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Thoracic Outlet Syndrome Tests have poor validity, as there is a false positive rate of 53-92%. So if someone does this test on you and you have a positive result (usually a + is elicited pain/numbness/tingling or loss of a pulse), it doesn't mean anything for sure. Positive tests should be "assessed cautiously".

1) ADSON's and Reverse Adson's Test: Setup: Pt seated or standing, doc stands behind pt, one hand on top of shoulder and other hand palpating radial pulse, EXTEND AND EXTERNALLY ROTATE one arm. Have pt TURN HEAD toward trouble side, then to the other side. Note reduction or loss of pulse. A (+) test: loss of RADIAL PULSE suggests vascular compression and paresthesia or radiculopathy in upper limb suggests neural compression. Mechanism: compression by anterior SCALENE or middle scalene. Text suggests inclusion of extension and valsalva in this test set, but those not covered in lab. A CERVICAL RIB AND SCALENUS SYNDROME.

2) TRACTION test: Setup: Pt seated with arm hanging freely at side. Examiner palpates radial pulse and pulls gently down on arm using epicondyles of humerus, noting any symptoms elicited. Loss of pulse->vascular compression, paresthesia/radiculopathy->neural compression. Positive test is loss or decrease of radial pulse, suggests CERVICAL RIB pressure or a malpositioned 1st rib on the tested side. A CERVICAL RIB AND SCALENUS SYNDROME.

3) Eden's test: Setup: pt seated, doc stands behind pt and hold both wrists, externally rotate and extend arms, and palpate radial pulse. Have patient sequentially lift chest, pause, take deep breath, hold it and bear down (Valsalva maneuver), jut chin forward/to chest, pause, and check for sensation at each level. Stop anytime pain is elicited in the progression. A positive finding is a loss of pulse (VASCULAR COMPRESSION). Positive findings suggest COSTOCLAVICULAR thoracic outlet syndrome but 50-68% of normal individuals will have a + test so don't get too excited.

4) Roo's test aka EAST (Elevated Arms Stress Test): Pt is seated wtih arms bilaterall abducted to 90 degrees, elbows flexed at 90, forearms vertical. Pt is asked to keep arms elevated and flap fingers into the palms 2x/second for 3 minutes. I had a hard time flapping fast enough for long, and experienced tingling in my pinkies and ring fingers at 1 minute. Lab prof says just about nobody can go for 3 minutes. Positive tests include inability to keep up the pace of hand flapping, downward drift of arms, pain in hands, paresthesia, and suggest COSTOCLAVICULAR thoracic outlet syndrome with neurovascular traction.

5) Wright's test: Have patient sit or stand, examiner stands behind them, grasp both wrists and find both radial pulses. Fingers over top, thumbs under wrist. Slowly move arms up in "snow angel" fashion until arms are straight up overhead, monitoring for reduction or loss of the radial pulse. Positive test suggests HYPERABDUCTION SYNDROME; compression of the axillary artery by a hypertonic pectoralis minor muscle, or an enlarged coracoid process. Normal individuals test positive 54-82% so interpret with caution.

6) Allen test: The fist pulse test. Have the patient hold up a hand in "how" position, then locate both the ulnar and radial arteries in that wrist. Have the patient make a fist, and while they are making a fist, occlude both arteries with thumbs. Have pt clench fist a couple more times to pump out arterial blood. Have pt open the hand to view the bloodless palm. Then release just one artery and watch the palm for signs of perfusion. Text and prof say to hold arteries shut for one minute, but lab prof suggests that a second or two will do. Repeat test on same hand but release other artery, then check both on the other hand. Use this test to rule out distal arterial dz/compromise as cause of numbness/tingling. Hyperabduction syndrome due to PERIPHERAL ARTERY COMPROMISE.

Thoracic Outlet Syndrome (TOS)
--some cases idiopathic
--generally split between neurogenic and vascular TOS
--neurogenic generally charactized by paresthesia along inside forearm/palm (C8, T1 dermatomes), weakness/atrophy of long finger flexors and thenar & intrinsic muscles of the hand, also cramping of extrinsic finger flexors
--vascular characterized by swelling/puffiness/blueness/heaviness/fatigue in the arm or hand, a pulsating lump above the clavicle, pain in the shoulder/neck that increases at night
--congenital variations in cervical ribs ("riblets" on C2, 3) and variant scalene muscles can predispose some individuals
--sometimes the brachial neurovascular bundle is compressed under the clavicle: costoclavicular syndrome
--hyperabduction syndrome I think is caused by a forward head jut? "compression between pectoralis minor and the coracoid process"
--the neurovascular bundle contains: brachial plexus, C8 and T1 nerve roots, and subclavian artery and vein



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