Scalenus syndrome is a kind of thoracic outlet syndrome. I treated 16 such cases with massage in combination with acupoint injection from 1989-1996. The results were satisfactory and introduced as follows.

Clinical Data
In this series, all the l6 cases were female, 24-40 years o1d, with a duration of il1ness from 3 months to 4 years (mean, 14months). All of them had a history of traumatic injury of the shoulder or continual backward extension of the neck, stretching the hand over the head, and hyperabduction of the upper arm in doing their jobs. They all had symptoms and signs like pain and numbness in the shoulder, arm, hand, grasp weakness, fullness in the infraclavicular fossa, hypertrophy of scalene muscle and positive vascular Adson sign. l2 cases got coldness of the affected limb and prolonged filling time of the capillaries; 9 cases got uncoordinated fine movements of the fingers; and 4 cases thenal muscular atrophy. X-ray findings were all normal except one showing lengthened 7th cervical transverse process.

Method of Treatment
1. Massage therapy: The patient was asked to take sitting position, with the head upright and neck muscle relaxed. The operator stood at the affected side of the patient, holding the affected arm in his left hand. Kneading and rolling manipulations were first applied at the shoulder and medial side of the upper arm (mainly on the distending and tender spots) for 3--5 minutes. Then, manipulations of kneading--pressing on acupoints Jianzhen (SI 9), Jianyu (LI 15), and Jianjing (GB 2l) with the thumb, forceful pressing-grasping with the thumb, the index and middle finger onTianzong (SI ll), Quchi (LI 11), Shousanli (LI10), and Hegu (LI 4), and then flicking-poking and lifting-pinching on Quepen (ST l2) and Jingbi (Extra 13) were performed, meanwhile the affected shoulder was continuously and slowly lifted and abducted by the operator's left hand for about 5 minutes. At the end, the affected limb was shaken for dozens of times, followed by repeated rubbing with palm along the most distending and sore points of the scalene muscles till the skin became warm and turned slightly red. The above manipulations were performed once a day.
2. Acupoint-injection: A mixture of 2ml of l% procaine hydrochloride and l00µg of Vit.B, was s1owly injected with a sterilized No.5 syringe needle into the acupoint Jingbi(Extra l3) after the needle was perpendicularly inserted into the skin and then advanced horizontally for about l cm until a needling sensation was experienced. The injection was given once every five days, and infra-red radiation was supplemented after the injection.

Therapeutic Result
15 cases got cure. Only l case complicated with lengthened 7th cervical transverse process still got pain and numbness of the upper arm and grasp weakness upon ill position of the affected arm, although she had got her condition improved with negative Adson sign.

Experience
The triangle between the scalene muscles is a narrow space at the thoracic outlet through which the brachial plexus nerve trunks and axillary vessels pass. Inflammation, trauma or irritation will cause spasm and edema of the local tissues and compression of the brachial plexus trunks and axillary vessels in this narrower space, leading to appearance of the symptoms and signs. Moreover, the compression and irritation of the brachial plexus trunks may in turn, increase spasm of the scalene muscles, resulting in a vicious circle. Therefore, relieving spasm and eliminating swelling should be the principle of treatment for this condition. In this study massage and point-injection are used to prevent this vicious circle of irritation--spasm-re-irritation of the muscular tissues by means of relaxing the spasmodic muscles to promote blood circulation and re1ieve pain by removing stagnation and obstruction in the meridians. Kneading, rolling, and rubbing manipulations should be mild, gentle and rhythmic at first in order not to cause new injuries of the scalene muscles but to promote circulation and accelerate absorption of inflammatory exudates and lower down the local sensitiveness to the pain. Then, forceful pinching—grasping along the course of the affected meridians is supplemented to promote circulation of Qi and blood, and relax the muscles and tendons by means of conduction of the meridian and collaterals. At last, flicking-poking and shaking manipulations are applied to relax local adhesion. Point Jingbi (Extra l3) is mainly indicated for numbness, weakness and myoatrophy of the upper limbs. The injection should not be made too deep lest the apex of the lung and vessels in the deeper part would be injured. No special handling is necessary for some patients who may get aggravated pain after the injection, for it may disappears spontaneously within one or two days. This comprehensive treatment should be carried on perseveringly and the relief of symptoms generally requires l-2 courses of treatment, i.e. 20-40 days. The patients should be advised to do suspension exercise of the muscles, correct shoulder drops, avoid stretching hand over the head, heavy-lifting, upward lifting and hyperabduction of the upper arm, especially during sleep.

By Peng Junyu