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88 m a s s a g e & b o d y w o r k s e p t e m b e r / o c t o b e r 2 0 1 7 Cervical rib person to person, and it is perfectly fine to experiment with different directions and see which gives the greatest relief of symptoms (Image 6). Gently stretch the skin and superficial tissues in the direction of greatest symptom reduction and hold that position for a minute or so. It is also helpful to encourage some gentle and easy passive and active movement of the cervical region immediately after this to help reestablish safe and pain-free movement for the region. Costoclavicular Syndrome Moving inferiorly from the scalene triangle, the next potential location for neurovascular problems is between the clavicle and first rib. In this location, the brachial plexus, as well as the subclavian vein and artery, are all susceptible to compression. The space between clavicle and first rib can vary significantly from person to person. In women, the shoulder has a lower position relative to the thorax than in men. This could be another reason this condition is far more prevalent in women than men. Other factors, such as poor posture, wearing of backpacks or straps across the shoulders, or various occupational activities, can lead to increased compression in the costoclavicular region. 3 Scalene tightness is also reported as a causative factor because when the muscles are tight, they may pull the first rib in a superior direction and decrease space between the rib and clavicle. One method commonly used to identify costoclavicular syndrome is called the military brace test. In this procedure, the scapula are squeezed together in Many of the special orthopedic tests used to identify variations of TOS focus on palpating and identifying the radial pulse. If the pulse diminishes during a positional movement, it would indicate a likely vascular (and probably also neurological) compression in that region. Yet, here is a good example of how a negative test may not truly show the presence of neurological involvement. If brachial plexus nerves are piercing directly through the scalene muscles, evaluating the pulse for potential compression in certain head or neck positions may be irrelevant because the nerves are getting compressed by tight muscles in every position, even if the vascular structures are not. In most cases, the anterior scalene TOS variation results from hypertonicity or problems directly in the scalene muscles. Therefore, massage and soft- tissue manipulation applied to this region can generally be helpful. However, the practitioner should be very careful about applying significant pressure in the anterior neck region as there are numerous sensitive structures in this area as well. The scalene muscles are superficial, and often it takes very little pressure to encourage some relaxation and decreased tightness in these muscles. Sometimes just applying a gentle traction force to the skin over the muscles can help decrease tightness and lessen symptoms. The direction of a traction force may vary from Massage can still be helpful for addressing hypertonicity of surrounding muscles. Anterior Scalene Syndrome Neurological or vascular compression may occur between the anterior and middle scalene muscles. Therefore, this TOS variation is frequently referred to as anterior scalene syndrome. Compression may impact the various fibers of the brachial plexus or the subclavian artery. Note that the subclavian vein does not pass through the scalene triangle so it is not involved in this variation (Image 5). Because both muscles insert on the first rib, they may pull the rib in a superior direction when hypertonic. Consequently, hypertonicity of the scalene muscles may decrease the size of the scalene triangle and increase potential neurovascular compression in this region. The space inside the scalene triangle for passage of the neurovascular structures may also be decreased from enlargement (hypertrophy) of the lower scalenes. Neurological compression may occur in this region even if there isn't a decreased space in the scalene triangle. In one recent anatomical investigation, researchers found close to 45 percent of the cadaver specimens had one or more branches of the brachial plexus that were piercing directly through the scalene muscles as opposed to coursing freely through the scalene triangle. 2 If that many people have nerves piercing directly through the scalenes, we should reconsider how often we use deep pressure techniques to treat these areas. 4 The cervical rib. Image is from 3D4Medical's Complete Anatomy application. Anterior scalene syndrome. Image is from 3D4Medical's Complete Anatomy application. Subclavian vein Brachial plexus Subclavian artery 5