What is Pectoralis Minor Syndrome?
Pectoralis Minor Syndrome: Understanding and Treating a Hidden Cause of Shoulder Discomfort
Pectoralis Minor Syndrome (PMS) is an often overlooked condition that can cause significant pain and dysfunction in the shoulder and arm. Despite being less known than other musculoskeletal issues, PMS plays a crucial role in many cases of unexplained upper extremity discomfort. This post aims to shed light on PMS, its causes, symptoms, and how treatments like acupuncture and dry needling can offer relief.
Key Points
Pectoralis Minor Syndrome (PMS) is a condition where the pectoralis minor muscle compresses nerves and blood vessels, leading to pain and numbness in the shoulder and arm.
Anatomy Matters: Understanding the location and function of the pectoralis minor muscle helps in recognizing how PMS develops.
Common Symptoms include shoulder pain, weakness, numbness, and tingling sensations that can mimic other conditions like thoracic outlet syndrome.
Diagnosis Challenges: PMS is often misdiagnosed due to overlapping symptoms with other shoulder and neck conditions.
Effective Treatments: Non-surgical options like physical therapy, acupuncture, and dry needling have shown promise in relieving PMS symptoms.
Lifestyle Modifications and Exercises play a vital role in managing PMS and preventing its recurrence.
Pectoralis minor muscle
What Is Pectoralis Minor Syndrome?
Pectoralis Minor Syndrome (PMS) is a condition where the pectoralis minor muscle compresses the brachial plexus nerves or the blood vessels underneath it. This compression can lead to a variety of symptoms in the shoulder, arm, and chest. PMS is similar to thoracic outlet syndrome but specifically involves the area beneath the pectoralis minor muscle.
Traditionally, brachial plexus symptoms were thought to stem from compression between the anterior and middle scalenes or between the clavicle and first rib, termed neurogenic thoracic outlet syndrome (NTOS). However, recent understanding of the dynamic role of the pectoralis minor in scapular kinematics and nerve compression has led to the recognition of PMS as a dominant cause underlying NTOS.
Despite being first described in the 1940s as a neuromuscular hyperabduction syndrome, PMS has only gained recognition in recent years as a significant contributor to anterior shoulder, arm, and chest pain. This delay is partly because PMS is difficult to isolate from other forms of neurovascular compression.
Anatomy of the Pectoralis Minor Muscle
The pectoralis minor is a thin, triangular muscle located beneath the larger pectoralis major muscle on the front of the chest wall. It originates from the third to fifth ribs and inserts onto the medial border and superior surface of the coracoid process of the scapula. This muscle plays a key role in stabilizing the scapula by drawing it forward and downward against the thoracic wall.
After coursing beneath the clavicle, the neurovascular bundle to the upper extremity runs deep to the pectoralis minor along the serratus anterior muscle. At this site, the pectoralis minor may compress one or more of these structures, leading to PMS.
Brachial plexus
Brachial Plexus Anatomy
The brachial plexus is a complex network of nerves that originates from the spinal cord in the neck and extends through the shoulder to innervate the muscles and skin of the chest, shoulder, arm, and hand. Specifically, it is formed by the anterior (ventral) rami of the lower four cervical spinal nerves (C5-C8) and the first thoracic spinal nerve (T1).
Anatomically, the brachial plexus is divided into five sections:
Roots: These are the five spinal nerve roots (C5-T1) that emerge from the spinal cord.
Trunks: The roots combine to form three trunks:
Upper Trunk: Formed by the union of C5 and C6 roots.
Middle Trunk: Continuation of the C7 root.
Lower Trunk: Formed by the union of C8 and T1 roots.
Divisions: Each trunk splits into an anterior and a posterior division.
Cords: The divisions regroup to form three cords named according to their position relative to the axillary artery:
Lateral Cord
Posterior Cord
Medial Cord
Branches: These cords give rise to the major peripheral nerves of the upper limb, including the musculocutaneous, axillary, radial, median, and ulnar nerves.
The brachial plexus passes between the anterior and middle scalene muscles in the neck, travels over the first rib, and continues under the clavicle (collarbone) toward the arm. Its primary function is to transmit motor and sensory signals between the spinal cord and the upper limb, enabling movement and sensation.
Pectoralis Minor Muscle and the Brachial Plexus
The pectoralis minor muscle lies directly anterior to the brachial plexus as it traverses from the neck into the arm. Specifically, the cords and branches of the brachial plexus, along with the axillary artery and vein, pass beneath the pectoralis minor muscle at the level of the coracoid process of the scapula.
When the pectoralis minor muscle becomes tight, shortened, or hypertrophied due to factors like poor posture, repetitive overhead activities, or muscle imbalances, it can compress the underlying neurovascular structures. This compression can lead to Pectoralis Minor Syndrome (PMS), characterized by symptoms such as:
Neurological Symptoms: Numbness, tingling, burning sensations, or weakness in the shoulder, arm, and hand.
Vascular Symptoms: Swelling, discoloration, or temperature changes in the affected limb due to compromised blood flow.
The interaction between the pectoralis minor muscle and the brachial plexus is a critical factor in PMS. For instance, when the arm is elevated or abducted, the angle between the pectoralis minor and the rib cage changes, potentially increasing compression on the brachial plexus. This is why activities involving repetitive overhead motions can exacerbate symptoms.
Understanding this anatomical relationship is essential for diagnosing PMS. It differentiates PMS from other forms of thoracic outlet syndrome that may involve compression at different anatomical sites, such as between the scalene muscles or between the clavicle and first rib. Effective treatment often involves addressing the tightness or dysfunction of the pectoralis minor muscle through physical therapy, acupuncture and dry needling, stretching exercises, posture correction, and in severe cases, surgical intervention.
Causes and Risk Factors of PMS
PMS typically results from prolonged or repetitive activities that cause the pectoralis minor muscle to become tight or shortened. Common causes and risk factors include:
Repetitive Overhead Movements: Activities like weightlifting, swimming, or throwing sports can overuse the pectoralis minor.
Poor Posture: Slouching or forward head posture places the shoulder in a position that shortens the pectoralis minor.
Trauma or Injury: Neck, chest, and upper-extremity trauma can lead to inflammation and muscle tightness.
Occupational Hazards: Jobs requiring prolonged arm elevation or carrying heavy loads can contribute to PMS.
Anatomical Variations: Some individuals may have a naturally tight or hypertrophied pectoralis minor muscle.
Understanding these risk factors is crucial for both prevention and treatment, as addressing them can alleviate symptoms and improve quality of life.
Pectoralis Minor Syndrome Symptoms
PMS can present a range of symptoms that often mimic other conditions, making diagnosis challenging. Common symptoms include:
Shoulder and Chest Pain: Aching or sharp pain in the front of the shoulder and chest area.
Numbness and Tingling: Paresthesia in the arm, forearm, or hand due to nerve compression.
Weakness: Reduced strength in the affected arm, making it difficult to perform daily activities.
Swelling or Discoloration: In some cases, vascular compression can lead to swelling or changes in skin color.
Limited Range of Motion: Tightness in the muscle can restrict shoulder movements, especially overhead.
Patients with PMS typically lack positive findings to classic provocative thoracic outlet tests, such as rotational neck maneuvers and Adson's, Wright's, Roos, and Cyriax tests. In fact, these maneuvers have been found unreliable, demonstrating high false-positive and false-negative rates. The most precise physical findings for PMS are tenderness and a positive Tinel's sign over the pectoralis minor insertion.
Diagnosis of Pectoralis Minor Syndrome
Diagnosing PMS requires a thorough clinical evaluation, as it shares symptoms with conditions like thoracic outlet syndrome and cervical radiculopathy. Key steps in the diagnostic process include:
Medical History: Discussing symptoms, activities, and any prior injuries with a healthcare provider.
Physical Examination: Assessing posture, muscle tenderness, and performing specific tests to reproduce symptoms.
Provocative Tests: Traditional tests like Adson's or Wright's may not always be positive in PMS. Instead, tenderness over the pectoralis minor insertion and a positive Tinel's sign are more indicative.
Elevated Arm Stress Test: Positioning the shoulder in extension and varying positions of abduction to reproduce pain through compression of the brachial plexus between the pectoralis minor and thoracic wall.
Imaging Studies: MRI or ultrasound may help visualize muscle tightness or rule out other conditions.
Nerve Conduction Studies: These tests assess the function of nerves and can detect compression or irritation.
Accurate diagnosis is essential to develop an effective treatment plan and avoid unnecessary interventions.
Pectoralis Minor Syndrome vs. Thoracic Outlet Syndrome
Pectoralis Minor Syndrome (PMS) and Thoracic Outlet Syndrome (TOS) are conditions that often present with similar symptoms due to compression of nerves and blood vessels, making them challenging to differentiate. However, the key distinction lies in the specific anatomical location where this compression occurs.
Thoracic Outlet Syndrome involves compression of the neurovascular bundle—comprising nerves, arteries, and veins—as it passes through the thoracic outlet, the space between the collarbone (clavicle) and the first rib. This compression can lead to a variety of symptoms, including pain in the neck and shoulder, numbness or tingling in the arm and hand, and weakened grip strength. TOS can be categorized into three types based on the structures affected:
Neurogenic TOS: Compression of the brachial plexus nerves.
Venous TOS: Compression of the subclavian vein.
Arterial TOS: Compression of the subclavian artery.
On the other hand, Pectoralis Minor Syndrome involves compression of the brachial plexus nerves or axillary vessels beneath the pectoralis minor muscle, which is located just below the pectoralis major on the anterior chest wall. PMS presents with pain in the front of the chest, the trapezius muscle, and around the scapula. Patients may also experience arm and hand pain or paresthesia (numbness and tingling). Unlike TOS, the compression in PMS occurs outside the thoracic outlet, specifically under the pectoralis minor muscle.
Understanding the difference between PMS and TOS is crucial for accurate diagnosis and effective treatment. While both conditions can cause similar neurological and vascular symptoms in the upper extremity, their management may differ. PMS often responds well to physical therapy focusing on stretching and strengthening the pectoralis minor muscle, improving posture, and correcting muscular imbalances. In contrast, TOS treatment may involve interventions targeting the scalene muscles, first rib, or clavicle to relieve compression in the thoracic outlet.
Treatment Options for Pectoralis Minor Syndrome
Non-Surgical Treatments
The initial approach to treating PMS is typically conservative, focusing on relieving muscle tightness and improving posture. Non-surgical treatments include:
Physical Therapy: Customized exercises to stretch the pectoralis minor and strengthen surrounding muscles. The goal is to improve pectoralis minor flexibility while retraining scapular movement and scapulohumeral control.
Postural Retraining: Techniques to correct slouched posture and reduce strain on the shoulder girdle.
Manual Therapy: Massage and mobilization to release muscle tension and improve flexibility.
Activity Modification: Adjusting or limiting activities that exacerbate symptoms.
Stretching Exercises: Moving the coracoid insertion away from the anterior rib origin to stretch the pectoralis minor. Unilateral self-stretching techniques have been found superior to supine or sitting manual stretches for improving flexibility. Additional exercises to retrain scapular kinematics are also recommended.
These interventions aim to restore normal muscle function and alleviate nerve compression without the need for surgery.
Acupuncture and Dry Needling for Pectoralis Minor Syndrome
Acupuncture and dry needling have emerged as effective treatments for PMS by targeting muscle tension and promoting healing. Here's how they help:
Acupuncture: Involves inserting fine needles at specific points to stimulate the body's natural pain-relief mechanisms and reduce inflammation. One study showed it improved shoulder endurance after acupuncture treatment.
Dry Needling: Focuses on releasing trigger points in the pectoralis minor muscle, decreasing tightness, and relieving nerve compression.
Benefits:
Reduces muscle spasms and pain.
Improves blood flow to the affected area.
Enhances range of motion and function.
Research has shown that these techniques can significantly improve symptoms of PMS, especially when combined with other therapies.
Other Treatments
In cases where conservative treatments are insufficient, additional interventions may be considered:
Medications: Anti-inflammatory drugs or muscle relaxants to manage pain and discomfort.
Steroid Injections: Reducing inflammation around the nerve and muscle.
Surgical Release: In rare cases, surgery to release the pectoralis minor muscle may be necessary.
It's important to work closely with a healthcare provider to determine the most appropriate treatment based on individual needs.
Conclusion
Pectoralis Minor Syndrome is a significant yet often underdiagnosed cause of shoulder and arm pain. Understanding its causes, symptoms, and treatment options is crucial for those affected. Non-surgical treatments, particularly acupuncture and dry needling, offer promising results in relieving symptoms and improving function. By addressing muscle tightness and promoting proper biomechanics, individuals can find relief and return to their daily activities with greater comfort.
Over to you
If you found this article helpful, please share it with friends or family members who might be dealing with pectoralis minor syndrome.
Sources:
Ammi M, Péret M, Henni S, Daligault M, Abraham P, Papon X, Enon B, Picquet J. Frequency of the Pectoralis Minor Compression Syndrome in Patients Treated for Thoracic Outlet Syndrome. Ann Vasc Surg. 2018 Feb;47:253-259. doi: 10.1016/j.avsg.2017.09.002. Epub 2017 Sep 22. PMID: 28943489. https://pubmed.ncbi.nlm.nih.gov/28943489/
Borstad, J. D., & Ludewig, P. M. (2006). Comparison of three stretches for the pectoralis minor muscle. Journal of Shoulder and Elbow Surgery, 15(3), 324-330. https://pubmed.ncbi.nlm.nih.gov/16679233/
Demondion X, Herbinet P, Van Sint Jan S, Boutry N, Chantelot C, Cotten A. Imaging assessment of thoracic outlet syndrome. Radiographics. 2006 Nov-Dec;26(6):1735-50. doi: 10.1148/rg.266055079. PMID: 17102047. https://pubmed.ncbi.nlm.nih.gov/17102047/
Sanders RJ, Annest SJ. Pectoralis Minor Syndrome: Subclavicular Brachial Plexus Compression. Diagnostics (Basel). 2017 Jul 28;7(3):46. doi: 10.3390/diagnostics7030046. PMID: 28788065; PMCID: PMC5617946. https://pubmed.ncbi.nlm.nih.gov/28788065/
Sanders RJ, Annest SJ. Thoracic outlet and pectoralis minor syndromes. Semin Vasc Surg. 2014 Jun;27(2):86-117. doi: 10.1053/j.semvascsurg.2015.02.001. Epub 2015 Feb 18. PMID: 25868762. https://pubmed.ncbi.nlm.nih.gov/25868762/
Hollinshead, W. H. (1945). The hyperabduction syndrome. Journal of the American Medical Association, 128(2), 81-84.
Ahmed AS, Graf AR, Karzon AL, Graulich BL, Egger AC, Taub SM, Gottschalk MB, Bowers RL, Wagner ER. Pectoralis minor syndrome - review of pathoanatomy, diagnosis, and management of the primary cause of neurogenic thoracic outlet syndrome. JSES Rev Rep Tech. 2022 Jun 30;2(4):469-488. doi: 10.1016/j.xrrt.2022.05.008. PMID: 37588453; PMCID: PMC10426640. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6514035/
Jones, M. R., Prabhakar, A., Viswanath, O., Urits, I., Green, J. B., Kendrick, J. B., Brunk, A. J., Eng, M. R., Orhurhu, V., Cornett, E. M., & Kaye, A. D. (2019). Thoracic Outlet Syndrome: A Comprehensive Review of Pathophysiology, Diagnosis, and Treatment. Pain and therapy, 8(1), 5–18. https://doi.org/10.1007/s40122-019-0124-2 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6514035/
Sanders RJ, Hammond SL, Rao NM. Diagnosis of thoracic outlet syndrome. J Vasc Surg. 2007 Sep;46(3):601-4. doi: 10.1016/j.jvs.2007.04.050. PMID: 17826254. https://pubmed.ncbi.nlm.nih.gov/17826254/
Sanders RJ, Hammond SL. Management of cervical ribs and anomalous first ribs causing neurogenic thoracic outlet syndrome. J Vasc Surg. 2002 Jul;36(1):51-6. doi: 10.1067/mva.2002.123750. PMID: 12096257. https://pubmed.ncbi.nlm.nih.gov/12096257/
Kaplan J, Kanwal A. Thoracic Outlet Syndrome. [Updated 2023 Apr 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK557450/
Vemuri C, Wittenberg AM, Caputo FJ, Earley JA, Driskill MR, Rastogi R, Emery VB, Thompson RW. Early effectiveness of isolated pectoralis minor tenotomy in selected patients with neurogenic thoracic outlet syndrome. J Vasc Surg. 2013 May;57(5):1345-52. doi: 10.1016/j.jvs.2012.11.045. Epub 2013 Feb 1. PMID: 23375605. https://pubmed.ncbi.nlm.nih.gov/23375605/
Polcaro L, Charlick M, Daly DT. Anatomy, Head and Neck: Brachial Plexus. [Updated 2023 Aug 14]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK531473/
Sanders RJ, Rao NM. The forgotten pectoralis minor syndrome: 100 operations for pectoralis minor syndrome alone or accompanied by neurogenic thoracic outlet syndrome. Ann Vasc Surg. 2010 Aug;24(6):701-8. doi: 10.1016/j.avsg.2010.02.022. Epub 2010 May 14. PMID: 20471786. https://pubmed.ncbi.nlm.nih.gov/20471786/
Sadeghi-Azandaryani M, Bürklein D, Ozimek A, Geiger C, Mendl N, Steckmeier B, Heyn J. Thoracic outlet syndrome: do we have clinical tests as predictors for the outcome after surgery? Eur J Med Res. 2009 Sep 28;14(10):443-6. doi: 10.1186/2047-783x-14-10-443. PMID: 19748851; PMCID: PMC3352227. https://pubmed.ncbi.nlm.nih.gov/19748851/
Dede, B. T., Temel, M. H., & Bağcıer, F. (2023). Dry needling with blinded technique in pectoralis minor syndrome. Turkish journal of physical medicine and rehabilitation, 69(2), 257–258. https://doi.org/10.5606/tftrd.2023.12535
Wang, I. L., Hu, R., Chen, Y. M., Chen, C. H., Wang, J., & Ho, C. S. (2021). Effect of Acupuncture on Timeliness of Male Shoulder Joint Endurance. International journal of environmental research and public health, 18(11), 5638. https://doi.org/10.3390/ijerph18115638
Disclaimer: This web site is intended for educational and informational purposes only. Reading this website does not constitute providing medical advice or any professional services. This information should not be used for diagnosing or treating any health issue or disease. Those seeking medical advice should consult with a licensed physician. Seek the advice of a medical doctor or other qualified health professional for any medical condition. If you think you have a medical emergency, call 911 or go to the emergency room. No acupuncturist-patient relationship is created by reading this website or using the information. Morningside Acupuncture PLLC and its employees and contributors do not make any express or implied representations with respect to the information on this site or its use.