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Evaluation-Physical Examination

Inspect the arm for symmetry with regard to size, color, and skin temperature. Palpation of the cervical spine, the scalenes, and the clavicle can be used to look for structural causes of TOS. A Tinel sign may be elicited over the supraclavicular fossa. A careful neurovascular examination should include strength testing of the muscles and checking sensation, especially in areas supplied by the lower brachial plexus.

A few provocative maneuvers have been described to test for TOS, but their use and specificity for establishing the diagnosis of TOS are unclear. For each of the following maneuvers, a positive test involves the decrease or elimination of a palpable pulse or reproduction of symptoms, such as paresthesias, sensation of heaviness, and/or fatigue, which are consistent with the diagnosis of TOS and that may not occur on the asymptomatic, contralateral side.

During the Adson maneuver, the examiner palpates the ipsilateral radial pulse, while the patient rotates the head toward the side being tested and extends the neck. The subject inhales to further compress the structures of the thoracic outlet. The Wright test is performed with the subject’s arm being progressively hyperabducted and externally rotated while assessing for ipsilateral radial pulse diminution and reproduction of paresthesias.

With the Roos stress test or the elevated arm stress test, the patient is asked to repeatedly open and close the hands for several minutes, holding the shoulders in abduction and external rotation of 90 degrees while the elbows are flexed at 90 degrees.

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