Thoracic Outlet Syndrome

Thoracic Outlet Syndrome

Thoracic Outlet Syndrome (TOS) is a painful pathology that affects individuals with developed musculature and/or poor posture.  It can present as pain and numbness in the arm, hand, and fingers.


  • Compression or irritation of brachial plexus roots (scalences, costoclavicular equal frequency)
  • Compression of subclavian artery (costoclavicular most frequent)
  • Compression of subclavian vein

3 potential locations of neurovascular compression: between scalene muscles, costoclavicular space (clavicle and 1st rib), pectoralis minor muscle

Causes: trauma, posture, repetitive stresses/overuse, anatomical alignment



Neurogenic: women

Venous: men

Arterial: equal distribution



Neurogenic thoracic outlet syndrome (90%)

  • dermatomal pain (usually in the ulnar region)
  • paresthesias
  • weakness/loss of dexterity
  • neck pain
  • occipital headaches


Arterial thoracic outlet syndrome (1%)

  • pain in hand (but rarely in shoulder or neck)
  • finger ischemia
  • paresthesias
  • coolness/pallor
  • weakness/loss of dexterity
  • early fatigue


Venous thoracic outlet syndrome (3%)

  • pain increases along course of axillary vein
  • feeling of heaviness in the affected extremity
  • arm swelling and cyanosis
  • stiffness in fingers
  • paresthesias


Provocative Maneuvers

Adson Test

Allen Test

Costoclavicular Test

Roos Test

Upper Limb Tension Test (neurogenic)


Physical Therapy

Postural reeducation/ergonomics

Stretching -scalenes, pectoralis minor

Strengthening – scapular muscles

Manual therapy – 1st rib manipulations, joint mobilization, taping

To schedule an appointment for this condition call 208-917-2660 or visit

DynaMed Plus [Internet]. Ipswich (MA): EBSCO Information Services. 1995 – . Record No. 115626, Thoracic outlet syndrome; [updated 2014 Dec 23, cite; [about 7 screens]. Available from Registration and login required.



Surgery: First rib resection and scalenectomy (FRRS)

The most frequent sports conducted by this group were baseball and softball, volleyball, and cheerleading and gymnastics, ranging from high-school to professional levels. The survey results revealed that 96% were improved in pain medication use, 75% would undergo FRRS on the contralateral side if needed, 82% had resolution of symptoms, and 94% were able to perform activities of daily living without limitation; 70% returned to the same or better level of athletic activity after FRRS, and this occurred within 1 year in 50%.


Shutze W, Richardson B, Shutze R, et al. Midterm and long-term follow-up in competitive athletes undergoing thoracic outlet decompression for neurogenic thoracic outlet syndrome. Journal of Vascular Surgery. 2017;66(6):1798-1805. doi:


Drop Shoulder Condition – scapular depression at rest, late insufficient upward rotation, general weakness upper and middle trapezius seen in people with TOS.  Physical therapy includes retraining of scapular muscles for proper recruitment with upper extremity motions

Watson LA, Pizzari T, Balster S. Thoracic outlet syndrome part 2: Conservative management of thoracic outlet. Manual Therapy. 2010;15(4):305-314. doi:


Nichols AW. Diagnosis and management of thoracic outlet syndrome. Current Sports Medicine Reports (American College of Sports Medicine). 2009;8(5):240-249.,url,uid,cookie&db=sph&AN=44304683&site=ehost-live.



Astym therapy vs. IASTM: What’s the difference?
       Astym therapy resulted from a groundbreaking research endeavor undertaken by a multidisciplinary research team including well-known scientists, therapists, and physicians, with support from major universities and hospitals.  In this Astym Research Project, the team had the unique advantage of being able to combine knowledge of physiology, cellular biology, and emerging scientific discoveries into the development of a whole new approach in the treatment of soft tissue dysfunction.  Astym therapy continues to forge new ground in the treatment of injuries and also expand the boundaries of physical therapy into new patient populations.  The Astym Research Project developed entirely unique new theories on how to engage soft tissue healing, and changed the actual paradigm on how to treat soft tissue dysfunction.
       Astym therapy, evidenced to engage the regenerative mechanisms of the body and promote the healing of soft tissues, has repeatedly been shown safe and effective in controlled clinical trials, clinical study, and large population outcomes studies.
       Astym treatment is different in goals and application from the Instrument-Assisted Soft Tissue Mobilization (IASTM) techniques.  IASTM uses tooled friction massage to mechanically break apart tissue, whereas Astym therapy’s aim is to engage the regenerative mechanisms of the body to repair damaged tissue and resorb scar tissue.  IASTM’s role in the treatment of soft tissue dysfunction is unclear, as IASTM has been shown to (a) not improve treatment results for ankle injury, (b) be comparable to no treatment being provided in elbow tendinopathy, and (c) result in a significant increase in pain and a significant decrease in the perception of function, where the ability to perform activities of daily living (ADL) decreased following IASTM.  There have been case studies suggesting IASTM may have a role in treatment, however, those studies have largely been multimodal, so conclusions from those are difficult or impossible to draw.  The research that has isolated IASTM for study suggests that clinical use may not be beneficial.
      For a fully referenced summary of research on Astym therapy and IASTM, please read this Research Overview.
Rock and Armor is proud to be an ASTYM Certified provider and happy to discuss if this mode of treatment is appropriate for your condition.  Call us at 208-917-2660.

Ankylosing Spondylitis-Rock and Armor Physical Therapy, Meridian, ID

Ankylosing Spondylitis

 Ankylosing Spondylitis (AS) is a chronic inflammatory rheumatic disease affecting primarily the sacroiliac joints (pelvis) and the spine. Age of onset usually begins between 15-30 years old with 80% of symptoms beginning before the age of 30 years old. AS is more common in men than women. The exact cause of the disease is unknown, but there is a combination of genetic and environmental factors seen with individuals with the disease. There is a gene called HLA-B27 that has been noted to be present in 90% of people with the diagnosis. However, only about 5% of people with this gene develop ankylosing spondylitis. The environmental factors that contribute to AS are less known but include mechanical stress to the entheses and pathological infections. Entheses is the attachment point of a tendon or ligament to the bone. Stresses occurring at this site are linked to the inflammatory response that occurs with AS.  

The chief complaint of a person with ankylosing spondylitis will be back pain worse upon waking up or after rest which lasts greater than 30 minutes. The back pain will also improve with movement. A person will have spinal stiffness and loss of mobility in the spine due to the bony fusion that occurs at the joints. Other common symptoms are fever, generalized fatigue, loss of appetite, difficultly breathing, and uveitis which is swelling of the eye. 

A diagnosis criteria for ankylosing spondylitis is called the Modified New York criteria. This includes the following: 1) Presence of either bilateral sacroiliitis greater than grade 2 or unilateral sacroiliitis greater than grade 3 on an x-ray. 2) Plus greater than one of the following: inflammatory low back pain for greater than 3 months that improves with exercise and does not improve with rest, limited lumbar spine motion in sagittal and frontal planes, and/or decreased chest expansion for age and sex. The Modified New York criteria for classification of grades include: grade 0 – normal sacroiliac joint, grade 1 – suspicious changes, grade 2 -minimal abnormality with erosions or sclerosis but normal joint width, grade 3 – unequivocal abnormality with erosion, sclerosis, widening, narrowing, or partial ankylosis, grade 4 – total ankylosis.  

The American College of Rheumatology developed evidenced based 2015 guidelines and recommendation for the treatment of ankylosing spondylitis. The guidelines strongly recommend the use of nonsteriodal anti-inflammatory drugs (NSAIDs). Some common NSAIDs include ibuprofen, Advil, and aspirin. Other medications strongly recommended are tumor necrosis factor (TNF) inhibitors. Both these medications are used to decrease pain and inflammation. In addition, it is strongly recommended for treatment with physical therapy. Physical therapy interventions may improve pain and function in ankylosing spondylitis. Interventions include posture training, strengthening, stretching, and flexibility exercises, deep breathing exercises, and pain management techniques. Evidence based research has concluded that physical therapy with mobilization treatment for 8 weeks may improve chest expansion, posture, and spine mobility in patients with ankylosing spondylitis. Rehabilitation programs may reduce fatigue and increase spinal mobility following treatment with tumor necrosis factor inhibitors in patients with ankylosing spondylitis. Also addition of cardiovascular training to flexibility training may improve cardiovascular fitness and peripheral joint pain in patients with ankylosing spondylitis. In conclusion, a combination of medication and physical therapy is important for managing ankylosing spondylitis. 

Hunter Huberty, SPT, University of North Dakota Physical Therapy Department, 2018

Ward MM, Deodhar A, Akl EA, et al. American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network 2015 Recommendations for the Treatment of Ankylosing Spondylitis and Nonradiographic Axial Spondyloarthritis. Arthritis & rheumatology (Hoboken, NJ). 2016;68(2):282-298. doi:10.1002/art.39298. 


DynaMed Plus [Internet]. Ipswich (MA): EBSCO Information Services. 1995 – . Record No. 143424, Ankylosing spondylitis; [updated 2017 Aug 28; [about 32 screens]. Available from Registration and login required. 

Spondy Injuries


Spondylolysis and Spondylolisthesis injuries are often referred to as “spondys”. These injuries involve damage to the pars interarticularis of vertebrae. They most commonly occur in the lumbar spine (especially L4 -L5) as a result of repetitive hyperextension movements.

Spondylolysis injuries are considered stress fractures of the pars interarticularis. This most often happens in young, athletic populations. Athletes that perform in gymnastics, football, basketball, volleyball, and swimming/diving are at higher risk for a spondylolysis injury.

Spondylolisthesis is defined as a translation of one vertebra over the adjacent caudal vertebra. This can be a translation in the anterior (anterolisthesis) or posterior direction (retrolisthesis). This is usually a progression from a spondylolysis and can cause more problems with decreased spinal stability and the increased risk of nervous system involvement.

It is possible to have a spondy due to degenerative or congenital factors that do not stem from athletics. It is also possible to have a spondylolisthesis due to a single traumatic event. Potential risk factors for these injuries include: Increasing age, female sex, pregnancies, African-American ethnicity, and generalized joint laxity.  A heavy backpack as noted by our colleague’s at Advanced Physical Therapy in Lincoln, NE,, can lead to spondylosis type injuries as well.

Symptoms and findings in spondylolysis spondylolisthesis injuries are:

· Low-back Pain and leg pain

· Pain

· Trophic changes

· Atrophy of the muscles, muscle weakness

· Tense hamstrings, hamstrings spasms

· Diminished ROM (spine)

· Disturbances in coordination and balance

· Neurological symptoms (possible evolution towards cauda equina syndrome)

· Dull pain, typically situated in the lumbosacral region after exercise, especially with an extension of the lumbar spine

Spondys can be treated conservatively if it has not progressed to a very unstable spondylolisthesis. At this point, surgery is usually recommended to reduce and stabilize the vertebrae. Physical therapy is a key component to any treatment plan and will focus on core stabilization exercises that promote neutral and posterior pelvic tilt positions. Extension of the spine is initially not advised due to risk of exacerbating the injury. Treatment plans will often include isometric core exercises and activities to promote core stability during gait and athletic movements.

A typical progression plan will look something like this:

(referenced from

1. Control pain and inflammation: Taking stress off the injured area allows physiological healing processes to take place. Therefore, it can be necessary to avoid rotational shearing forces and extension movements by a temporary cessation of sporting activities and/or wearing a brace.

2. Daily stabilization: Neuromuscular stabilization techniques, including activation of transversus abdominis and other core stabilizer muscles must be started after the acute symptoms have decreased. This section includes education and postural training.

3. Strength and flexibility: As paraspinal muscle spasms and hamstrings tightness are seen in patients with spondylolysis, stretching exercises can be added to the rehabilitation program. Flexibility training is useful in patients with hypomobility of the back spine.

4. Functional movement: The main goal of physiotherapy is to increase functional abilities through a home exercise program. As soon as primary pain decreases, patients should be encouraged to resume activities as tolerated.

-Zach Hadden, SPT, Creighton University Physical Therapy Department, 2018 Graduate

ACL Injuries


The ACL injury commonly occurs in a variety of sports. There are a few different ways this can happen, but all usually involve a valgus and internal rotation moment at the knee. The majority of ACL injuries (70%) are non-contact and occur with cutting, rapid deceleration, and landing after a jump. Controlling excessive valgus/IR moments during these movements is key to preventing injury.

Women are three times more likely to sustain an ACL injury than men. This is often thought to be due to the differences of female anatomy compared to male anatomy. Females generally have a wider pelvis that leads to a greater Q angle. This can put the knee into a slight valgus position even when standing in neutral. Other factors include lesser muscle strength and greater ligamentous laxity in females.

Treatment options for ACL injury depends on severity, age, and activity level. Non-operative treatment involving physical therapy is usually preferred if there is minimal anterior tibial subluxation, has no additional knee injuries, is older than 35 or is not highly active. It is certainly possible to lead a normal life without an intact ACL if high level athletic movements are not performed regularly. Alternatively, surgical repair may be preferred if tibia has marked anterior subluxation, additional intra-articular damage, or is younger than 25 and/or is a highly active individual.

Surgical repair often uses grafts taken from the patella, semitendinosus, and gracilis. Tunnels are then drilled in the tibia and femur to run the grafts through. The grafts are then pinned in place with the correct amount of tension. This procedure can also be done with double or triple tunnels for increased strength.

Physical therapy rehabilitation should be performed whether or not the individual underwent surgical intervention for an ACL injury. Goals of rehab should include: achieving full ROM, regain functional stability, improve muscle strength, achieve highest possible functional level, and decrease risk of re-injury.

Rehab protocols should begin with decreasing pain and regaining full ROM in the knee (especially full knee extension). Early weight-bearing (once allowed) and light strengthening is also important in the early stages of rehab. Initially, open chain exercises involving the hip and knee may be better tolerated and important for gaining enough strength to support body weight in closed chain exercises. Additionally, it is important to employ techniques to reduce swelling, prevent scar tissue buildup, and preserve patellar mobility in the early stages of recovery. Previously, CPM machines were employed for increased motion in the acute stages, but do not have the outcomes to justify use of these devices.

Steadman Protocol

It is important to pay attention to changes in signs and symptoms to help guide treatment progressions. Protocol is important to follow, but not everyone will be ready to progress in the same time frames. Return to sport will typically occur at the 6-8 month mark. This must be

evaluated individually and is dependent on the level of activity that is required for the sport. The 3 Hop Test has been shown to be a good indicator of knee performance in return to sport and can be utilized with other tests to determine readiness.

-Zach Hadden, SPT, Creighton Physical Therapy Class 2018

Resistance Training is Healthy for Youth

A recent critically acclaimed journal published a study that revealed what we already suspected.  Resistance training in addition to free play can serve as a protective means against injury and a positive catalyst for the development of physical literacy to offset the impact of diminishing physical activity and early sport specialization in today’s youth.  When your kids get stronger, everyone wins.  Rock and Armor has numerous classes geared towards kids of all ages and athletic abilities.  Call 208-917-2660 to learn more about these classes today.

Shoulder Labrum Injuries

We have been seeing a higher rate of shoulder labrum injuries and want to briefly touch on this type of Injury.  The labrum is a piece of cartilage that lines the socket of the shoulder blade, providing more depth and stability for the ball of the humerus to articulate through.

Sudden jerks or forceful movements can injury this soft tissue structure, seen in most all types of sports and overhead lifting activities.  To further complicate matters, the long head of the biceps tendon attaches into the top of the shoulder labrum and can often times lead to pathology known as a SLAP tear (Superior Legion Anterior to Posterior).  This is detected with a Biceps Speeds test.


Because the labrum is inside the Glenohumeral joint capsul, it is not able to heal on its own as blood cells and healing properties are diluted with the surrounding synovial fluid.

Many individuals are able to fully function in a pain free manner even with a glenohumeral labrum defect.  This is usually accomplished through range of motion and aggressive strengthening exercise.  For those who continue to experience pain, instability, or catching, surgical options may be necessary.  Recovery from such a procedure usually consists of physical therapy and 6-8 months for full recovery.

If you think you may have this type of injury, our team of skilled physical therapists would be happy to give you a physical evaluation and point you in the right direction.  Please call 208-91702660 and we will get you right in!