Chapter 7: How Do They Diagnose It?

The Human Spring Approach to Thoracic Outlet Syndrome

Why this matters card explaining that a good examination aims to discover why compression developed so the underlying cause can be corrected, not simply labeled or treated.

How Do They Diagnose It?

It is by doubting that we come to investigate, and by investigating that we recognize the truth.

—Peter Abelard

The Most Important Purpose of the Examination

In this chapter, I inform you which medical history, physical examination, orthopedic examination, neurological examination, vascular examination, and diagnostic examination components are essential to a thorough thoracic outlet syndrome physical examination. This will allow you to check your doctor’s work to ensure there is sufficient information to lead to the correct thoracic outlet syndrome diagnosis and treatment plan.

In the next chapter, you will learn that this is not such an easy task. That is because there are about 30 different conditions that mimic thoracic outlet syndrome and can cause symptoms similar to neurogenic thoracic outlet syndrome and vascular thoracic outlet syndrome. So, your doctor has to be a “Sherlock Holmes” detective of medicine to determine which of the 30 differential diagnoses is responsible, sometimes in a matter of minutes.

The most important purpose of the examination is for you and your doctor to get a complete understanding of what is causing your thoracic outlet syndrome symptoms, so you can remove the underlying cause of thoracic outlet syndrome, reduce the compression, and reach maximum medical improvement and long-term recovery.

What makes examining patients with a possible thoracic outlet syndrome diagnosis more challenging is that you could have two, three, four, and even five of these different diagnoses at the same time, overlapping one another. This is called double crush syndrome, triple crush syndrome, quadruple crush syndrome, and quintuple crush syndrome.

Also, as you learned in Chapter 1, there are many different names for the same diagnosis of thoracic outlet syndrome (TOS). Confused enough? So are most doctors and healthcare professionals!

Thoracic outlet syndrome (TOS) is one of the most commonly misdiagnosed, underdiagnosed, mistreated, and misunderstood peripheral nerve compression disorders in medicine. This confusion about thoracic outlet syndrome diagnosis is why many of you are not finding relief from chronic neck pain, shoulder pain, arm numbness, tingling hands, upper back pain, and other symptoms of chronic suffering.

The Case History and Examination

The medical history and physical examination is a systematic diagnostic process by which your physician, chiropractor, physical therapist, or other healthcare professional investigates your thoracic outlet syndrome symptoms, together with your medical history, orthopedic examination, neurological examination, vascular examination, and diagnostic tests, if necessary, to make the correct thoracic outlet syndrome diagnosis, determine the underlying cause, and develop the most appropriate treatment plan.

Step One, The Medical History— This is the back-and-forth conversation with your doctor. After your first visit, a good doctor will write a detailed accounting of the events that have possibly contributed to or caused your current condition. A significant portion of a correct thoracic outlet syndrome diagnosis, differential diagnosis, and treatment plan comes from obtaining a thorough medical history.

The Symptoms

A symptom is subjective evidence of disease that you feel but cannot directly see or examine. One important component of every thoracic outlet syndrome examination is to determine exactly which thoracic outlet syndrome symptoms you have. However, thoracic outlet syndrome (TOS) is a little trickier. Symptoms of thoracic outlet syndrome can range from mild neck pain, shoulder pain, arm pain, numbness, tingling, weakness, cold hands, swelling, and sensory changes to limb-threatening vascular complications and, in rare cases, life-threatening complications (1).

Ten most common thoracic outlet syndrome (TOS) symptoms reported in patients with neurogenic thoracic outlet syndrome include the following (2).

Numbness, burning pain, or tingling in the upper limb, arm, or hand (98 percent)
Neck pain and cervical pain (88 percent)
Trapezius pain and upper back pain (92 percent)
Shoulder pain and/or arm pain (88 percent)
Collarbone pain (clavicle pain) (76 percent)
Chest pain and upper chest pain (72 percent)
Headache at the base of the skull (occipital headache) (76 percent)
Numbness, burning pain, or tingling in all five fingers (58 percent)
Numbness, burning pain, or tingling only in the fourth and fifth fingers (ring and little fingers) (26 percent)
Numbness, burning pain, or tingling in the third (middle) finger (14 percent)

Auto Accident or Work-Related Thoracic Outlet Syndrome

The timing of the thoracic outlet syndrome symptoms is important (3). The first thing I always ask a patient is whether they have experienced any trauma, such as a sports injury, motor vehicle accident (car accident), whiplash injury, work-related injury, or other acute trauma to the neck, upper back, shoulder, or chest.

One of the key questions the doctor should discuss is what type of work you do. Patients who perform repetitive overhead work, prolonged overhead lifting, or hold their heads and shoulders in awkward positions for extended periods may develop chronic muscle spasms that contribute to thoracic outlet syndrome. Occupations associated with a higher-than-normal incidence of thoracic outlet syndrome (TOS) include dentists, electricians, hairdressers, barbers, painters, mechanics, dental hygienists, and others who perform repetitive upper-extremity work.

Patients with thoracic outlet syndrome usually do not develop the condition from one strenuous activity but rather from repeated poor posture and prolonged static positioning. Individuals who read or watch television in bed, recline in a chair at work or home, spend long hours working at a computer, or lean back while driving frequently describe histories that are highly suggestive of thoracic outlet syndrome.

These are the most common activities of daily living (ADLs) that place chronic strain on the suspension muscles responsible for protecting the thoracic outlet and maintaining an open passageway for the brachial plexus, subclavian artery, and subclavian vein.

Sitting for prolonged periods at a desk or workstation in static postures.
Sitting or lying in awkward static postures while working at a computer, using a laptop, or watching television.
Leaning back in bed while supported by pillows.
Sitting in a recliner while reading or watching television.
Driving long distances with the seat reclined.
Performing prolonged overhead work with the arms elevated.
Carrying heavy luggage, backpacks, purses, shoulder bags, book bags, briefcases, or musical instruments.

Any prolonged leaning of the body to one side or backward can produce chronic muscle contraction and persistent muscle spasm patterns that gradually compress the thoracic outlet, resulting in brachial plexus compression, nerve compression, and, in some patients, blood vessel compression.

Almost 100 percent of the time, I can predict exactly which side of the couch people sit on while watching television simply by evaluating their symptoms. I'm usually about 99 percent accurate, which often startles them, as though I had been watching them through the window. I don't need to do that because the compression associated with thoracic outlet syndrome is remarkably predictable when you understand the laws of gravity, physics, biomechanics, and nature. Science makes diagnosis predictable.

Symptoms on One Side or Both Sides Is an Important Clue

One key component of the patient history is determining whether the symptoms occur on one side (unilateral thoracic outlet syndrome) or both sides (bilateral thoracic outlet syndrome). Patients often describe numbness, tingling, burning pain, weakness, or shooting pain into one arm with milder symptoms affecting the opposite arm.

When I hear this history, my first thought is often thoracic outlet syndrome. Cervical disc herniations and herniated cervical discs rarely compress nerve roots on both sides simultaneously except in very unusual circumstances. During more than 30 years of practice, I have seen only a handful of these cases, and they involved large central cervical disc herniations rather than the more common one-sided disc herniations. In addition, these central disc herniations are almost always associated with significant trauma. If there has been no recent trauma, I strongly suspect thoracic outlet syndrome rather than a herniated cervical disc or cervical radiculopathy.

Physical Examination

The physical examination for thoracic outlet syndrome (TOS) is where doctors find the objective signs of thoracic outlet syndrome. A sign is objective evidence of disease that the doctor can see, feel, or detect during a physical examination or with diagnostic tests.

The doctor should check for lumps, asymmetry, swelling, discoloration (such as bruising), or evidence of trauma. The doctor should also evaluate the lymph nodes, reflexes, and cranial nerves as part of a complete neurological examination. We are not going to review every component of a physical examination. Instead, we are going to review the most important findings that help determine whether you have thoracic outlet syndrome (TOS).

What to Look for if You Suspect Thoracic Outlet Syndrome (TOS)

Woman watching a posture and movement assessment on a desktop screen while learning how clinicians evaluate posture, muscle tension, biomechanics, and movement to identify the true cause of TOS compression.

Physical Examination

Skin Color

If the veins are compressed from venous thoracic outlet syndrome (VTOS), the doctor might see a light blue discoloration (cyanosis) of the skin resulting from poor circulation or inadequate oxygenation of the blood in the arm.

If the artery is compressed from arterial thoracic outlet syndrome (ATOS), your doctor might see pallor, which is a paleness, pallidness, lack of color, an ashen hue, pastiness, or a gray tone to your skin caused by reduced arterial blood flow.

Examination for Swelling, Inflammation and/or Edema (Pitting Edema)

Next, your doctor should examine the skin, muscles, joints, and soft tissues for swelling, inflammation, or edema. One of the most common physical signs of thoracic outlet syndrome is swelling. Swelling can occur anywhere in the neck, shoulder, chest, arm, forearm, hand, or fingers. There are two types of swelling commonly found in patients with thoracic outlet syndrome: inflammatory swelling and edema swelling.

The doctor might also observe enlarged or swollen superficial veins in the arm, shoulder, upper chest, or neck caused by impaired venous drainage.

Inflammation recognition guide showing neck, collarbone, and supraclavicular swelling, with labeled areas that help explain how inflammation can change the appearance of the neck and upper chest.

Inflammation Swelling

Inflammation swelling is swelling of injured or strained tissues, including strained muscles, ligaments, tendons, fascia, and joints. It may be acute following a recent motor vehicle accident, sports injury, or fall, or chronic from repetitive strain, poor posture, prolonged computer work, occupational overuse, or other daily activities affecting the neck, chest, and shoulder.

I can usually see obvious signs of inflammation swelling that patients and even their close friends and family members cannot recognize. That is because thoracic outlet syndrome often develops gradually over weeks, months, or even years, making the slow onset of swelling difficult to appreciate.

Normally, you should be able to see a well-defined outline of the collarbone (clavicle), neck muscles, and the hollow above the collarbone known as the supraclavicular fossa. If these normal anatomical landmarks are no longer visible, you may have inflammation swelling affecting the neck, upper chest, shoulder, or thoracic outlet region.

Clinical photo showing a woman's neck and supraclavicular region used to demonstrate visible anatomical landmarks, muscle definition, and soft tissue changes associated with thoracic outlet syndrome examination.

The best way to recognize this change is to compare yourself with someone who is healthy. Stand side-by-side in front of a mirror with your neck and upper chest exposed. Compare the outlines of the collarbones, neck muscles, and supraclavicular fossae. If you cannot clearly see these normal anatomical structures beneath the skin, you may have inflammation swelling associated with thoracic outlet syndrome.

Edema Swelling

Edema swelling is an abnormal accumulation of fluid within the interstitial tissues between the skin and muscles. In patients with thoracic outlet syndrome, swelling may involve the fingers, hand, forearm, arm, or the entire upper extremity. This occurs because compression of the subclavian vein restricts the normal drainage of blood and tissue fluid from the arm, producing venous thoracic outlet syndrome.

The first visible sign is often swollen fingers, especially in the morning when putting on rings or a wedding ring becomes difficult. I obtain a more accurate assessment of swelling by photographing both hands and comparing them side-by-side.

Clinical photo comparing both hands of a thoracic outlet syndrome patient, showing visible differences in muscle mass, hand size, and tissue swelling used to assess vascular and neurological compression during physical examination.

Another, more advanced sign of swelling is pitting edema. This is a classic sign of significant fluid accumulation. During my 28 years in practice, I observed upper-extremity pitting edema seven times in patients with severe venous thoracic outlet syndrome. Although physicians commonly associate pitting edema with poor circulation in the lower legs, it can also occur in the forearm, hand, and arm when venous drainage is severely compromised.

Clinical photo showing a clinician pressing into a patient's swollen forearm to test for pitting edema associated with venous thoracic outlet syndrome and poor circulation.

To test for pitting edema, the doctor presses firmly with the thumb into the calf, forearm, or hand. If an indentation remains after the thumb is removed, the patient has pitting edema.

A Clinical Example of Severe Venous Thoracic Outlet Syndrome

One Saturday afternoon, I performed a six-hour treatment on piano player Sonny Burke's thoracic outlet. The purpose of the treatment was to reduce severe muscle spasms that were pulling his collarbone downward onto the subclavian vein, producing significant venous thoracic outlet syndrome. I could feel a large amount of accumulated fluid between the skin and muscles because the narrowed vein severely restricted the normal return of blood and interstitial fluid from his arm.

The following Monday he returned in a panic.

"What did you do to me?" he exclaimed.

I looked down and saw a hand that appeared almost skeletal, with the skin tightly covering the bones. I was not alarmed because it would have been impossible for the muscles to atrophy that dramatically in only two days. The hand simply appeared thin because the excessive fluid had completely drained after restoring venous outflow.

By opening the thoracic outlet and relieving pressure on the subclavian vein, the accumulated edema disappeared. Once the swelling resolved, the severe muscle atrophy became visible. Years of poor circulation, inadequate oxygen delivery, reduced nutrient supply, and profound grip weakness had prevented him from exercising the muscles of his hand.

I looked down and said, "That is what your hand should look like after receiving almost no normal blood flow or exercise for five years."

"What am I going to do to fix it?" he asked.

I had the perfect answer.

"You are going to strengthen it by playing the piano again."

You should have seen the look on his face!

Posture Evaluation

The first step in examining yourself for these postural changes associated with thoracic outlet syndrome (TOS) involves an examination of your posture. We talked about posture extensively in Chapter 4, “The Control of Tension on Your Human Spring.”

These are the two most important things that can cause a shift in the structures to compress the thoracic outlet, narrow the thoracic outlet tunnel, compress the brachial plexus, or compress the subclavian artery and vein.

Muscle Weakness (Muscle Imbalance)—Weakness in the muscles that suspend the shoulder over the thoracic outlet, such as the upper trapezius muscle and levator scapulae muscle, can happen either from muscle fatigue caused by constant contraction or muscle spasm, or from general muscle weakness. This muscle imbalance can contribute to thoracic outlet syndrome, shoulder depression, poor posture, and compression of the thoracic outlet.
Muscle Spasms or Muscle Tension—A myofascial trigger point, muscle spasm, or sustained muscle contraction can cause direct or indirect compression of the thoracic outlet. The ribs can elevate into the thoracic outlet by a sustained contraction of the anterior scalene, middle scalene, and posterior scalene muscles, and the shoulder can be pulled or dragged down into the thoracic outlet by sustained contraction of the pectoralis minor muscle, subclavius muscle, coracobrachialis muscle, short head of the biceps muscle, and the anterior neck muscles, increasing brachial plexus compression, subclavian artery compression, and subclavian vein compression.

These are the postural changes that might suggest muscle contractions are compressing the thoracic outlet or weakness in the muscles that suspend the shoulder over the thoracic outlet and maintain the thoracic outlet tunnel. A lot of doctors look for the “high” shoulder. I look for the low shoulder, because the low shoulder is usually the shoulder that is pulled down by muscle spasms and contributes to thoracic outlet syndrome compression.

Your head is tilted down.
Your head leans to the side of the symptoms.
Your shoulders droop forward and down on the side of the symptoms.
Your hands are rotated inward on the side of the symptoms (only the thumb and the knuckle of one finger should be showing in the mirror).

That is because the muscles are pulling the head down and pulling the shoulder down and into the thoracic outlet tunnel, narrowing the space. These postural changes tend to increase compression of the brachial plexus nerves, subclavian artery, and subclavian vein, producing many of the classic thoracic outlet syndrome symptoms, including neck pain, shoulder pain, arm numbness, hand tingling, arm weakness, and poor circulation.

Range of Motion of the Neck, Shoulder, Elbow, and Hand

Patients with thoracic outlet syndrome are usually capable of bending their neck forward, backward, and rotating the neck to the right and left. They almost always have difficulty with lateral neck bending (side bending). The reason is because the scalene muscles are contracting, preventing the neck from bending normally to the side.

If the anterior scalene, middle scalene, and posterior scalene muscles are in spasm, they will elevate the first rib and second rib and pull the upper neck toward the shoulder. These muscles can become enlarged or swollen from constant muscle tension, further narrowing the thoracic outlet and increasing compression of the brachial plexus, subclavian artery, and subclavian vein.

The exact ranges of motion of the shoulder, elbow, and hand are a little complex to review in this book. If your range of motion is reduced, you can usually recognize it yourself.

Infographic warning that jaw dysfunction may contribute to neck tension, headaches, muscle guarding, and thoracic outlet compression, and advises avoiding pressure on the jaw and jaw-based neck adjustments.

1. Jaw Examination (Examination for TMJ Syndrome)

Temporomandibular joint (TMJ) syndrome is a disorder affecting the muscles and joints of the jaw. The jaw can develop arthritis, joint dysfunction, muscle spasms, and chronic jaw pain just like any other joint in the body.

The problem with patients who have TMJ syndrome is that the jaw pain and muscle tension can spread into the neck, shoulder, upper back, and surrounding muscles. These muscle spasms may contribute to thoracic outlet syndrome, chronic neck pain, headaches, facial pain, and muscle tension, making recovery more difficult. If a doctor wants to give you the best chance of completely reversing your thoracic outlet syndrome, they should have a strategy to evaluate and address your TMJ disorder at the same time.

I take out my phone and videotape your mouth opening and closing. Then I play the video back in slow motion so we can carefully review the movement of the jaw.

If we see the jaw deviate to one side during opening, it usually signifies TMJ dysfunction affecting both sides of the jaw. It is important to look and feel for any jaw joint dislocation, jaw clicking, jaw popping, jaw locking, or abnormal movement of the temporomandibular joint (TMJ) by watching and placing a light contact over the jaw just anterior (forward) and inferior (below) the ear. If you see, feel, or hear the jaw pop out of alignment, you may have a misaligned jaw or temporomandibular joint dysfunction (TMJ disorder).

Couple watches Dr. Stoxen's trigger point and muscle palpation demo on a desktop while viewing the same video on a smartphone, learning how clinicians identify thoracic outlet compression.

2. Neurologic Evaluation

Reflexes—Do you have damage to your brain, spinal cord, or peripheral nerves?

The first neurological examination a doctor should perform is a reflex examination of your elbow, wrist, and forearm reflexes. These deep tendon reflex tests help determine whether your symptoms are caused by a brain disorder, spinal cord disorder, cervical spinal nerve compression, peripheral nerve injury, or another neurological condition. During a complete neurological examination, the doctor should also examine your cranial nerves to identify signs of brain, brainstem, or central nervous system disease.

The Sensory Exam—Are Your Nerves Compressed, Pinched, or Damaged?

The sensory examination evaluates whether you have nerve compression, nerve irritation, or nerve damage by testing pain sensation (pinprick), light touch sensation, temperature sensation, and sensory perception. The examination is performed by lightly brushing or touching strategic areas of the skin over the neck, shoulder, arm, forearm, hand, and fingers to determine whether sensation is normal or altered.

The doctor will touch your skin with either a pin or a soft brush and ask whether the sensation feels "sharp" or "dull." This sensory mapping helps determine whether a cervical spinal nerve, brachial plexus nerve, or peripheral nerve is compressed or injured. Each cervical nerve root (dermatome) supplies sensation to a specific region of the shoulder, arm, forearm, hand, and fingers, allowing the doctor to identify the level of nerve compression or nerve injury.

The nerve level corresponds to a specific dermatome that should be tested during the neurological sensory examination with the brush and pin.

The most common symptoms of a pinched nerve, compressed nerve, cervical radiculopathy, brachial plexus injury, or thoracic outlet syndrome include neck pain, shoulder pain, arm pain, numbness, tingling, burning sensations, muscle weakness, loss of sensation, altered reflexes, or a combination of these symptoms. The spinal nerve level that may be compressed is listed on the left, and the most common area of pain, numbness, tingling, or sensory disturbance is listed on the right.

C2 — back of the head, occipital pain, headaches, occipital headaches
C3 — back of the head, behind the eye, behind the ear, upper neck pain
C4 — base of the neck, upper shoulder, trapezius region
C5 — upper shoulder, deltoid region, upper arm weakness
C6 — thumb, index finger, middle finger, forearm pain, C6 radiculopathy
C7 — middle finger, triceps region, C7 radiculopathy
C8 — ring finger, little finger, hand weakness, grip weakness
T1 — little finger, inner forearm, intrinsic hand muscle weakness, thoracic outlet syndrome symptoms

Common mistake graphic showing that patients focus on where pain occurs, while clinicians look for what repeatedly created compression, using inflammation mapping to identify the underlying cause.

3. Palpation

Deep Muscle Palpation—Muscle Tension, Trigger Point, and Inflammation Examination

The most important part of a thoracic outlet syndrome physical examination is checking for painful muscle spasms, trigger points, muscle knots, myofascial trigger points, muscle tension, and chronic muscle inflammation. These muscle spasms, also known as trigger points, myofascial trigger points, muscle knots, or super contractions, can be painful or nonpainful. The question is, how do you find them? You stick your thumb into them.

There are two ways to find the muscle compressive spasms responsible for thoracic outlet syndrome compression.

There are 10 muscles that, when chronically contracted, can compress the thoracic outlet, thoracic outlet tunnel, brachial plexus, subclavian artery, and subclavian vein. You can determine which muscles are involved by the pain and pattern of pain radiation, referred pain, arm numbness, hand tingling, and muscle weakness.
They are painful if you press on them. Deep muscle palpation (pushing your thumb deep into the muscle) is a reliable way to examine for trigger points, myofascial trigger points, muscle spasms, super contractions, and painful muscle tension. Muscles that are not in chronic spasm generally do not hurt during palpation.

Refer to Chapter 13, "What Works and Why?" for the location of these muscles. You are going to examine yourself and treat yourself at the same time.

These muscles, when chronically contracted, compress the thoracic outlet, thoracic outlet tunnel, brachial plexus, subclavian artery, and subclavian vein.

Push the pad of your thumb deep into each muscle to check for a rope-like muscle, tight muscle band, hard muscle, trigger point, or myofascial trigger point that becomes increasingly painful the deeper you press.

Here is a list of all 10 muscles that either directly compress or contribute to the compression of the thoracic outlet and thoracic outlet tunnel.

Anterior scalene muscle — (compression of the interscalene triangle, brachial plexus, subclavian artery, and subclavian vein)
Middle scalene muscle — (compression of the interscalene triangle, brachial plexus, subclavian artery, and subclavian vein)
Posterior scalene muscle — (compression of the interscalene triangle)
Anterior neck muscles — (compression of the neck and thoracic outlet)
Pectoralis minor muscle (pec minor) — (compression of the costoclavicular space and subpectoral space)
Coracobrachialis muscle — (compression of the costoclavicular space and subpectoral space)
Biceps short head muscle — (compression of the costoclavicular space and subpectoral space)
Latissimus dorsi muscle — (compression of the costoclavicular space and subpectoral space)
Lower trapezius muscle — (compression of the costoclavicular space and subpectoral space)
Subclavius muscle — (compression of the interscalene triangle, costoclavicular space, and subpectoral space)

The subclavius muscle is the only muscle capable of compressing the interscalene triangle, costoclavicular space, and subpectoral space, making it one of the most important muscles to evaluate and treat in every case of thoracic outlet syndrome. In my more than 30 years of experience treating patients who failed nonsurgical treatment, I have never had a patient tell me that a previous doctor examined or treated the subclavius muscle.

You rarely hear doctors discuss the posterior scalene muscle when treating thoracic outlet syndrome. Do they understand that if this muscle develops a chronic spasm, it can elevate the second rib, and because the second rib is mechanically connected to the first rib, it can elevate the entire upper rib cage, contributing to thoracic outlet compression?

You rarely hear doctors discuss the lower trapezius muscle or latissimus dorsi muscle. Do doctors realize these muscles can depress the shoulder into the thoracic outlet and thoracic outlet tunnel when they remain in chronic spasm?

You rarely hear doctors discuss the coracobrachialis muscle or the short head of the biceps during thoracic outlet syndrome treatment. Do doctors understand that these muscles are heavily used during shoulder flexion, including holding a computer mouse, smartphone, tablet, or typing with outstretched arms? These muscles attach to the same coracoid process as the pectoralis minor and can contribute to depression of the shoulder, increasing thoracic outlet compression.

The current vision of thoracic outlet syndrome is often limited to the muscles surgeons prefer to surgically release or resect. This narrow focus represents a significant misunderstanding of human anatomy, human biomechanics, and human engineering.

If your doctor does not examine all 10 of these compressive muscles for trigger points, muscle spasms, myofascial trigger points, and super contractions, you are likely wasting your time. What is acceptable about doctors failing to examine and treat muscles they are expected to understand? If they do not perform deep tissue examination and deep tissue treatment on all 10 muscles, you are definitely wasting your time. It is time to find a doctor who will.

There are photographs illustrating exactly where to perform deep muscle palpation, identify trigger points, and examine each muscle for thoracic outlet syndrome in Chapter 13, "What Works and Why?"

Couple watches a Vibeassage self-help tutorial on a desktop and smartphone, learning how to reduce muscle guarding, improve circulation, decrease tension, and support recovery with simple at-home self-treatment techniques.

Motor Examination

Manual Muscle Strength Testing

Manual muscle strength testing (MMT), looking for muscle weakness, can help pinpoint the muscles involved in thoracic outlet syndrome (TOS), neurogenic thoracic outlet syndrome (NTOS), brachial plexus compression, and nerve compression syndromes. The muscles are weak because they are contracting 24 hours a day, seven days a week, leading to muscle fatigue, muscle imbalance, and chronic muscle tightness.

Dr. Stoxen performing a thoracic outlet syndrome orthopedic examination on a seated female patient, demonstrating arm and shoulder positioning used to assess brachial plexus compression and vascular compression.

Watch the Examination callout card showing a woman with shoulder pain viewing Dr. Stoxen's examination video on a desktop and smartphone, with a Watch Now button linking to a lesson on first rib movement, clavicle motion, and joint spring evaluation.

Spine, First and Second Rib Examination

The spinal examination I perform is a motion palpation examination. Motion palpation is a hands-on examination technique used to locate spinal joint dysfunction, joint stiffness, joint locking, reduced joint play, restricted spinal motion, and loss of normal spring mechanics within the spinal column, first rib, second rib, and extremities.

It is a technique developed by Henri Gillet, a Belgian chiropractor, in which the practitioner's hands are used to assess the movement of specific spinal segments while the patient moves. The purpose is to evaluate the dynamic movement of the vertebral joints, costovertebral joints, costotransverse joints, and extravertebral joints to identify joint dysfunction, spinal dysfunction, rib dysfunction, and biomechanical abnormalities associated with thoracic outlet syndrome.

The Cervical Rotation Lateral Flexion Orthopedic Test

During this orthopedic test, I look for stiffness, joint locking, reduced joint play, restricted joint spring, and abnormal movement in the lower cervical spine and upper ribs. More specifically, I evaluate for first rib elevation, second rib elevation, first rib fixation, second rib fixation, and first rib dysfunction, which are common findings in patients with thoracic outlet syndrome.

During the examination, I assess the joint play and joint spring of all twelve ribs. I also evaluate for restricted motion, reduced joint mobility, and loss of normal biomechanics of the clavicle (collarbone), sternoclavicular joint, acromioclavicular joint, shoulder girdle, and thoracic outlet.

I have been evaluating spinal and rib motion for subtle movement abnormalities for more than 30 years. After examining well over one million spinal and rib segments, approximately 12 hours per day, more than six days per week, I can recognize abnormal movement patterns associated with thoracic outlet syndrome, cervical dysfunction, rib dysfunction, and spinal biomechanical disorders.

A doctor uses his or her hands to introduce motion into the joints while evaluating joint play, joint spring, end-feel, spinal mobility, rib mobility, and segmental motion for stiffness or locking. Developing this level of palpation skill requires years of experience. Some chiropractors become highly skilled in motion palpation, spinal manipulation, first rib adjustment, and manual therapy, while others develop only a limited level of proficiency. Some practitioners no longer evaluate joint play or perform hands-on adjustments of the spine, ribs, and extremities, relying instead primarily on passive therapies.

Examination of the Shoulder

The key to examining the shoulder in patients with thoracic outlet syndrome is manual muscle strength testing. However, in strong athletes, construction workers, weightlifters, or former athletes, an inexperienced physician or therapist may overlook subtle muscle weakness, muscle inhibition, or nerve-related weakness during routine muscle testing.

Doctors and therapists should always follow positive or negative muscle strength testing with deep tissue palpation, trigger point examination, muscle palpation, and soft tissue examination of the ten muscles most commonly involved in thoracic outlet syndrome, brachial plexus compression, and shoulder dysfunction.

The structure of the shoulder that most commonly descends into the thoracic outlet and thoracic tunnel is the clavicle (collarbone). The position of the clavicle is determined by the balance between the muscles that pull the shoulder downward into the thoracic outlet and the muscles responsible for shoulder elevation, shoulder suspension, scapular stabilization, and maintaining the normal thoracic outlet space.

When movement of the clavicle becomes restricted, it can narrow the space between the collarbone and the chest, reducing the size of the costoclavicular space, thoracic outlet, and thoracic tunnel, resulting in compression of the brachial plexus, subclavian artery, and subclavian vein (13). You and your doctor can evaluate clavicular movement by placing your opposite hand over the collarbone while lifting your arm upward and backward. During this examination, assess for clicking, restricted motion, decreased mobility, pain, numbness, tingling, weakness, reproduction of symptoms, and signs of thoracic outlet syndrome.

Examination for Other Areas of Compression

Headaches and cervicogenic headaches—base of the skull
Cervical herniated discs and thoracic herniated discs—neck and upper back
Hyperabduction syndrome and shoulder compression syndrome—shoulder
Cubital tunnel syndrome and ulnar nerve compression—elbow
Median nerve compression and pronator syndrome—forearm
Carpal tunnel syndrome and median nerve entrapment—wrist
Guyon's canal syndrome (ulnar tunnel syndrome) and ulnar nerve compression—wrist and hand

I also perform a comprehensive examination for other nerve compression syndromes, peripheral nerve entrapment syndromes, and compression disorders affecting the shoulder, arm, elbow, forearm, wrist, and hand. I check for rib misalignments, first rib dysfunction, pinched nerves, cervical herniated discs, and thoracic herniated discs of the spine and thorax. I evaluate for hyperabduction syndrome, shoulder subluxation, rotator cuff syndrome, shoulder impingement syndrome, and brachial plexus compression of the shoulder. Farther down the arm, I examine for cubital tunnel syndrome, ulnar nerve compression, median nerve compression, pronator syndrome, and carpal tunnel syndrome, which involves median nerve entrapment at the wrist. I also examine for Guyon's canal syndrome (ulnar tunnel syndrome) involving compression of the ulnar nerve in the hand.

If you have thoracic outlet syndrome together with another nerve compression syndrome, it is called double crush syndrome.

If you have two additional compression syndromes or peripheral nerve entrapment syndromes, it is called triple crush syndrome, and so on. You would be surprised how many patients I have found with multiple nerve compression syndromes occurring at the same time. If your doctor fails to examine for multiple areas of nerve compression and multiple compression syndromes, you cannot put much confidence in the diagnosis or treatment plan.

This type of misdiagnosis is called underdiagnosis, an incomplete diagnosis, or a condition that is not diagnosed. The reason I perform a comprehensive examination is because I want to identify and treat every source of nerve compression, every compression syndrome, and every musculoskeletal dysfunction at the same time, so that by the end of treatment you are as close to full recovery and maximum medical improvement as humanly possible. This comprehensive approach also reduces the possibility of misdiagnosis, underdiagnosis, and failed treatment.

I never want to say to you at visit 10, "At first I thought it was thoracic outlet syndrome, but after 10 treatments I discovered you also have carpal tunnel syndrome." If we had identified and treated both thoracic outlet syndrome and carpal tunnel syndrome from your very first visit, we could have been working to reverse both conditions throughout your entire treatment program.

To see videos demonstrating manual muscle testing, orthopedic muscle testing, and musculoskeletal examination techniques, visit www.teamdoctorsacademy.com.

Infographic explains that thoracic outlet syndrome cannot be diagnosed by one orthopedic test alone and should be evaluated through history, physical examination, posture, biomechanics, neurological findings, and vascular findings before surgery.

Orthopedic Tests for Thoracic Outlet Syndrome

Orthopedic Tests Doctors Use to Diagnose Thoracic Outlet Syndrome

There are many orthopedic tests, clinical examination tests, and physical examination tests that doctors use to determine whether you have thoracic outlet syndrome. However, when you look at these thoracic outlet syndrome orthopedic tests the way I do, you can learn far more than simply whether compression of the thoracic outlet is present.

The reason many doctors fail to learn as much from these orthopedic examination tests as they should is because they rigidly follow standardized textbook protocols for performing each test. Those protocols are useful for assigning a diagnosis, but they often fail to explain the underlying cause of thoracic outlet syndrome or why the compression developed. Following the protocol exactly may help identify the condition, but it rarely explains the underlying biomechanics.

Doctors often debate the reliability of these tests using terms such as false positive and false negative. A false-positive orthopedic test occurs when someone without thoracic outlet syndrome produces a positive test result. With this mindset, many physicians become focused on debating the accuracy of the test rather than understanding what the examination is revealing about the patient's biomechanics, nerve compression, and movement dysfunction.

Every examination finding provides valuable information about the cause of the patient's signs and symptoms. I never look at an orthopedic test as simply positive or negative. Hands-on physical examination, manual examination, and palpation of the human body are an art form. Every piece of information obtained during the examination helps determine the cause of thoracic outlet syndrome, identify contributing compression syndromes, and develop the most appropriate treatment plan for that specific patient.

It is similar to asking two different artists to sculpt a person out of clay or draw the human body. Both may recognize what they are creating, but one artist possesses a much deeper understanding of form, proportion, and detail. The same is true in orthopedic examination, physical diagnosis, and manual medicine. When an examiner has truly mastered the art of examination, you recognize that level of skill immediately.

Tests for Compression at the Interscalene Triangle

There are specific orthopedic tests for thoracic outlet syndrome (TOS) that evaluate compression at the interscalene triangle caused by scalene muscle spasms, first rib elevation, and compression of the brachial plexus, subclavian artery, and subclavian vein. These tests also evaluate pectoralis minor syndrome and subclavius muscle compression, which can compress the collarbone onto the ribs and contribute to thoracic outlet syndrome symptoms.

Why is it so important to perform these thoracic outlet syndrome orthopedic tests and examine the muscles attached to the ribs?

A swelling above the collarbone around the neck most commonly indicates abnormal movement of the first rib and second rib. This swelling may represent inflammation, soft tissue swelling, or irritation related to an elevated first rib, a common finding in patients with thoracic outlet syndrome and first rib dysfunction (12).

Morley’s sign (tenderness in the supraclavicular fossa) may have diagnostic value for thoracic outlet syndrome diagnosis, particularly when it is clearly one-sided and reproduces symptoms such as neck pain, shoulder pain, arm pain, arm numbness, hand tingling, or brachial plexus pain (16).

This finding should be followed by an examination of first rib mobility, first rib springiness, joint play, and first rib position using the Cervical Rotation Lateral Flexion Test, Adson’s test, and the Costoclavicular Maneuver, all common thoracic outlet syndrome tests.

When the first rib becomes locked in an elevated position, pain commonly develops where the rib attaches to the sternum. Pain may also occur between the shoulder blades (interscapular pain) because the ribs attach to the thoracic spine posteriorly. Therefore, upper back pain and pain between the shoulder blades may be caused by an elevated first rib and thoracic outlet compression. Remember, an isolated first rib elevation rarely occurs. When one rib elevates, it influences the position of the remaining ribs because the intercostal muscles interconnect all twelve ribs.

The intercostal muscles are several groups of muscles that run between the ribs to form and move the chest wall. These muscles play a major role in the mechanics of breathing, rib cage expansion, chest wall movement, and respiratory function by expanding and contracting the chest cavity during inhalation and exhalation.

Compression of the Costoclavicular Space and Subpectoral Space

Difficulty Breathing, Shortness of Breath, and Chest Tightness

Another important muscle attached to the ribs is the pectoralis minor muscle. When the pectoralis minor develops chronic muscle spasms or tightness, it can elevate and lock the third, fourth, and fifth ribs, creating costoclavicular compression, subpectoral compression, and narrowing of the thoracic outlet. This rib restriction can lead to difficulty breathing, shortness of breath, chest tightness, pain with deep breathing, reduced athletic performance, and exercise intolerance while walking, running, or participating in sports.

Heart Attack False Alarm

Shoulder dysfunction and rib fixation may produce upper back pain, mid-back pain, pain between the shoulder blades, chest pain, chest tightness, difficulty taking a deep breath, shortness of breath, and radiating arm pain. These symptoms frequently resemble those of a heart attack, causing many patients with thoracic outlet syndrome to seek emergency medical evaluation because they believe they are having a cardiac event.

Orthopedic Tests for Scalene Muscle Spasms Causing First Rib Elevation

Adson’s Test—Scalene Muscles and First Rib Elevation

Adson’s test more specifically evaluates compression of the brachial plexus, subclavian artery, and subclavian vein as they pass through the interscalene triangle, making it one of the classic thoracic outlet syndrome orthopedic tests.

Here is how I perform Adson’s test.

I stand behind the patient. One hand stabilizes the involved shoulder while the other palpates the radial pulse. I assess the pulse while gently depressing the shoulder. I then move the arm into extension, adduction, and external rotation, continually monitoring the pulse for changes that may indicate vascular thoracic outlet syndrome or arterial compression.

Next, I place the shoulder and arm into several different positions while continuing to monitor the pulse. If one position causes the pulse to diminish, I know there is likely muscular compression of the thoracic outlet, costoclavicular space, or interscalene triangle.

I then ask the patient to rotate the head toward the involved side. This increases tension in the anterior scalene and middle scalene muscles, narrowing the interscalene triangle while I continue to monitor the pulse. If the pulse decreases, it suggests that scalene muscle compression is contributing to thoracic outlet syndrome.

Next, I ask the patient to inhale deeply and hold the breath. This elevates the rib cage, including the first rib and second rib. If the pulse decreases during deep inhalation, I conclude that elevation of the ribs caused by scalene muscle spasms is narrowing the thoracic outlet and contributing to neurovascular compression.

Some physicians believe Adson’s test is unreliable because of its reported false-positive rate. I believe this is a misunderstanding of how the test should be interpreted. We do not need complete compression of the brachial plexus, subclavian artery, or subclavian vein to establish a medical need for treatment. Detecting early thoracic outlet narrowing, subclinical thoracic outlet syndrome, or mild thoracic outlet compression before permanent nerve or vascular injury occurs is clinically valuable.

These findings often represent the earliest stages of thoracic outlet syndrome and should be treated before they progress into chronic thoracic outlet syndrome with significant nerve compression, vascular compression, persistent pain, weakness, numbness, and loss of athletic performance. If one of my professional boxers developed subclinical thoracic outlet syndrome, I would never allow it to progress into full-blown thoracic outlet syndrome before an important championship fight. We identify these early compression syndromes and treat them before they become career-limiting injuries.

Adsons Test?

I take the pulse to feel the radial artery pulse and blood circulation pulsating against my fingertips. Then I move your arm behind your back and rotate it into adduction, extension, and external rotation, a classic thoracic outlet syndrome (TOS) provocative test position.
I stop there and move the arm and shoulder into different positions for a few seconds while I’m feeling the pulse. If there is a specific position that causes a decrease in the pulse, then I know it is most likely muscle compression or muscle spasm compressing the thoracic outlet, subclavian artery, or neurovascular bundle around the shoulder.
Then I ask you to rotate your head toward the involved side, which twists the anterior and middle scalene muscles further, narrowing the interscalene triangle and increasing brachial plexus and subclavian artery compression.
If I feel the pulse decrease at this point, I know the majority of the compression is coming from the scalene muscles, producing scalene muscle compression, brachial plexus compression, or thoracic outlet syndrome.
Then I ask you to inhale deeply and hold your breath. This causes your rib cage, including the first rib and second rib, to elevate, which can further narrow the thoracic outlet and costoclavicular space.
Positive Test: If the pulse decreases here, then I have determined the first rib, second rib, and surrounding muscles are most likely pulled by muscle spasms into the thoracic outlet, causing vascular thoracic outlet syndrome, subclavian artery compression, or thoracic outlet compression.

First Rib Motion Palpation Test

I use this first rib motion palpation examination to evaluate first rib stiffness, first rib fixation, first rib elevation, first rib dysfunction, and first rib motion restriction, which are common findings in thoracic outlet syndrome (TOS) and other compression syndromes. You have to have a very sensitive touch to detect abnormal first rib movement, rib mobility, and thoracic outlet biomechanics.

How to do the first rib motion palpation test

You are seated.
I place my thumb on the base of your first rib and concentrate on how the first rib moves, glides, or fails to move during the examination.
I rotate your head to the opposite side of the pain.
Then I side bend your head and neck toward the painful side.
While I am performing this first rib mobility test, I use my opposite hand to feel the movement of the first rib, upper ribs, and surrounding tissues on the affected side.
Normally, I feel the first rib and upper ribs roll downward away from my touch as normal rib motion occurs.
A positive first rib motion palpation test occurs when I feel an abrupt stop in first rib movement with my opposite hand at the same time I feel an abrupt stop in the side bending motion of your neck.
If I determine that the first rib is elevated, locked, fixated, or restricted, it may contribute to thoracic outlet compression, brachial plexus compression, subclavian artery compression, or subclavian vein compression, and the first rib may need to be adjusted downward to help restore the normal opening of the thoracic outlet and thoracic outlet tunnel.

The subluxation, or slight misalignment, of the first rib where it attaches to the spine is associated with first rib dysfunction, first rib elevation, first rib fixation, and thoracic outlet syndrome, resulting in malfunction of the first rib.

The purpose of this test is to check for first rib elevation and second rib elevation. The rib can be pulled up and back into the thoracic outlet, causing compression of the brachial plexus nerves, subclavian artery, or subclavian vein, leading to neurogenic thoracic outlet syndrome (NTOS), venous thoracic outlet syndrome (VTOS), or arterial thoracic outlet syndrome (ATOS). The anterior scalene and middle scalene muscles are what pull the ribs out of position. If they remain elevated in an abnormal position for too long, the joint can become locked in that position by tension in the ligaments, contributing to chronic thoracic outlet compression.

In this test, I rotate the head away from the painful side until it cannot move any farther. While maintaining that position, I bend the neck to the side as far down as possible. If I cannot achieve full rotation and side-bending, the cervical rotation lateral flexion test is considered positive. Again, performing this test in the most stringent way to obtain a true positive or negative finding is not useful for helping reverse thoracic outlet syndrome, neck pain, shoulder pain, arm numbness, hand tingling, or brachial plexus compression. It simply reflects what doctors who are focused on assigning a diagnosis rather than correcting the cause of the compression tend to emphasize.

I am moving the head and neck in multiple directions while simultaneously placing my hand on the first rib on the opposite side to evaluate first rib movement, first rib mobility, joint play, and joint spring. I want to determine whether the rib is elevated, the direction of the elevation, where the joint play or joint spring is locked, and the severity of the restriction. This information helps determine how to reduce the scalene muscle spasms, restore normal first rib mobility, and adjust the rib out of its locked position so it can return to its normal anatomical position and reduce thoracic outlet compression.

One scientific study found that more than 90 percent of patients who had a positive cervical rotation lateral flexion test also had first rib dysfunction, first rib elevation, or first rib fixation, supporting its value in evaluating thoracic outlet syndrome (18).

Some researchers suggest that the most objective way to evaluate first rib movement and second rib movement is with a cineradiographic examination. While this imaging technique is interesting and more objective, it is generally unnecessary in clinical practice and is primarily useful for practitioners who cannot visualize the biomechanics of the thoracic outlet through experience, skilled palpation, and hands-on examination.

In a study by Lindgren in 1992, the cervical rotation lateral flexion test was found to be as accurate as the highly objective cineradiographic examination for identifying first rib dysfunction and abnormal first rib mobility, making it an effective clinical test for evaluating patients with thoracic outlet syndrome (19).

Costoclavicular Maneuver—Compression of the Collarbone on the Rib Cage (Costoclavicular Syndrome Test)

We will now discuss the Costoclavicular Maneuver, a clinical thoracic outlet syndrome test used for testing spasms in the anterior scalene, middle scalene, pectoralis minor, and subclavius muscles that can cause first rib elevation, collarbone (clavicle) depression, and compression of the brachial plexus, subclavian artery, and subclavian vein. Costo means rib and clavicular means collarbone. With this test, we are trying to determine if there is a narrowing or compression of the thoracic outlet between the first rib and the collarbone (clavicle) that may produce the symptoms of neurogenic thoracic outlet syndrome (NTOS) or vascular thoracic outlet syndrome (VTOS).

First, I ask the patient to sit while I feel the radial pulse. Then I put my other hand on the shoulder. With the hand that is checking the pulse, I pull the arm back and push down on the shoulder to reproduce thoracic outlet compression. I hold the position and move the arm through different positions for a minute or two while checking for a reduced pulse, loss of the radial pulse, or an inability to detect the pulse. I also ask whether the patient experiences arm pain, shoulder pain, neck pain, numbness, tingling, weakness, heaviness, coldness of the hand, or other thoracic outlet syndrome symptoms. If there are any changes in the pulse or the patient develops symptoms such as pain, numbness, tingling, or weakness in the arm or hand, this is considered a positive Costoclavicular Maneuver.

What I learn from this thoracic outlet syndrome examination is different from what many other doctors conclude. A positive test helps me identify compression caused by muscle spasms involving the pectoralis minor, subclavius, latissimus dorsi, and scalene muscles, which narrow the costoclavicular space and compress the brachial plexus and subclavian blood vessels. By identifying the specific muscles creating the compressive force, I can more accurately determine the cause of thoracic outlet syndrome and provide more precise non-surgical thoracic outlet syndrome treatment.

Costoclavicular Maneuver (Military Brace Test)

You would be standing or sitting.
I stand behind you, grasp your wrist, and use my fingers to feel your radial pulse at the wrist.
Then you would push your chest out and shoulders back into the military brace position, which narrows the costoclavicular space of the thoracic outlet.
Positive test: If the costoclavicular space is already narrowed by thoracic outlet syndrome (TOS), there will be a reduction or loss of the radial pulse caused by subclavian artery compression as it passes through the thoracic outlet (thoracic tunnel) beneath the collarbone (clavicle). You may also develop arm numbness, hand numbness, arm tingling, hand tingling, weakness, pain, or other neurovascular symptoms within approximately three to ten seconds after the shoulders are retracted.

This is how I perform the Costoclavicular Maneuver

I stand behind you, grasp your wrist, and use my fingers to monitor your radial pulse.
Then you push your chest out and shoulders back.
With my other hand, I depress and retract the scapula (shoulder blade) downward and backward toward the rib cage, further narrowing the costoclavicular space and thoracic outlet.
This maneuver pulls the collarbone (clavicle) backward and downward, increasing the likelihood of subclavian artery compression, subclavian vein compression, and brachial plexus compression if thoracic outlet syndrome is present.
By performing the scapular depression and retraction myself, I can more precisely control the shoulder position, reproduce symptoms, and better evaluate the degree of thoracic outlet compression and costoclavicular compression.

Hyperabduction Maneuver—Wright’s Test

In this Wright’s Test (Hyperabduction Maneuver) for thoracic outlet syndrome, I am feeling the pulse to assess the radial pulse rhythm, pulse intensity, and blood flow. Then I ask the patient to lift his or her arm overhead and extend it back behind the body. If the muscles are free from thoracic outlet compression and muscle compression spasms, the patient will not experience shoulder pain, arm pain, numbness, tingling, or thoracic outlet syndrome symptoms.

If there is a reduction of the radial pulse, or if there is complete loss of the pulse, then the Wright’s Test is positive. The patient will also feel arm tingling, hand tingling, numbness, or neurological symptoms if I hold the position long enough. The doctor will then determine that you have thoracic outlet syndrome (TOS) and record the test as positive (+) in your medical record.

What I determined from this test is that a positive result indicates a compression spasm of either the pectoralis minor muscle, subclavius muscle, or latissimus dorsi muscle, or, more likely, all of the above, causing compression of the brachial plexus, subclavian artery, and subclavian vein beneath the pectoralis minor muscle or collarbone (clavicle). This neurovascular compression is consistent with neurogenic thoracic outlet syndrome and may also contribute to vascular thoracic outlet syndrome.

I immediately determine which postural habits, movement patterns, repetitive strain activities, or lifestyle habits caused this particular pattern of muscle spasms and thoracic outlet compression. Then I know exactly where to work to reverse the compression, restore normal biomechanics, and reduce the patient's thoracic outlet syndrome symptoms.

A pulse oximeter is a safe, convenient, noninvasive, and inexpensive method for measuring blood oxygen saturation (SpO₂), arterial oxygen saturation, pulse rate, and blood flow into the arm and fingers. I place the pulse oximeter on the patient's finger and then perform the thoracic outlet syndrome orthopedic tests, while observing the pulse rate and oxygen saturation. If the pulse oximeter shows no pulse during a particular movement or arm position, I know the vascular compression is present. The price varies from approximately $20 to $400, but a $30 pulse oximeter is generally sufficient for home use. You can purchase one and determine exactly when and where you lose your pulse. This information can help identify the cause of your thoracic outlet syndrome (TOS), vascular thoracic outlet syndrome, or positional vascular compression, with or without the assistance of a doctor.

Wright's Test (Hyperabduction Maneuver) for Thoracic Outlet Syndrome

You are seated.
I take the radial pulse at your wrist to establish a baseline pulse.
Then, starting with your arm at your side, I slowly raise your arm into hyperabduction (overhead arm position) while continuously monitoring your radial pulse.
If I detect a reduction, interruption, or complete loss of your radial pulse, the Wright's Test (Hyperabduction Maneuver) is considered positive for possible thoracic outlet syndrome (TOS), vascular thoracic outlet syndrome, subclavian artery compression, or neurovascular compression.
The coracobrachialis muscle and the short head of the biceps brachii also attach to the coracoid process of the scapula. During the test, I also evaluate for restricted shoulder movement caused by muscle shortening, muscle tightness, muscle spasm, trigger points, or increased muscle tension in the coracobrachialis and short head of the biceps brachii.
I also assess the muscle tension, flexibility, and movement of the anterior deltoid, upper trapezius, latissimus dorsi, and surrounding shoulder girdle muscles, looking for abnormal tension patterns that may contribute to thoracic outlet compression, brachial plexus compression, shoulder dysfunction, or restricted shoulder mobility.

Roos Test (Elevated Arm Stress Test)

With this test, I ask you to raise your arms into a position similar to being under arrest, with your arms elevated out to the sides to shoulder height and your elbows bent to 90 degrees.
Then I ask you to slowly open and close your hands for three minutes.
If you are unable to keep your arms in this position for three minutes, or if you develop thoracic outlet syndrome symptoms such as arm pain, arm heaviness, arm weakness, hand numbness, hand tingling, or shoulder fatigue during the test, some doctors consider this a positive Roos Test or positive Elevated Arm Stress Test (EAST).

With this test, I ask patients to raise their arms into a position similar to performing a military press. Their arms are elevated out to the sides to shoulder height with the elbows bent to 90 degrees.

Then I ask the patient to slowly open and close the hands for three minutes. If they are unable to maintain this position for three minutes, or if they experience neck pain, shoulder pain, arm pain, arm heaviness, arm weakness, hand numbness, hand tingling, or thoracic outlet syndrome symptoms during the test, some doctors consider this a positive Roos Test or positive Elevated Arm Stress Test (EAST).

The problem with this thoracic outlet syndrome test is that many people are simply too weak to hold their arms in this position for three minutes. A round of boxing lasts three minutes. Most people are surprised at how difficult it is to keep their hands up to guard their face during boxing for three minutes. Even professional boxers have difficulty maintaining this position. The results of the Roos Test may also be influenced if you have already spent the day working with your arms overhead.

What this test tells me is that the patient not only has a positive Roos Test, but most likely has muscle compression, muscle spasms, and weakness involving the deltoid muscle, trapezius muscle, and possibly the subclavius muscle, all of which may contribute to thoracic outlet compression. Hand numbness, hand tingling, and arm paresthesia may also indicate compression or spasms involving the pectoralis minor muscle, subclavius muscle, and latissimus dorsi muscle, which are commonly associated with thoracic outlet syndrome.

Here again, I am forming my treatment approach to identify and reduce these compression spasms, restore normal thoracic outlet biomechanics, and relieve the nerve compression contributing to the patient's thoracic outlet syndrome symptoms.

Modified Upper Limb Tension Test

Modified upper limb tension test, also known as the brachial plexus tension test, upper limb neurodynamic test (ULNT), or the Elvey test, is an orthopedic test used in the diagnosis of thoracic outlet syndrome (TOS), brachial plexus compression, and nerve compression from the neck to the arm. With this test, the patient is lying down. I put the arm out to the side, parallel to the table. I start by applying gentle pressure to the shoulder to 90 degrees, then rotate the arm and shoulder backward and extend the wrist.

If the patient feels numbness, tingling, burning, or reproduction of symptoms, it could mean there is compression of the brachial plexus, nerve compression, or thoracic outlet compression affecting the nerves from the neck to the arm (22). Doctors like to do this test to diagnose neurogenic thoracic outlet syndrome (neurogenic TOS), which we all know is nice for those doctors who are focused on naming your thoracic outlet syndrome diagnosis. What I learn from this test is that the patient might have a compression spasm of the pectoralis minor muscle, the subclavius muscle, the short head of the biceps muscle, the coracobrachialis muscle, and the scalene muscles, all of which can contribute to thoracic outlet syndrome and brachial plexus compression. The patient might also have a locked collarbone where it attaches to the sternum, contributing to costoclavicular compression.

I will work on these muscles and manipulate the collarbone to improve sternoclavicular joint mobility, clavicle mobility, and thoracic outlet mobility. Also, I have some great exercises that naturally mobilize the collarbone and help reduce thoracic outlet compression.

Cyriax Release Test

The Cyriax Release Test is both an orthopedic test for thoracic outlet syndrome and a temporary conservative treatment for thoracic outlet syndrome that allows short-term symptom relief. The patient sits in a chair with the arms pinned down and the elbows bent at 90 degrees. I put some pillows underneath the forearm to elevate the shoulders, so the shoulder girdle is elevated, opening the thoracic outlet and thoracic outlet tunnel. If the symptoms of brachial plexus compression, nerve compression, subclavian artery compression, or subclavian vein compression diminish, then this is a positive sign of thoracic outlet syndrome.

The symptoms could take hours to decrease. Because the symptoms go away, it is considered a treatment. The treatment is temporary and, in my opinion, offers no permanent relief from thoracic outlet syndrome. This could allow a patient to get 5–10 minutes of relief to fall asleep, but he or she might wake up in the middle of the night with the symptoms returning because the underlying thoracic outlet compression has not been corrected.

Summary of Orthopedic Tests

If your doctor orders diagnostic tests, such as MRI for thoracic outlet syndrome, CT scan, or EMG (electromyography) immediately after this examination, without first attempting a conservative treatment, physical therapy, or other nonsurgical treatment for thoracic outlet syndrome, they may not know how to treat thoracic outlet syndrome without surgery. If they do not begin some form of conservative treatment, it might be time to find a healthcare professional who is willing to provide nonsurgical thoracic outlet syndrome treatment before considering surgery.

Cyriax Release Test

Sit in a chair with your arms pinned down and your elbows bent at 90 degrees.
Place pillows underneath your forearms to elevate your shoulders so the shoulder girdle is elevated, helping open the thoracic outlet and thoracic outlet tunnel.
If the symptoms of brachial plexus compression, nerve compression, subclavian artery compression, or subclavian vein compression decrease, this is considered a positive sign of thoracic outlet syndrome.

Conclusion

These orthopedic tests are key elements in determining the location and cause of nerve compression, vascular compression, and thoracic outlet compression. Your symptoms may be caused by thoracic outlet syndrome, a cervical herniated disc, cervical radiculopathy, pinched nerve in the neck, hyperabduction syndrome, median nerve compression, cubital tunnel syndrome, ulnar nerve entrapment, wrist nerve compression, or carpal tunnel syndrome. Learning how to differentiate these conditions is essential for obtaining an accurate thoracic outlet syndrome diagnosis, selecting the appropriate nonsurgical treatment, and avoiding unnecessary surgery. You can learn more about how to differentiate these conditions by reading this chapter.

All of these compression syndromes, nerve compression syndromes, and vascular compression syndromes cause symptoms downstream from the site of compression. Therefore, your symptoms may be caused by thoracic outlet syndrome (TOS), cervical radiculopathy, a herniated cervical disc, carpal tunnel syndrome, cubital tunnel syndrome, median nerve entrapment, ulnar nerve entrapment, hyperabduction syndrome, double crush syndrome, or even several of these conditions occurring simultaneously.

If your doctor leaves out the deep palpation examination of the 10 primary muscles that can pull the shoulder into the thoracic outlet, including the scalene muscles, pectoralis minor, subclavius, coracobrachialis, and other key muscles that contribute to thoracic outlet compression, brachial plexus compression, and subclavian artery or vein compression, then you know those muscles are unlikely to be addressed during your thoracic outlet syndrome treatment or nonsurgical rehabilitation.

Again, if your doctor leaves this critical part of the thoracic outlet syndrome examination out of your evaluation, I suggest you get up, thank the doctor, pay for your visit, and find a healthcare professional who performs a complete thoracic outlet syndrome physical examination, identifies the true cause of your nerve compression, and provides treatment directed at correcting the underlying thoracic outlet compression, not simply treating the symptoms.

Now spring out of the doctor's office, perform your own self-examination, and begin learning how to identify the true cause of your thoracic outlet syndrome symptoms.

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Frequently Asked Questions

What is the Roos Test (Elevated Arm Stress Test / EAST)?

The Roos Test, also known as the Elevated Arm Stress Test (EAST), is one of the most commonly used provocative orthopedic tests for evaluating thoracic outlet syndrome (TOS). During the test, the patient raises both arms to approximately 90 degrees of shoulder abduction and external rotation with the elbows bent to 90 degrees, then repeatedly opens and closes the hands for up to three minutes while the examiner observes for pain, numbness, tingling, weakness, heaviness, fatigue, or an inability to complete the test.

Throughout this book, you will learn that although the Roos Test (EAST) is an excellent screening test because it frequently reproduces thoracic outlet syndrome symptoms, it cannot diagnose TOS by itself and should always be interpreted together with a comprehensive evaluation of Human Spring biomechanics, posture, movement, and neurovascular function.

Which diagnostic tests are most useful for thoracic outlet syndrome (TOS)?

The most useful diagnostic tests for thoracic outlet syndrome (TOS) depend on whether neurogenic, venous, or arterial compression is suspected. A thorough medical history, physical examination, Human Spring biomechanical assessment, posture and movement analysis, and provocative tests remain the foundation of diagnosis, while imaging and specialized studies help confirm the diagnosis or rule out other conditions.

Commonly used diagnostic tests include dynamic ultrasound, MRI, MR angiography (MRA), CT angiography (CTA), X-rays, electromyography (EMG), nerve conduction studies (NCS), vascular Doppler ultrasound, venography, arteriography, and selected vascular studies performed with the arm in provocative positions. Throughout this book, you will learn that no single diagnostic test can diagnose thoracic outlet syndrome (TOS), and that the most accurate diagnosis comes from combining these tests with a comprehensive evaluation of Human Spring biomechanics, posture, movement, and neurovascular function.

When should vascular testing be performed for thoracic outlet syndrome (TOS)?

Vascular testing should be performed whenever thoracic outlet syndrome (TOS) is suspected to involve compression of the subclavian artery or subclavian vein, or when patients develop arm swelling, discoloration, coldness, heaviness, prominent veins, diminished pulses, or symptoms that suggest reduced blood flow or effort thrombosis (Paget-Schroetter syndrome). Because vascular compression is often dynamic, testing should ideally be performed with the arm placed in the positions that reproduce the patient's symptoms rather than only at rest, using studies such as dynamic Doppler ultrasound, CT angiography (CTA), MR angiography (MRA), venography, or arteriography when indicated.

Throughout this book, you will learn why vascular testing is most valuable when guided by a comprehensive evaluation of Human Spring biomechanics, posture, movement, and the patient's clinical symptoms, rather than being used as a routine screening test for every person with thoracic outlet syndrome (TOS).

How is neurogenic thoracic outlet syndrome differentiated from cervical radiculopathy?

Neurogenic thoracic outlet syndrome (NTOS) and cervical radiculopathy can produce similar symptoms, including neck pain, arm pain, numbness, tingling, and weakness, but they differ in the location and cause of nerve compression. In cervical radiculopathy, a spinal nerve root is compressed at the cervical spine, usually by a herniated disc, bone spur, or spinal stenosis, whereas in NTOS, the brachial plexus is compressed outside the spine as it passes through the thoracic outlet.

Throughout this book, you will learn how a detailed history, neurological examination, provocative orthopedic tests, imaging when appropriate, and a comprehensive evaluation of Human Spring biomechanics, posture, and movement patterns help distinguish neurogenic thoracic outlet syndrome from cervical radiculopathy and lead to the correct diagnosis.

Which nerve roots are most commonly involved in thoracic outlet syndrome (TOS)?

The T1 nerve root is most commonly involved in neurogenic thoracic outlet syndrome (TOS) because the lower trunk of the brachial plexus (C8–T1) is particularly vulnerable to compression as it passes through the thoracic outlet. Compression of the T1 fibers often produces numbness and tingling in the ring and little fingers, weakness of the intrinsic hand muscles, reduced grip strength, and difficulty with fine motor tasks.

Throughout this book, you will learn why the T1 nerve root and the lower trunk of the brachial plexus are especially susceptible to compression and how restoring Human Spring biomechanics helps relieve pressure on these nerves and restore normal hand function.

Which fingers typically become numb with thoracic outlet syndrome (TOS)?

The ring finger and little finger are the fingers that most commonly become numb in thoracic outlet syndrome (TOS) because compression usually affects the lower trunk of the brachial plexus (C8–T1), particularly the T1 nerve fibers. As the condition progresses, numbness may spread into the inner forearm, hand, and occasionally involve additional fingers depending on which portions of the brachial plexus are compressed.

Throughout this book, you will learn how the pattern of finger numbness helps identify which nerves are involved and why understanding Human Spring biomechanics is essential for relieving nerve compression and restoring normal sensation in thoracic outlet syndrome (TOS).

What are the three most important special tests for thoracic outlet syndrome (TOS)?

Although no single special test can diagnose thoracic outlet syndrome (TOS), three provocative maneuvers are used most frequently during the physical examination:

Roos Test (Elevated Arm Stress Test – EAST) – The patient holds both arms elevated while repeatedly opening and closing the hands for up to three minutes. Reproduction of pain, numbness, tingling, heaviness, weakness, or fatigue suggests possible thoracic outlet syndrome.
Adson's Test (Adson's Maneuver) – The examiner monitors the radial pulse while the patient extends the neck, rotates the head toward the affected side, and takes a deep breath. Reproduction of symptoms may indicate compression within the interscalene triangle.
Wright's Test (Hyperabduction Test) – The examiner gradually elevates the arm into full abduction and external rotation while assessing for symptom reproduction or vascular changes. A positive test may suggest compression beneath the pectoralis minor or elsewhere within the thoracic outlet. Throughout this book, you will learn that while these are the three most commonly used special tests for thoracic outlet syndrome (TOS), none of them is accurate enough to establish the diagnosis on its own. The most reliable diagnosis comes from combining these tests with a comprehensive evaluation of Human Spring biomechanics, posture, movement, neurological findings, vascular assessment, and the patient's symptom pattern.

Which is the best orthopedic test for diagnosing thoracic outlet syndrome (TOS)?

There is no single best orthopedic test for diagnosing thoracic outlet syndrome (TOS) because no provocative maneuver has sufficient sensitivity and specificity to diagnose the condition on its own. Among the available tests, the Roos Test (Elevated Arm Stress Test – EAST) is generally considered the best screening test because it most consistently reproduces the symptoms of thoracic outlet syndrome, but it also produces false-positive results in people without TOS.

Throughout this book, you will learn that the most accurate diagnosis of thoracic outlet syndrome (TOS) comes from combining the Roos Test, Adson's Test, Wright's Test, and other provocative maneuvers with a comprehensive evaluation of Human Spring biomechanics, posture, movement, neurological findings, vascular assessment, and the patient's symptom pattern, rather than relying on any single orthopedic test.

Which patients respond best to conservative (non-surgical) treatment?

Patients with neurogenic thoracic outlet syndrome (TOS) generally respond best to conservative (non-surgical) treatment, especially when their symptoms are primarily caused by poor posture, sustained muscle contraction, Human Spring biomechanical dysfunction, muscle tightness, fascial restrictions, and inflammation rather than permanent structural abnormalities. Patients who actively correct posture, modify aggravating activities, reduce inflammation, and restore normal movement of the neck, shoulders, clavicle, first rib, and surrounding soft tissues are often the most likely to achieve lasting improvement without surgery.

Throughout this book, you will learn why addressing the underlying biomechanical causes of thoracic outlet syndrome (TOS) allows many patients to recover successfully with conservative treatment while avoiding unnecessary surgery.

What doctor treats thoracic outlet syndrome (TOS)?

Several types of physicians treat thoracic outlet syndrome (TOS), depending on the type and severity of the condition. Patients may be evaluated by chiropractors vascular surgeons, orthopedic surgeons, neurosurgeons, physical medicine and rehabilitation (PM&R) physicians, sports medicine physicians, neurologists, physical therapists, or other clinicians experienced in diagnosing and treating thoracic outlet syndrome.

Because most patients have neurogenic thoracic outlet syndrome, they often respond best to clinicians who understand Human Spring biomechanics, posture, movement dysfunction, and conservative (non-surgical) treatment rather than relying on surgery alone. Throughout this book, you will learn how choosing a healthcare provider with expertise in the biomechanics of thoracic outlet syndrome (TOS) can significantly improve the accuracy of diagnosis and the success of treatment.

What type of doctor specializes in thoracic outlet syndrome (TOS)?

Several healthcare professionals treat thoracic outlet syndrome (TOS), including vascular surgeons, orthopedic surgeons, neurosurgeons, physical medicine and rehabilitation (PM&R) physicians, sports medicine physicians, neurologists, and chiropractors. Because most patients have neurogenic thoracic outlet syndrome, they often benefit most from clinicians who specialize in diagnosing and correcting Human Spring biomechanics, posture, movement dysfunction, muscle imbalance, and soft tissue restrictions through comprehensive conservative care.

Throughout this book, you will learn why selecting a healthcare provider—whether a chiropractor, physician, or therapist—with extensive experience in the biomechanical evaluation and treatment of thoracic outlet syndrome (TOS) is often more important than the provider's professional title alone.

Can an orthopedist diagnose thoracic outlet syndrome (TOS)?

Yes. An orthopedic surgeon can diagnose thoracic outlet syndrome (TOS), particularly when they have experience evaluating conditions affecting the neck, shoulder, and upper extremity.

Diagnosis should include a detailed history, physical examination, provocative orthopedic tests, and an assessment of Human Spring biomechanics, posture, movement patterns, and neurovascular function, with imaging or other diagnostic studies used when appropriate. Throughout this book, you will learn that accurately diagnosing thoracic outlet syndrome (TOS) depends less on the physician's specialty than on their experience recognizing the biomechanical causes of the condition and distinguishing it from other disorders that produce similar symptoms.

Does a neurologist treat thoracic outlet syndrome (TOS)?

I'd make it slightly more precise. Neurologists do evaluate and diagnose neurogenic TOS and help exclude other neurological disorders, but they generally do not provide definitive treatment for the underlying biomechanical cause.

A neurologist can help evaluate and diagnose neurogenic thoracic outlet syndrome (TOS) by performing a neurological examination, ordering tests such as electromyography (EMG) and nerve conduction studies (NCS), and ruling out other neurological conditions. However, neurologists generally do not treat the underlying biomechanical causes of thoracic outlet syndrome, such as poor posture, abnormal Human Spring biomechanics, muscle dysfunction, first rib restrictions, or fascial tightness.

Throughout this book, you will learn why successful treatment of thoracic outlet syndrome (TOS) requires identifying and correcting the mechanical source of compression rather than simply confirming that nerve dysfunction is present.

Can a chiropractor treat thoracic outlet syndrome (TOS)?

Yes. Many chiropractors successfully treat neurogenic thoracic outlet syndrome (TOS) using conservative (non-surgical) treatment, especially when they have advanced training in biomechanics, soft tissue therapy, rehabilitation, and movement disorders.

Treatment may include restoring first rib and clavicular mobility, improving spinal and shoulder mechanics, deep soft tissue treatment, reducing muscle and fascial restrictions, correcting posture, and restoring Human Spring biomechanics to relieve compression of the brachial plexus, subclavian artery, and subclavian vein. Throughout this book, you will learn how Dr.

James Stoxen's Human Spring Approach builds upon these conservative principles by identifying and correcting the underlying biomechanical causes of thoracic outlet syndrome (TOS), helping many patients recover without surgery.

Does physical therapy help thoracic outlet syndrome (TOS)?

Yes, physical therapy can help thoracic outlet syndrome (TOS) when it addresses the underlying causes of compression rather than focusing only on stretching and strengthening exercises. The best results are typically achieved when treatment includes effective deep soft tissue therapy, reduction of muscle and fascial restrictions, restoration of normal movement, correction of posture, and improvement of Human Spring biomechanics before progressing to exercise.

Throughout this book, you will learn why restoring normal tissue mobility and opening the thoracic outlet should come before rehabilitation exercises, allowing many patients with thoracic outlet syndrome (TOS) to recover without surgery.

When should thoracic outlet syndrome (TOS) be suspected?

Thoracic outlet syndrome (TOS) should be suspected when a person has persistent or recurrent neck, shoulder, arm, or hand pain accompanied by numbness, tingling, weakness, swelling, color changes, coldness, or symptoms that worsen with certain arm positions or prolonged postures. It should also be considered when symptoms are triggered by prolonged computer or cell phone use, overhead activities, driving, sleeping positions, or other activities involving sustained contraction of the muscles surrounding the thoracic outlet, especially when routine imaging studies are normal or other diagnoses have failed to explain the symptoms.

Throughout this book, you will learn how recognizing these characteristic patterns and evaluating Human Spring biomechanics can help identify thoracic outlet syndrome (TOS) earlier and lead to more effective treatment.

How is thoracic outlet syndrome (TOS) diagnosed?

Thoracic outlet syndrome (TOS) is diagnosed by combining a detailed medical history, a thorough physical examination, assessment of Human Spring biomechanics, posture and movement analysis, provocative tests, neurological and vascular evaluation, and selected imaging or electrodiagnostic studies when appropriate. Because TOS is often a dynamic condition, no single MRI, X-ray, ultrasound, or nerve test can diagnose every case, making a careful biomechanical examination essential for identifying the source of compression.

Throughout this book, you will learn how a comprehensive biomechanical evaluation provides a more accurate diagnosis of thoracic outlet syndrome (TOS) than relying on any single test alone.

What is the physical examination for thoracic outlet syndrome (TOS)?

The physical examination for thoracic outlet syndrome (TOS) includes evaluating posture, Human Spring biomechanics, neck and shoulder movement, first rib and clavicle mobility, muscle tension, fascial restrictions, strength, sensation, circulation, and provocative maneuvers that reproduce the patient's symptoms. The examination should also identify the underlying biomechanical factors contributing to compression of the brachial plexus, subclavian artery, and subclavian vein, rather than simply determining whether provocative tests are positive or negative.

Throughout this book, you will learn how a comprehensive biomechanical physical examination provides the most effective approach for diagnosing thoracic outlet syndrome (TOS) and developing an individualized treatment plan.

What orthopedic tests are used to diagnose thoracic outlet syndrome (TOS)?

No single orthopedic test can diagnose thoracic outlet syndrome (TOS) by itself. Instead, clinicians use a combination of provocative maneuvers along with a detailed biomechanical examination to determine whether compression of the brachial plexus, subclavian artery, or subclavian vein is occurring. The most commonly used orthopedic and provocative tests include:

Adson's Test
Modified Adson's Test
Halstead Maneuver (Costoclavicular Maneuver)
Military Brace Test
Costoclavicular Test
Wright's Hyperabduction Test
Hyperabduction Test
Roos Test (Elevated Arm Stress Test – EAST)
EAST (Elevated Arm Stress Test)
Upper Limb Tension Test (ULTT)
Elvey's Brachial Plexus Tension Test
Morley's Test
Eden's Test
Allen's Test (thoracic outlet version)
Cyriax Release Test
Candlestick Test
Bakody's Sign (primarily for cervical radiculopathy but useful in differential diagnosis)
Spurling's Test (to help differentiate cervical nerve root compression from TOS)
Shoulder Abduction Relief Test
Supraclavicular Pressure Test
Scalene Compression Test
Pectoralis Minor Compression Test
Upper Extremity Neurodynamic Tests
Pulse Obliteration Tests (performed in various arm positions) These tests are often combined with:
Postural assessment
Human Spring biomechanical analysis
Cervical spine examination
First rib mobility assessment
Clavicular motion assessment
Scapular movement analysis
Muscle palpation
Fascial mobility assessment
Neurological examination
Vascular examination Throughout this book, you will learn that while orthopedic tests can help reproduce symptoms, no single test is sufficiently accurate to diagnose thoracic outlet syndrome. The most reliable diagnosis comes from combining these tests with a comprehensive evaluation of Human Spring biomechanics, posture, movement, muscle function, and neurovascular compression.

What is Adson's Test (Adson's Maneuver)?

Adson's Test (Adson's Maneuver) is a provocative orthopedic test used during the evaluation of thoracic outlet syndrome (TOS) to assess whether the brachial plexus or subclavian artery may be compressed within the interscalene triangle. During the test, the patient extends the neck, rotates the head toward the affected side, takes a deep breath, and holds it while the examiner monitors the radial pulse and asks whether symptoms such as pain, numbness, or tingling are reproduced.

Throughout this book, you will learn that although Adson's Test can help identify possible thoracic outlet syndrome, it is not accurate enough to diagnose TOS by itself and should always be interpreted together with other provocative tests and a comprehensive evaluation of Human Spring biomechanics, posture, movement, and neurovascular function.

What is Wright's Test (Hyperabduction Test)?

Wright's Test, also called the Hyperabduction Test, is a provocative orthopedic test used during the evaluation of thoracic outlet syndrome (TOS) to determine whether the brachial plexus or subclavian artery is compressed beneath the pectoralis minor muscle or within the thoracic outlet. During the test, the examiner slowly elevates the patient's arm overhead into full abduction and external rotation while monitoring the radial pulse and asking whether symptoms such as pain, numbness, tingling, or heaviness are reproduced.

Throughout this book, you will learn that although Wright's Test can help identify possible thoracic outlet syndrome, it cannot diagnose TOS by itself and should always be interpreted together with other provocative tests and a comprehensive evaluation of Human Spring biomechanics, posture, movement, and neurovascular function.

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Glossary

Browse terms by letter or search the glossary.

A Acute Trauma

A sudden injury such as a motor vehicle accident, whiplash injury, sports injury, or work-related injury that may initiate thoracic outlet syndrome by producing muscle injury, inflammation, and protective muscle guarding.

A Adson's Maneuver

Another name for Adson's Test, a provocative orthopedic examination used to evaluate compression within the interscalene triangle by monitoring the radial pulse and symptom reproduction during specific neck and arm positions.

A Adson's Test

A classic provocative orthopedic test for thoracic outlet syndrome (TOS). The examiner monitors the radial pulse while positioning the arm, rotating the head toward the involved side, and asking the patient to inhale deeply. The test evaluates compression caused primarily by the anterior scalene, middle scalene, and elevated first rib.

A Activities of Daily Living (ADLs)

Routine activities such as computer work, driving, sleeping posture, reading in bed, carrying bags, and overhead work that may contribute to thoracic outlet syndrome through prolonged muscle contraction and poor biomechanics.

A Allen's Test (Thoracic Outlet Version)

A provocative orthopedic test listed among the examination procedures used in the evaluation of thoracic outlet syndrome. It is interpreted together with the patient's history, physical examination, and biomechanical findings rather than as a stand-alone diagnostic test.

A Anterior Neck Muscles

Muscles located on the front of the neck that can contribute to thoracic outlet compression when chronically contracted. These muscles are evaluated during deep palpation because they may depress the shoulder and narrow the thoracic outlet.

A Anterior Scalene Muscle

One of the primary muscles forming the interscalene triangle. Chronic spasm or shortening elevates the first rib and compresses the brachial plexus, subclavian artery, and subclavian vein.

A Arterial Thoracic Outlet Syndrome (ATOS)

The vascular form of thoracic outlet syndrome caused by compression of the subclavian artery. Patients may demonstrate pallor, diminished pulses, or vascular insufficiency.

A Arteriography

An imaging study used to evaluate the arterial circulation in patients with suspected arterial thoracic outlet syndrome or vascular compression.

A Arm Numbness

One of the most common symptoms of thoracic outlet syndrome resulting from compression of the brachial plexus.

A Asymmetry

Unequal appearance of body structures observed during physical examination. The chapter recommends evaluating asymmetry of the neck, shoulders, clavicles, and upper extremities during thoracic outlet syndrome assessment.

B Bakody's Sign

An orthopedic test primarily used to evaluate cervical radiculopathy during the differential diagnosis of thoracic outlet syndrome.

B Bilateral Thoracic Outlet Syndrome

Thoracic outlet syndrome affecting both upper extremities. Bilateral symptoms often provide important diagnostic clues distinguishing thoracic outlet syndrome from cervical disc disorders.

B Brachial Plexus

The network of nerves supplying the upper extremity. Compression of the brachial plexus is responsible for the neurological symptoms of neurogenic thoracic outlet syndrome.

B Brachial Plexus Compression

Mechanical compression of the brachial plexus occurring within the thoracic outlet, costoclavicular space, or subpectoral region. It produces pain, numbness, tingling, weakness, and sensory disturbances.

B Burning Pain

A common neurological symptom of thoracic outlet syndrome resulting from irritation or compression of peripheral nerves within the brachial plexus.

C Candlestick Test

Another name sometimes used for the Roos Test (Elevated Arm Stress Test) during thoracic outlet syndrome evaluation.

C Carpal Tunnel Syndrome

Compression of the median nerve at the wrist. The chapter emphasizes that carpal tunnel syndrome may coexist with thoracic outlet syndrome as part of double crush syndrome.

C Case History

The detailed discussion between the patient and healthcare provider regarding symptoms, injuries, occupational history, daily activities, and aggravating factors. The chapter considers the case history one of the most important parts of thoracic outlet syndrome diagnosis.

C Cervical Disc Herniation

A herniated intervertebral disc within the cervical spine capable of producing symptoms similar to thoracic outlet syndrome. Distinguishing cervical disc herniation from thoracic outlet syndrome is an important part of the differential diagnosis.

C Cervical Radiculopathy

Compression of a cervical spinal nerve root producing pain, numbness, tingling, and weakness. Cervical radiculopathy is one of the major disorders that must be differentiated from thoracic outlet syndrome.

C Cervical Rotation Lateral Flexion Test

An orthopedic examination used to assess first rib elevation, first rib fixation, first rib dysfunction, and thoracic outlet syndrome. The examiner evaluates both cervical motion and first rib mobility simultaneously.

C Clavicle (Collarbone)

The bone forming the superior boundary of the costoclavicular space. Abnormal movement or depression of the clavicle may contribute to thoracic outlet compression.

C Clavicular Motion Assessment

Evaluation of movement of the clavicle during shoulder motion. Restricted clavicular movement may contribute to narrowing of the thoracic outlet and costoclavicular space.

C Cold Hands

A vascular symptom of thoracic outlet syndrome resulting from compromised arterial circulation.

C Compression Syndrome

Any disorder resulting from abnormal mechanical compression of nerves, arteries, veins, or other tissues. Thoracic outlet syndrome is presented as one of several compression syndromes evaluated during the examination.

C Computed Tomography Angiography (CTA)

A specialized CT imaging study used to evaluate arterial and venous structures in patients with suspected vascular thoracic outlet syndrome.

C Coracobrachialis Muscle

One of the ten primary muscles examined during thoracic outlet syndrome evaluation. Chronic contraction contributes to depression of the shoulder and narrowing of the thoracic outlet.

C Costoclavicular Maneuver

A provocative orthopedic examination evaluating compression between the clavicle and first rib. The maneuver reproduces symptoms caused by compression of the brachial plexus and subclavian vessels.

C Costoclavicular Space

The anatomical space between the clavicle and first rib through which the brachial plexus and subclavian vessels pass. Narrowing contributes to thoracic outlet syndrome.

C Cranial Nerve Examination

A neurological examination evaluating the function of the twelve cranial nerves to help exclude disorders of the brain and central nervous system during thoracic outlet syndrome assessment.

C Cubital Tunnel Syndrome

Compression of the ulnar nerve at the elbow. The chapter emphasizes evaluating cubital tunnel syndrome because it commonly coexists with thoracic outlet syndrome in double crush syndrome.

D Deep Muscle Palpation

A hands-on examination technique in which the examiner presses deeply into muscles with the thumb to identify muscle spasms, trigger points, myofascial trigger points, muscle knots, and chronic muscle tension contributing to thoracic outlet syndrome. The author considers this the single most important component of the physical examination.

D Deep Tendon Reflex

An involuntary muscle response elicited by tapping a tendon with a reflex hammer. Deep tendon reflexes help determine whether neurological symptoms arise from the brain, spinal cord, nerve roots, or peripheral nerves.

D Dermatome

An area of skin supplied by a single spinal nerve root. Sensory testing of dermatomes helps identify the level of cervical nerve root or brachial plexus involvement.

D Diagnostic Examination

The comprehensive process of collecting information through the medical history, physical examination, neurological examination, orthopedic testing, vascular evaluation, and imaging studies to establish the diagnosis of thoracic outlet syndrome.

D Differential Diagnosis

The systematic process of distinguishing thoracic outlet syndrome from approximately thirty other disorders capable of producing similar symptoms.

D Double Crush Syndrome

The coexistence of thoracic outlet syndrome with a second nerve compression syndrome elsewhere along the same nerve pathway, such as carpal tunnel syndrome or cubital tunnel syndrome.

D Duplex Ultrasound

A vascular imaging technique combining ultrasound and Doppler evaluation to assess blood flow through arteries and veins during thoracic outlet syndrome assessment.

D Dynamic Doppler Ultrasound

A Doppler ultrasound examination performed while the arm is placed into provocative positions to identify dynamic vascular compression associated with thoracic outlet syndrome.

E Edema

Abnormal accumulation of fluid within tissues. In thoracic outlet syndrome, edema most commonly develops because compression of the subclavian vein impairs normal venous drainage.

E Edema Swelling

Swelling caused by accumulation of interstitial fluid rather than inflammation alone. The chapter describes edema swelling as a characteristic finding in severe venous thoracic outlet syndrome.

E Elevated Arm Stress Test (EAST)

Another name for the Roos Test, a provocative orthopedic examination in which patients repeatedly open and close their hands while holding their arms elevated for up to three minutes.

E Electromyography (EMG)

An electrodiagnostic study measuring muscle electrical activity. EMG is commonly used to help evaluate neurogenic thoracic outlet syndrome and exclude other neurological disorders.

E Elvey Test

Another name for the Modified Upper Limb Tension Test (ULTT) used to evaluate tension and compression affecting the brachial plexus.

E Examination

The systematic evaluation of a patient using history, observation, palpation, neurological assessment, orthopedic testing, vascular examination, and diagnostic studies to determine the cause of thoracic outlet syndrome.

F False-Negative Test

An examination result in which thoracic outlet syndrome is present but the provocative test fails to reproduce symptoms. The chapter notes that excessive focus on false negatives may distract clinicians from understanding biomechanics.

F False-Positive Test

A provocative examination result suggesting thoracic outlet syndrome in a person without the disorder. The author argues that clinicians should interpret orthopedic tests biomechanically rather than simply labeling them positive or negative.

F First Rib Dysfunction

Abnormal movement, fixation, or elevation of the first rib contributing to narrowing of the thoracic outlet and compression of neurovascular structures.

F First Rib Elevation

Superior displacement of the first rib caused primarily by chronic contraction of the scalene muscles. Elevation narrows the interscalene triangle and contributes to thoracic outlet syndrome.

F First Rib Fixation

Restriction of normal first rib movement caused by ligament tension, chronic muscle spasm, or joint dysfunction.

F First Rib Motion Palpation Test

A manual examination used to evaluate first rib movement, stiffness, fixation, and elevation while the head is rotated and side bent.

F First Rib Spring

The normal elastic movement of the first rib during respiration and cervical motion. Reduced first rib spring indicates abnormal biomechanics contributing to thoracic outlet syndrome.

G Gillet Motion Palpation

A manual examination technique developed by Henri Gillet for assessing dynamic movement of spinal segments, ribs, and joints. The chapter applies Gillet motion palpation to evaluate thoracic outlet biomechanics.

G Grip Strength

The force generated by the muscles of the hand. Reduced grip strength commonly accompanies T1 nerve involvement and neurogenic thoracic outlet syndrome.

G Guyon's Canal Syndrome

Compression of the ulnar nerve within Guyon's canal at the wrist. The chapter stresses evaluating Guyon's canal syndrome because it frequently coexists with thoracic outlet syndrome as part of a multiple compression syndrome.

H Hand Tingling

One of the most common symptoms of thoracic outlet syndrome, usually resulting from compression of the brachial plexus, particularly the C8–T1 nerve fibers.

H Henri Gillet

A Belgian chiropractor who developed the technique of motion palpation, allowing clinicians to evaluate dynamic spinal, rib, and joint movement through skilled manual examination.

H History Taking

The process of gathering information regarding symptoms, injuries, work activities, posture, lifestyle, aggravating factors, and previous treatment. The chapter considers history taking fundamental to accurate diagnosis.

H Hyperabduction Maneuver

Another name for Wright's Test, in which the arm is elevated overhead to reproduce compression beneath the pectoralis minor or elsewhere within the thoracic outlet.

H Hyperabduction Syndrome

A compression syndrome produced when prolonged overhead arm positioning narrows the thoracic outlet. Hyperabduction syndrome is included among the differential diagnoses evaluated during the examination.

I Incomplete Diagnosis

A diagnosis in which one or more contributing disorders remain unrecognized. The chapter warns that failure to evaluate all potential compression sites leads to incomplete diagnosis and unsuccessful treatment.

I Inflammation Swelling

Swelling caused by inflammation of muscles, ligaments, tendons, fascia, or joints following injury or repetitive strain.

I Interscalene Triangle

The triangular anatomical space bordered by the anterior scalene and middle scalene muscles through which the brachial plexus and subclavian artery pass. Compression within this space is a major cause of neurogenic thoracic outlet syndrome.

I Intrinsic Hand Muscles

The small muscles located within the hand. Weakness of these muscles commonly indicates T1 nerve involvement in neurogenic thoracic outlet syndrome.

J Jaw Clicking

An audible or palpable click occurring during movement of the temporomandibular joint (TMJ). Jaw clicking may indicate TMJ dysfunction contributing to neck muscle tension and thoracic outlet syndrome.

J Jaw Examination

Evaluation of jaw movement, joint motion, clicking, popping, locking, and deviation during opening and closing. The chapter recommends assessing TMJ dysfunction because it commonly contributes to chronic cervical muscle tension.

J Jaw Locking

Restriction of normal jaw motion caused by dysfunction of the temporomandibular joint. Jaw locking may contribute to chronic neck pain and muscle tension.

J Jaw Popping

Abnormal movement of the temporomandibular joint producing an audible or palpable popping sensation.

J Joint Play

The small amount of passive movement normally present within joints. Motion palpation evaluates joint play to identify stiffness, fixation, and restricted motion contributing to thoracic outlet syndrome.

J Joint Spring

The elastic resistance encountered during passive joint movement. Loss of normal joint spring suggests fixation or dysfunction affecting the spine, ribs, clavicle, or shoulder girdle.

K Knuckle Sign

A postural observation in which only the thumb and one finger knuckle remain visible when viewing the hand from the front. Excessive inward rotation of the arm may indicate muscle contraction patterns associated with thoracic outlet syndrome.

L Latissimus Dorsi

One of the ten primary muscles evaluated during thoracic outlet syndrome examination. Chronic contraction of the latissimus dorsi can depress the shoulder girdle into the thoracic outlet.

L Levator Scapulae

A shoulder suspension muscle responsible for elevating and supporting the shoulder girdle. Weakness or fatigue of the levator scapulae allows the shoulder to descend into the thoracic outlet.

L Lymph Node Examination

Assessment of cervical and supraclavicular lymph nodes during the physical examination to identify swelling or other abnormalities unrelated to thoracic outlet syndrome.

L Loss of Radial Pulse

A reduction or disappearance of the radial pulse during provocative testing, suggesting compression of the subclavian artery within the thoracic outlet.

L Lower Trapezius

One of the ten primary muscles evaluated for chronic muscle spasm during thoracic outlet syndrome examination. Persistent contraction may depress the shoulder and contribute to thoracic outlet compression.

M Magnetic Resonance Angiography (MRA)

A specialized MRI study used to visualize arteries and veins. MRA is helpful when evaluating suspected arterial or venous thoracic outlet syndrome and is most useful when performed in provocative arm positions.

M Magnetic Resonance Imaging (MRI)

An imaging study used to evaluate the cervical spine, brachial plexus, soft tissues, and surrounding anatomical structures. MRI helps exclude other causes of symptoms but cannot diagnose every case of thoracic outlet syndrome by itself.

M Manual Muscle Strength Testing (MMT)

A clinical examination that evaluates muscle strength to identify weakness associated with brachial plexus compression, neurogenic thoracic outlet syndrome, or peripheral nerve injury.

M Maximum Medical Improvement (MMI)

The point at which a patient has recovered as completely as reasonably possible with available treatment. The chapter emphasizes identifying every contributing compression syndrome to achieve maximum medical improvement.

M Medical History

The detailed record of the patient's symptoms, injuries, occupations, activities of daily living, and prior medical problems. The medical history is considered one of the most important components of thoracic outlet syndrome diagnosis.

M Median Nerve Compression

Compression of the median nerve, most commonly in the forearm or wrist. The chapter stresses evaluating median nerve compression because it frequently coexists with thoracic outlet syndrome.

M Misdiagnosis

An incorrect diagnosis resulting in inappropriate treatment. The chapter identifies thoracic outlet syndrome as one of the most commonly misdiagnosed peripheral nerve compression disorders.

M Modified Upper Limb Tension Test (ULTT)

A provocative orthopedic examination, also known as the Elvey Test or Upper Limb Neurodynamic Test, used to evaluate tension and compression affecting the brachial plexus.

M Morley's Sign

Tenderness within the supraclavicular fossa that reproduces thoracic outlet syndrome symptoms. Morley's sign may indicate first rib dysfunction and compression within the thoracic outlet.

M Motion Palpation

A manual examination technique used to evaluate spinal joints, ribs, clavicles, and extremities by assessing joint movement, restriction, fixation, and biomechanical dysfunction.

M Motor Examination

The portion of the neurological examination assessing muscle strength, coordination, and motor function to identify nerve compression or neurological injury.

M Muscle Imbalance

An imbalance between muscles that elevate and depress the shoulder girdle. Muscle imbalance contributes to abnormal posture and thoracic outlet compression.

M Muscle Inhibition

Reduced muscle activation caused by nerve compression or pain. Muscle inhibition may be detected during manual muscle strength testing.

M Muscle Knot

A common descriptive term for a localized area of chronic muscle contraction or myofascial trigger point.

M Muscle Spasm

An involuntary muscle contraction. Chronic muscle spasms involving the scalenes, pectoralis minor, subclavius, and related muscles are considered primary causes of thoracic outlet syndrome in the Human Spring Model.

M Myofascial Trigger Point

A localized area of chronically contracted muscle producing pain, tenderness, referred pain, and abnormal movement patterns. The chapter recommends deep palpation of all ten compressive muscles to identify trigger points.

N Nerve Compression

Mechanical pressure applied to a peripheral nerve, producing pain, numbness, tingling, weakness, or altered sensation. Thoracic outlet syndrome is presented as one form of nerve compression syndrome.

N Nerve Conduction Study (NCS)

An electrodiagnostic study evaluating the speed of electrical conduction through peripheral nerves. Nerve conduction studies help differentiate thoracic outlet syndrome from other neurological disorders.

N Neurogenic Thoracic Outlet Syndrome (NTOS)

The most common form of thoracic outlet syndrome caused by compression of the brachial plexus, particularly the C8–T1 nerve fibers.

N Neurological Examination

A comprehensive evaluation of reflexes, sensation, muscle strength, cranial nerves, and peripheral nerve function used to identify neurological causes of symptoms.

N Neurological Symptom

A symptom such as numbness, tingling, burning, weakness, or altered sensation resulting from nerve compression or nerve dysfunction.

N Neurovascular Compression

Simultaneous compression of nerves and blood vessels within the thoracic outlet. The chapter emphasizes that both neurological and vascular structures may be compressed together.

N Neurovascular Bundle

The combined brachial plexus, subclavian artery, and subclavian vein passing through the thoracic outlet.

O Objective Sign

A finding that can be observed, measured, or detected by the examiner during the physical examination or diagnostic testing.

O Occipital Headache

A headache located at the base of the skull. Occipital headaches are listed among the most common symptoms reported by patients with thoracic outlet syndrome.

O Orthopedic Examination

A systematic evaluation of the musculoskeletal system using observation, palpation, range-of-motion testing, muscle testing, and provocative maneuvers to identify thoracic outlet syndrome and related disorders.

O Orthopedic Test

A specialized physical examination maneuver designed to reproduce symptoms or identify biomechanical dysfunction contributing to thoracic outlet syndrome.

P Palpation

A hands-on examination technique using the examiner's fingers or thumb to evaluate muscles, joints, ligaments, tendons, swelling, trigger points, and tissue tenderness.

P Pallor

Abnormal paleness of the skin caused by reduced arterial blood flow. Pallor may be observed in arterial thoracic outlet syndrome.

P Pectoralis Minor

One of the ten primary compressive muscles evaluated during thoracic outlet syndrome examination. Chronic contraction narrows the subpectoral space and contributes to thoracic outlet compression.

P Peripheral Nerve Compression

Compression affecting nerves outside the brain and spinal cord, including the median, ulnar, and brachial plexus nerves.

P Physical Examination

The systematic evaluation of the patient's body through inspection, palpation, neurological testing, orthopedic examination, and vascular assessment to identify objective signs of thoracic outlet syndrome.

P Pinprick Sensation

A component of the neurological sensory examination using a pin to evaluate pain perception and identify nerve compression.

P Pitting Edema

A form of edema in which pressure applied to swollen tissue leaves a persistent indentation. The chapter describes pitting edema as an advanced sign of severe venous thoracic outlet syndrome.

P Posterior Scalene Muscle

One of the three scalene muscles evaluated during thoracic outlet syndrome examination. Chronic spasm may elevate the second rib and contribute indirectly to thoracic outlet compression.

P Postural Evaluation

Observation of head position, shoulder height, arm rotation, and overall alignment to identify muscle imbalances and postural changes contributing to thoracic outlet syndrome.

P Provocative Orthopedic Test

An examination maneuver designed to reproduce thoracic outlet syndrome symptoms by temporarily increasing compression of the thoracic outlet.

P Pulse Oximeter

A noninvasive device measuring pulse rate and blood oxygen saturation (SpO₂). The author recommends using a pulse oximeter during provocative testing to detect positional vascular compression.

R Radial Pulse

The pulse felt at the wrist over the radial artery. During thoracic outlet syndrome testing, changes in the radial pulse help identify vascular compression of the subclavian artery.

R Radiculopathy

A disorder caused by compression or irritation of a spinal nerve root. Cervical radiculopathy is one of the primary conditions that must be distinguished from thoracic outlet syndrome.

R Range of Motion (ROM)

The amount of movement available at a joint. Patients with thoracic outlet syndrome commonly demonstrate restricted lateral neck bending because of chronic scalene muscle contraction.

R Referred Pain

Pain perceived at a location distant from the actual source of tissue irritation. The chapter explains that patterns of referred pain help identify which compressive muscles are involved in thoracic outlet syndrome.

R Reflex Examination

Assessment of deep tendon reflexes to determine whether symptoms arise from the brain, spinal cord, cervical nerve roots, or peripheral nerves.

R Roos Test

Also known as the Elevated Arm Stress Test (EAST). A provocative orthopedic examination in which patients repeatedly open and close their hands while holding both arms elevated for up to three minutes. Reproduction of pain, numbness, tingling, heaviness, or weakness suggests thoracic outlet syndrome.

R Rotation Lateral Flexion Test

Another name for the Cervical Rotation Lateral Flexion Test, used to evaluate first rib dysfunction, elevation, and fixation associated with thoracic outlet syndrome.

S Scalene Compression Test

A provocative examination listed among orthopedic tests used during thoracic outlet syndrome evaluation to assess compression associated with the scalene muscles.

S Scalene Muscle

One of the three paired muscles forming the interscalene triangle. Chronic contraction elevates the ribs and narrows the thoracic outlet, producing neurovascular compression.

S Second Rib Dysfunction

Abnormal movement or fixation of the second rib that may accompany first rib dysfunction and contribute to thoracic outlet compression.

S Sensory Examination

A neurological examination evaluating light touch, pinprick, temperature, and other sensory modalities to identify nerve compression or nerve injury.

S Shoulder Depression

Downward displacement of the shoulder girdle caused by weakness of shoulder suspension muscles or chronic contraction of shoulder-depressing muscles. Shoulder depression contributes to thoracic outlet compression.

S Shoulder Suspension Muscles

Muscles such as the upper trapezius and levator scapulae that elevate and support the shoulder girdle above the thoracic outlet. Weakness of these muscles increases compression.

S Spinal Motion Palpation

Manual assessment of movement between adjacent spinal segments to identify fixation, stiffness, and biomechanical dysfunction contributing to thoracic outlet syndrome.

S Spurling's Test

An orthopedic examination primarily used to identify cervical radiculopathy during the differential diagnosis of thoracic outlet syndrome.

S Subclavian Artery

The major artery supplying blood to the upper extremity. Compression of the subclavian artery produces arterial thoracic outlet syndrome.

S Subclavian Artery Compression

Mechanical narrowing of the subclavian artery caused by muscles, ribs, or the clavicle. It may produce pallor, diminished pulses, and vascular symptoms.

S Subclavian Vein

The major vein draining blood from the upper extremity. Compression of the subclavian vein produces venous thoracic outlet syndrome.

S Subclavian Vein Compression

Mechanical narrowing of the subclavian vein producing impaired venous drainage, swelling, edema, and venous thoracic outlet syndrome.

S Subclavius Muscle

One of the ten primary muscles evaluated during thoracic outlet syndrome examination. The author considers it the only muscle capable of simultaneously contributing to compression of the interscalene triangle, costoclavicular space, and subpectoral space.

S Subpectoral Space

The anatomical space beneath the pectoralis minor through which portions of the brachial plexus and subclavian vessels pass. Narrowing contributes to thoracic outlet syndrome.

S Supraclavicular Fossa

The hollow located above the clavicle. Tenderness or swelling within the supraclavicular fossa, known as Morley's Sign, may indicate thoracic outlet syndrome.

S Supraclavicular Pressure Test

A provocative examination listed among orthopedic tests for thoracic outlet syndrome that evaluates tenderness and compression above the clavicle.

S Symptom

Subjective evidence of disease experienced by the patient, such as pain, numbness, tingling, weakness, or swelling. Symptoms differ from objective physical signs detected during examination.

T T1 Nerve Root

The cervical-thoracic nerve root most commonly involved in neurogenic thoracic outlet syndrome. Compression produces numbness of the ring and little fingers, intrinsic hand muscle weakness, and decreased grip strength.

T Temperature Sensation

A component of the neurological sensory examination used to identify abnormalities in peripheral nerve function.

T Temporomandibular Joint (TMJ)

The joint connecting the mandible to the skull. TMJ dysfunction may contribute to cervical muscle tension and complicate thoracic outlet syndrome.

T Thoracic Outlet

The anatomical passageway through which the brachial plexus, subclavian artery, and subclavian vein travel between the neck and upper extremity.

T Thoracic Outlet Syndrome (TOS)

A neurovascular compression syndrome involving the brachial plexus, subclavian artery, or subclavian vein within the thoracic outlet. Chapter 7 focuses on its diagnosis through history, examination, and provocative testing.

T Triple Crush Syndrome

The coexistence of thoracic outlet syndrome with two additional nerve compression syndromes affecting the same nerve pathway.

T Trigger Point

A localized area of chronically contracted muscle that is painful during deep palpation and contributes to thoracic outlet compression.

U Ulnar Nerve Compression

Compression of the ulnar nerve at the elbow or wrist. Ulnar nerve compression commonly coexists with thoracic outlet syndrome in double crush syndrome.

U Underdiagnosis

Failure to recognize one or more contributing disorders during the diagnostic evaluation. The chapter warns that underdiagnosis often leads to unsuccessful treatment.

U Upper Limb Neurodynamic Test (ULNT)

Another name for the Modified Upper Limb Tension Test, used to evaluate brachial plexus tension and nerve compression.

U Upper Trapezius

One of the primary shoulder suspension muscles responsible for maintaining the shoulder above the thoracic outlet. Weakness or fatigue contributes to shoulder depression and thoracic outlet syndrome.

V Vascular Examination

The portion of the physical examination assessing arterial and venous circulation through pulse examination, observation of skin color, swelling, edema, and provocative vascular testing.

V Vascular Thoracic Outlet Syndrome (VTOS)

Thoracic outlet syndrome involving compression of the subclavian vein, producing swelling, edema, venous congestion, and impaired venous drainage.

V Venography

An imaging study evaluating venous circulation. Venography is considered the gold standard when venous thoracic outlet syndrome or thrombosis is suspected.

V Venous Thoracic Outlet Syndrome (VTOS)

A vascular form of thoracic outlet syndrome caused by compression of the subclavian vein, resulting in swelling, edema, discoloration, and impaired venous return.

W Weakness

Loss of muscle strength resulting from nerve compression or prolonged muscle fatigue. Weakness is one of the hallmark symptoms of neurogenic thoracic outlet syndrome.

W Wright's Test

Also known as the Hyperabduction Test, a provocative orthopedic examination evaluating compression beneath the pectoralis minor and within the thoracic outlet by elevating the patient's arm while monitoring the radial pulse and symptoms. No major glossary terms beginning with X appear in Chapter 7. No major glossary terms beginning with Y appear in Chapter 7. No major glossary terms beginning with Z appear in Chapter 7.

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