Thoracic outlet syndrome(Vera’s quick Google searching)
Thoracic outlet syndrome is defined as a neurovascular symptom complex associated with compression of the brachial bundle which includes the brachial plexus and/or subclavian vessels. This compression may be caused by several anatomical structures in one or more of the following three compartments: the inter scalene triangle, the costoclavicular space, or retropectoralis minor space.
Jonathan’s thaught’s - none of the testing is hugely accurate and we might suspect TOS bases on patients symptoms - Particularly non dermatomal arm symptoms coming on with working overhead or neck rotation towards affected side. Roo’s and Adson’s tests felt to be most helpful in our clinical situation (best sensitivity and specificity). A trial of physical therapy is not contra-indicated if a patient has TOS so if we suspect TOS providing some sessions of this first could be a good decision - if the patient does not show improvement referral on for further investigation (MRI/US) through an ACP would be appropriate.
Click on the test name below to see video of test demonstrated
This tests venous, arterial and neuro symptoms in tension.
Gillard et al (2001) found sensitivity 84% and specificity 30% - In other words low accuracy hence weak clinical value
To perform the test the patient sits with the head in the neutral position, the arms abducted and externally rotated to 90 degrees, and the elbows flexed to 90 degrees. The patient is then requested to flex and extend the fingers for up to three minutes. The examiner watches for any dropping of the extremity during this time which could indicate fatigue or arterial compromise. The therapist should also observe the color of the distal extremity comparing left with right and monitor symptom onset.
This test is positive when the patient is unable to maintain elevation for a 3 minute period or when symptoms are induced.
Decreases the space in the interscalene triangle.
Gillard et al (2001) found sensitivity 79%. Specificity 76%
To perform have the patient in upright sitting position with his arms remaining supported in his lab. Then the patient rotates and extends his neck to the tested side. This is followed by a deep inspirational breath which is held for up to 30 seconds, as the examiner palpates for any changes in the radial pulse. A modification is described with the shoulder in 15 degrees of abduction and the head maintained in the testing position for 1 minute while the subject breathes normally.
This test is positive, in case the radial pulse abolished or if the patient’s familiar symptoms are reproduced.
Decreases retro pectoralis minor space in the 1st step and costoclavicular in 2nd step
Gillard et al (2001) found it was no good as it was very unclear how to position the patient for this test!
To perform the test, the patient sits in a comfortable position. For the first part of the test, the patient’s arm is passively brought into abduction and external rotation to 90° without tilting the head. The elbow is flexed no more than 45°. The arm is then held for 1 min. The tester monitors the patient’s symptom onset and the quality of the radial pulse. The test is repeated with extremity in hyperabduction (end range of abduction).
A positive result is a decrease in the radial pulse and/or reproduction of the patient’s symptoms. Be aware, that other authors have described adding on the effect of cervical spine motion like flexion, extension, and left and right rotation.
Neurovasular bundle compression in costoclavicular space.
There are no diagnostic accuracy studies that I found.
To perform the test, the patient sits in a comfortable position. For the first part of the test, the patient’s arm is passively brought into abduction and external rotation to 90° without tilting the head. The elbow is flexed no more than 45°. The arm is then held for 1 min. The( tester monitors the patient’s symptom onset and the quality of the radial pulse. The test is repeated with extremity in hyperabduction (end range of abduction).
A positive result is a decrease in the radial pulse and/or reproduction of the patient’s symptoms. Be aware, that other authors have described adding on the effect of cervical spine motion like flexion, extension, and left and right rotation.
Halstead Test: (also known as Reverse Adson’s)
Used for neurovascular TOS testing. No good evidence of value as different studies use different positions for this test!
The patient is sitting or standing. The therapist continuously palpates the radial pulse on the side being tested. While still palpating the radial pulse, the therapist abducts the arm to 45 degrees, extends the shoulder to 45 degrees, and externally rotates the upper extremity while applying a downward distraction to the arm. The patient is then asked to fully turn her head away from the side being tested and extend the cervical spine
NB: MRI and US testing are thought to be most accurate (not sure if this has been studied in depth!).
Further reading: https://pubmed.ncbi.nlm.nih.gov/27632823/