1. Thoracic Outlet Syndrome TOS

2. Thoracic Outlet Syndrome Thoracic outlet syndrome results from compression of the subclavian vessels and brachial plexus. Patients may complain of neck and shoulder pain with numbness and tingling in the upper extremity. The ulnar side is typically involved. Using the extremity in an overhead or elevated position is difficult.

3. Clinical Signs and Symptoms Upper extremity pain. Upper extremity paresthesias. Grip weakness.

4. Clinical Signs and Symptoms Upper extremity edema. Upper extremity coldness. Excessive dryness of the arm or hand. Excessive sweating of the arm or hand.

5. Thoracic Outlet

7. Adson’s Test Procedure: Patient seated – establish amplitude of pulse. Compare amplitude b/l. Deep breath. Rotate head and elevate chin to side being tested. Repeat to opposite side. Positive Test: A decrease or absence of the radial pulse. Paresthesias or radiculopathy in the upper extremity.

8. Adson’s Test Structures Affected: Compression of the vascular component of the neurovascular bundle (subclavian artery) by one of the following: Spastic or hypertrophied scalenus anterior muscle Cervical rib Mass such as a Pancoast tumor. Compression of the neural component of the neurovascular bundle (brachial plexus).

9. Adson’s Test

10. Costoclavicular Test Procedure: Patient seated – establish radial pulse. Patient force shoulders posterior and flex chin to chest. Positive Test: Decrease or absence of the radial pulse. Paresthesias or radiculopathy in the upper extremity.

11. Costoclavicular Test Structures Affected: Compression is caused by a decrease in the space between the clavicle and the first rib. A recent or healed fracture of the clavicle or first rib with or without callus formation, dislocation of the medial aspect of the clavicle, or spastic or hypertrophied subclavius muscle could cause the compression.

12. Costoclavicular Test

13. Wright’s Test Procedure: Patient seated – establish radial pulse. Hyperabduct the arm and take the pulse again. Positive Test: Decrease or absence of the radial pulse. Structures Affected: Compression of the axillary artery by a spastic or hypertophied pectoralis muscle or a deformed or hypertrophied coracoid process.

14. Wright’s Test

15. Traction Test Procedure: Patient seated – establish radial pulse. Maintain pulse, extend and traction arm. Positive Test: A decreased or obliterated pulse alone is not diagnostic; however, when if the test is repeated on the other side and reveals no change it is positive. Structures Affected: A subluxated or malpositioned first rib or a cervical rib.

16. Traction Test

17. Halstead Maneuver Procedure: Patient seated – establish radial pulse and note amplitude. With opposite hand, pull on the patient’s arm and have him hyperextend the neck. Repeat on opposite side. Positive Test: Decrease or absence of the radial pulse. Radiculopathy in the upper extremity.

18. Halstead Maneuver Structures Affected: Decrease or absence of the pulse indicates a cervical rib, subluxation, or malposition of the first rib. A radicular component indicates compression of the brachial plexus by the scalenus anterior muscle.

19. Halstead Maneuver

20. Bracial Plexus Irritation Irritation of the brachial plexus may be due to various factors such as the following: Cervical rib Severe upper traction of the arm Fractured clavicle Pulmonary apical mass

21. Clinical Signs and Symptoms Upper extremity radicular pain Upper extremity paresthesias Grip weakness

22. Brachial Plexus Stretch Test Procedure: Patient seated. Laterally flex the head opposite to the side affected. Extend the shoulder and elbow on the affected side.

23. Brachial Plexus Stretch Test Positive Test: Pain and/or paresthesia along the distribution of the brachial plexus. Pain on the side of lateral bending may indicate a nerve root problem. Local cervical pain on the side of bending could be a facet joint problem on that side.

24. Brachial Plexus Stretch Test