A comprehensive guide to thoracic outlet syndrome: causes, symptoms, diagnosis, special tests, and treatment options
Thoracic Outlet Syndrome (TOS) is a condition that affects the space between the collarbone and the first rib—the thoracic outlet—where nerves and blood vessels pass from the neck into the arm. When these structures are compressed, it can lead to pain, numbness, and weakness in the upper extremity. TOS is often overlooked or misdiagnosed due to its overlapping symptoms with other shoulder or nerve conditions.
🔍 What Causes Thoracic Outlet Syndrome?
TOS can be caused by various structural or postural factors that reduce the space in the thoracic outlet. Common causes include:
- Poor posture (rounded shoulders, forward head)
- Repetitive overhead activity (common in athletes, manual laborers)
- Anatomical anomalies (like a cervical rib)
- Trauma or injury (e.g., whiplash, clavicle fracture)
- Muscle imbalances (tight scalene or pectoralis minor muscles)
⚠️ Symptoms of TOS
Symptoms vary depending on whether nerves, arteries, or veins are compressed. They typically affect one arm and include:
- Numbness or tingling in the arm or fingers
- Weakness or fatigue in the arm and hand
- Cold sensitivity or discoloration of the hand
- Pain in the neck, shoulder, or chest
- Swelling in the arm (in vascular TOS)
🧪 Special Tests for Thoracic Outlet Syndrome
Clinicians use several special tests to provoke symptoms and help diagnose TOS. Here are a few key ones:
🎗️ Adson’s Test
Used to assess compression between the scalene muscles and subclavian artery.
How it’s done: The patient extends the neck and rotates the head toward the tested side while inhaling deeply. The clinician palpates the radial pulse.
Positive result: Diminished or absent radial pulse.
Indicates: Compression by scalene muscles.
🧍♂️ Roos Test (Elevated Arm Stress Test)
Also known as the “hands-up” test, it evaluates neurovascular compromise from prolonged compression.
How it’s done: The patient raises both arms to 90° abduction and external rotation, then repeatedly opens and closes their fists for 3 minutes.
Positive result: Numbness, tingling, weakness, or inability to complete the test.
Indicates: Neurovascular TOS.
💪 Wright’s Test (Hyperabduction Test)
Assesses compression beneath the pectoralis minor.
How it’s done: The patient’s arm is passively abducted above the head while the clinician monitors the radial pulse.
Positive result: Decreased pulse or symptom reproduction.
Indicates: Compression under the pectoralis minor tendon.
🧍♀️ Costoclavicular Maneuver
Checks for compression between the clavicle and first rib.
How it’s done: The patient pulls their shoulders down and back (military posture). The clinician palpates the pulse.
Positive result: Weakened pulse or symptom onset.
Indicates: Compression between clavicle and rib.
📝 Conclusion
Thoracic Outlet Syndrome is a complex condition that requires careful evaluation and a good understanding of anatomy and movement. Special tests help identify where the compression occurs and guide treatment, which may include physical therapy, posture correction, or in rare cases, surgery. Accurate diagnosis is key to effective management and restoring function in the upper extremity.
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