Coat Hanger Phenomenon & The Pretzel Leg Sign (14 of 24)

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In this video Dr. Goldstein presents two common signs seen in the clinic that may be a clue there is an autonomic problem.


Now we get to the Coat-Hanger Phenomenon.  One example of the power of obtaining the autonomic history is the Coat-Hanger Phenomenon.   In people who have neurogenic orthostatic hypotension or orthostatic intolerance, they can complain of pain, or like a charley horse kind of sensation, in the back of the neck and shoulder areas in the distribution that’s like a coat hanger.  And it goes away when the person is lying down.  That’s an important symptom.  And the way I explain it is that the muscles that control your head are tonically active, otherwise your head be falling down all the time.  Tonically active.  That means they’re using up oxygenated blood all the time.  Well suppose you’re in a critical situation where there’s a drop in blood flow at the delivery of oxygenated blood to the head.  In that situation these muscles are not getting enough oxygenated blood.  They’re tonically active, so they’re producing lactic acid and you get a charley horse, just like you’d have a cramp anywhere else.  It’s a skeletal muscle thing.  So, I think when somebody complains of Coat Hanger Phenomenon, that’s a very important sign or symptom.  And that is not invented.  That’s a real phenomenon.  It points to ischemia to the skeletal muscle holding your head up. 

Another example of the importance of the autonomic history is what I call Pretzel Legs Phenomenon.  This is a strong sign of orthostatic intolerance or orthostatic hypotension.  When you see somebody with that kind of a posture as you walk in the room, you think, well I don’t know what this person has, but whatever it is, it’s real.  The person is trying to use muscle pumping to get blood up towards the chest

Dr. David S. Goldstein
David S. Goldstein, M.D., Ph.D

Chief, Autonomic Medicine Section
NINDS, National Institutes of Health

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18 thoughts on “Coat Hanger Phenomenon & The Pretzel Leg Sign (14 of 24)”

  1. The coat hanger syndrome is exactly what I have, now I understand why I can’t keep my head up and the pain is so severe. It really affects your balance and I also have multiple sclerosis

    1. One possible cause is craniocervical instability, which is common in people with Ehlers-Danlos syndrome (but possible for anyone of course). Sometimes a neck brace will help.

  2. I’m unable to view this video for some reason. Would it be possible to add a photo or further description to explain what “pretzel legs” looks like?

    1. Well, I just took a picture of my own pretzel legs. They’re just always up in the air as much as possible. That is even better than being pretzeled out, or a combination is best! You can find Dr. Goldstein’s video about it on You Tube!! I certainly would like to go see that man. You can message me on messenger if you like – Joey Narciso, the pic with the yawning dog!

  3. Heather Clifford

    I am blown away every day learning something new about my disorders. I have EDS and POTS along with some other comorbidities, so does my Mom. Coat Hanger pain and constant knots in my neck, trap muscles and around both of my shoulder blades is just one of many, many symptoms I deal with every day. Finding out why I have always crossed my legs and arms like a pretzel because it feels right is unbelievable!!! I just thought it was another weird thing us EDSers do!! You have no idea how nice it is to hear validation that these things are not just in our heads, we’re not hypochondriacs like so many of us are accused of. Thank you so much 😊

  4. I’ve been told i don’t have EDS despite having all the symptoms bar the bendiness (the EDS society think I likely do have it). But I have pain in my neck and shoulders often – could well be coathangar pain. And i have sat with my legs wrapped that way for years and years. Very interesting.

  5. Crystal Springstead

    In addition to pots, and degenerative spinal issues, and a bunch of GI and cardio issues, I also have craniocervical instability and chari zero. That also causes coat hanger pain. Which causes which? I thought my CCI and Chari were causing pots and coat hanger pain, amongst other things.

  6. “Which comes first? The chicken or the egg?”
    I have a whole myriad of symptoms, but my neurologist said, “I just don’t know what is causing your symptoms. Maybe you should see a cardiologist.”
    I have coat hanger pain & orthostatic intolerance, this causes physical stress and raises my cortisol. The cortisol levels seem to impact my spine (I haven’t seen many studies on this but it seems to be a key) and now I have an MRI with the start of degenerative disk disease. I have reactive hypoglycemia, postprandial hypotension, issues with the urinary system (perhaps increased insulin leading to diabetes insipidus-like symptoms.), intolerance to heat (heart rate increases to 165 sitting in a shower chair in the shower), pre-syncope symptoms while standing. Walking seems better, until I stop. My symptoms worsen throughout the day, however my healthcare providers insist on autonomic testing and blood tests in the early morning. I am a high school science teacher that is about ready to lose her job after 20 years. I can barely stand up or sit up without dealing with severe chronic pain and pre-syncope.
    I want to be a teacher, a good mom, a good wife, a good friend, a good daughter. We are all in desperate need of answers and I have no more answers than I did 3 months ago. My heart breaks for those who have suffered for years before finding providers to support them.
    Thank you so much to everyone advocates, educates, and supports those with dysautonomia.


    My husband struggles with neck and back pain, actually it moves around on his back. We just learned a name for it. Coat Hanger Pain. Now how can we alliveate his pain besides having to lay down? We are getting desperate.
    Thank you,
    Norah Hendershot
    January 26, 2022

    1. We recommend you see a physician who is trained in autonomic medicine. Visit our physician finder at

  8. I notice both the coathanger and pretzel leg phenomena in myself, but I have sticklers syndrome type I . I have many migraines and other headaches, joint pain, and fatigue.

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