurological symptoms. This should prompt an anatomical evaluation, which it did, and the imaging revealed a blood clot. Surgery was performed.

Is that how TOS always presents?

No, and let us imagine this scenario again, but shift the symptoms and signs a bit, to demonstrate how TOS (and a lot of other MSK issues) can either be primarily functional or primarily surgical, yet still have the same name.

 

Scenario  #1

What if she didn't have swelling but reported neurological symptoms in her right upper extremity every time she tried to shoot the basketball so she stopped playing?

I would have . . .

• seen her in clinic within a few days,
• assessed her for a TOS (ex. Adson's Sign) that would require surgery.
• If my exam elicited similar symptoms and weakness in my office, I would suspect an anatomical problem.
• She may have the rare condition of a rib attached to her cervical vertebra, and this cervical rib and the typical first rib pinch the nerve when she plays basketball.
• It would prompt me to refer her to an orthopedic surgeon.

In this scenario, my clinical suspicion would be that she'll improve with surgery because her orthopedic tests are consistent and reproducible.

 

Scenario #2

I see this scenario most frequently: functional TOS.

Imagine she has

• no weakness of muscles,
• no significant limitation in playing basketball but she may have vague neurological symptoms at the end of practice or game. 
• She doesn't stop playing.

The less precise and predictable the symptoms, the less likely she has something surgery will fix.

I will . . .

• assess for a surgical TOS with the same orthopedic tests (Adson's Sign).
• If these tests are negative, then
• proceed with treating her as a functional, not surgical, TOS.

The typical presentation for functional TOS is

• neck and shoulder pain,
• non-specific neurological symptoms that come and go, and
• the surgeon couldn't find anything OR surgeon found a herniated disc but doesn't want to do surgery.

Three scenarios of the same condition of TOS.

The presentations determined severity and treatment.

 

Perspective on Orthopedic Tests

By no means do I expect that you now feel comfortable distinguishing between a surgical and functional TOS. It's not always easy myself and it's not within your scope.

But consider this: you were likely taught some basic orthopedic tests for a variety of MSK issues during massage school.

The majority of orthopedic tests were designed by orthopedic surgeons primarily to determine which patient would best be treated with surgery, not necessarily to determine a precise diagnosis for non-surgical issues.

You can use these assessments to assess severity so that you do due diligence before proceeding with the massage.

The more discomfort and greater limited function an orthopedic test reveals, the more likely that person should be evaluated by a physician in addition to your care or instead of your care.

Furthermore, read articles by physical therapy and orthopedic specialists about TOS and other orthopedic conditions. How does the author describe their method to distinguish between surgical and non-surgical issues, aka functional (i.e try rehabilitation first)? 

 

Touchpoints

• Majority of MSK issues are predominantly functional/non-surgical.
• People who NEED surgery have significant functional impairment.
• My course Assessments equips you with how to use assessments so that you can better determine the severity of a person's condition.
• In Collab Lab, grab a volunteer and walk through the assessments taught in the Assessments Course.
• In Collab Lab, look up an article in Google Scholar about Thoracic Outlet Syndrome.