Zaid Hjab The term thoracic outlet syndrome (TOS) encompasses numerous scenarios of compression (neurological and vascular) in the thoracic outlet region of the shoulder girdle. The syndrome can be divided into two sub classify cations: TOS caused by neurological factors and TOS caused by vascular problems. Neurological and vascular conditions also may be observed together.

1. Assessment of thoracic outlet syndrome
Report about
College of
Health and medical technology
Baghdad
Department of
Physiotherapy & Rehabilitation
Done by
Zaid Hjab Tawfeeq
4th
stage student
Supervised by
Raed Farooq Khaleel
M.Sc. Physiotherapy, B.M. Tech.

2. 1
Definition:
The term thoracic outlet syndrome (TOS) encompasses numerous scenarios
of compression (neurological and vascular) in the thoracic outlet region of the
shoulder girdle. The syndrome can be divided into two sub classify cations: TOS
caused by neurological factors and TOS caused by vascular problems. Neurological
and vascular conditions also may be observed together.
Thoracic outlet syndromes may combine neurological and vascular signs, or the
signs and symptoms of neurological deficit, restriction of arterial flow, or restriction
of venous flow may be seen individually.
The patient may complain of fatigue in the shoulder, vague shoulder pain, achiness,
and sense of heaviness in the shoulder, all of which can affect speed and control
while doing activity (e.g., throwing, swimming) especially with the arm in abduction
and lateral rotation.
Signs and Symptoms of TOS

3. 2
Assessment of Thoracic Outlet Syndrome:
With thoracic outlet tests that involve taking the pulse, the examiner must find
the pulse before positioning the patient’s arm or cervical spine. Because the pulse
may be diminished even in a “normal” individual, looking for the reproduction of
symptoms is more important than looking for diminution of the pulse. Unless
stated, the duration of these provocative tests should be no more than 1 to 2
minutes.
Adson Maneuver:
This test is probably one of the most common methods of testing for thoracic
outlet syndrome reported in the literature. The examiner locates the radial pulse.
The patient’s head is rotated to face the test shoulder. The patient then extends
the head while the examiner laterally rotates and extends the patient’s shoulder.
The patient is instructed to take a deep breath and hold it. A disappearance of the
pulse indicates a positive test.
Adson Maneuver test

4. 3
Costoclavicular Syndrome (Military Brace):
The examiner palpates the radial pulse and then draws the patient’s shoulder
down and back. A positive test is indicated by an absence of the pulse and implies
possible thoracic outlet syndrome (costoclavicular syndrome). This test is
particularly effective in patients who complain of symptoms while wearing a
backpack or heavy coat.
Halstead Maneuver:
The examiner finds the radial pulse and applies a downward traction on the test
extremity while the patient’s neck is hyperextended and the head is rotated to
the opposite side. Absence or disappearance of a pulse indicates a positive test
for thoracic outlet syndrome.
Costoclavicular Syndrome (Military Brace)
Halstead Maneuver

5. 4
Provocative Elevation Test:
The patient elevates both arms above the horizontal and is asked to rapidly open
and close the hands fifteen times. If fatigue, cramping, or tingling occurs during
the test, the test is positive for vascular insufficiency and thoracic outlet
syndrome. This test is a modification of the Roos test.
Roos Test (Elevated Arm Stress Test [EAST]):
The patient stands and abducts the arms to 90°, laterally rotates the shoulder,
and flexes the elbows to 90° so that the elbows are slightly behind the frontal
plane. The patient then opens and closes the hands slowly for 3 minutes. If the
patient is unable to keep the arms in the starting position for 3 minutes or suffers
ischemic pain, heaviness or profound weakness of the arm, or numbness and
tingling of the hand during the 3 minutes, the test is considered positive for
thoracic outlet syndrome on the affected side. Minor fatigue and distress are
considered negative tests. The test is sometimes called the positive abduction and
external rotation (AER) position test, the “hands up” test, or the elevated arm
stress test (EAST).
Roos Test

6. 5
Shoulder Girdle Passive Elevation:
This test is used on patients who already present with symptoms. The
patient sits, and the examiner grasps the patient’s arms from behind
and passively elevates the shoulder girdle up and forward into full
elevation (a passive bilateral shoulder shrug); the position is held for 30
or more seconds. Arterial relief is evidenced by stronger pulse, skin
color change (more pink), and increased hand temperature. Venous
relief is shown by decreased cyanosis and venous engorgement.
Neurological signs go from numbness to pins and needles or tingling, as
well as some pain, as the ischemia to the nerve is released. This is
referred to as a release phenomenon.
Shoulder Girdle Passive Elevation
B- RELIEF POSITIONA- START POSITION

7. 6
Wright Test or Maneuver:
Wright advocated “hyper abducting” the arm so that the hand is brought
over the head with the elbow and arm in the coronal plane with the shoulder
laterally rotated He advocated doing the test in the sitting and then the supine
positions. Having the patient take a breath or rotating or extending the head and
neck may have an additional effect. The pulse is palpated for differences. This test
is used to detect compression in the costoclavicular space and is similar to the
costoclavicular syndrome test.
Examiners have modified this test over time so that it has come to be
described as follows. The examiner flexes the patient’s elbow to 90° while the
shoulder is extended horizontally and rotated laterally the patient then rotates
the head away from the test side. The examiner palpates the radial pulse, which
becomes absent (disappears) when the head is rotated away from the test side.
The test done in this fashion has also been called the Allen maneuver. The pulse
disappearance indicates a positive test result for thoracic outlet syndrome.
A- Wright test B- Modified Wright test Or B
maneuver (Allen maneuver).

8. 7
References:
1-David J. Magee. Derrick Sueki. Orthopedic Physical Assessment. Fifth edition. Elsevier
Saunders. January 2008. Pp 46.
2-David J. Magee. Orthopedic physical assessment. Sixth edition. Elsevier Saunders. December
2013. Pp 344-347.