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the back while the arms are extended posteriorly (Image 7). The position is held for about a minute to assess if neurological symptoms appear. The pulse may also be palpated to assess if the pulse dissipates in intensity while in this position. The role of massage in addressing costoclavicular compression is more indirect. Treating the scalene muscles may reduce tightness and mediate their role in elevating the first rib. Overall treatment of the cervical and upper thoracic region can be very beneficial in reestablishing proper neuromuscular balance and facilitating less painful and more natural movements. Pectoralis Minor (Hyperabduction) Syndrome The final TOS variation is called the pectoralis minor syndrome or hyperabduction syndrome. As its name implies, the primary culprit is the pectoralis minor muscle. The brachial plexus along with the axillary artery and vein (branches from the subclavian artery and vein) all course underneath the pectoralis minor muscle in the upper thoracic region. In this variation, the structures may be compressed against the upper rib cage. This TOS variation may be clarified with an evaluation procedure called the Wright abduction test. The client's arm is lifted overhead in a fully abducted position (usually with the elbow flexed) and held in this position for about 60 seconds to SCIENCE OF NERVES A B M P m e m b e r s e a r n F R E E C E a t w w w. a b m p . c o m / c e b y r e a d i n g M a s s a g e & B o d y w o r k m a g a z i n e 89 6 7 Traction force applied to the scalenes. Military brace test. effective for helping to address this problem. Keep in mind that the pectoralis minor lies deep to the pectoralis major muscle, so it is not easy to get pressure applied to the pectoralis minor without working through the pectoralis major first. Many practitioners also attempt to stretch the pectoralis minor by bringing the arm into full flexion overhead. This position may cause a sensation of stretch in the anterior shoulder girdle and feel like it is really stretching the pectoralis minor. However, keep in mind that bringing the arm overhead into this position does very little to stretch the pectoralis minor because it is attached to the coracoid process of the scapula and not to the humerus, so it actually moves very little in this position. Most practitioners have heard of TOS, but may not realize there are different variations, which tissues are involved, and where the problem is located. Helping to effectively address this problem is greatly enhanced when you can narrow down the most prominent contributing factors. Notes 1. M. A. Ferrante and N. D. Ferrante, "The Thoracic Outlet Syndromes: Part 1. Overview of the Thoracic Outlet Syndromes and Review of True Neurogenic Thoracic Outlet Syndrome," Muscle Nerve 55, no. 6 (2017): 782–93. doi:10.1002/mus.25536. 2. V. Leonhard et al., "Anatomical Variations in the Brachial Plexus Roots: Implications for Diagnosis of Neurogenic Thoracic Outlet Syndrome," Annals of Anatomy 206 (2016): 21–6. doi:10.1016/j.aanat.2016.03.011. 3. M. Pecina, A. Markiewitz, and J. Krmpotic-Nemanic, Tunnel Syndromes: Peripheral Nerve Compression Syndromes (Boca Raton: CRC Press, 2001). Whitney Lowe is the developer and instructor of one of the profession's most popular orthopedic massage training programs. His texts and programs have been used by professionals and schools for almost 30 years. Learn more at www.academyofclinicalmassage.com. 8 Wright abduction test. assess if neurological symptoms recur (Image 8). If they recur within about 30–45 seconds, this is a good indicator of potential neurovascular compression underneath the pectoralis minor. It is interesting to note that if the primary neurovascular compression is between the clavicle and first rib (costoclavicular variation) those symptoms will generally be relieved with the Wright abduction test because this movement lifts the clavicle off the rib cage. This variation seems to be predominantly caused by hypertonicity within the pectoralis minor muscle. Postural challenges may contribute to the problem as well. As a result, massage is generally