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• Muscle spasm in head/neck/shoulder region
• Range of motion
• Try to reproduce symptoms that appear from brachial plexus compression by tilting the head away from the affected side. Radiating pain is indicative of TOS but does not typically present in CTS or other shoulder-related conditions.
• Applying pressure with a finger over the brachial plexus of the affected side will typically evoke symptoms of TOS but not CTS or cervical disk disease.

Cervicoscapular Region

The cervicoscapular region is the muscular area of the upper chest and neck. The areas of observation and evaluation include:

• Observation of posture during sitting and standing. It is most common to see the head placed forward of the thorax (chest) with rounded shoulders turned inward. When this position is maintained over a long term period, it causes changes in the length and strength of muscles in this region.
• The extent of cervical range of motion and any pain associated with movement
• Evaluation of individual chest/neck muscles for tightness, weakness, or tenderness
• Range of motion of the shoulders and the degree of discomfort. Rotator cuff tendonitis (irritation of the rotator cuff which are the 4 muscles that elevate and move the shoulder) is a common finding.

Provocative Maneuvers

In addition to the physical examination, an important aspect in the diagnosis of thoracic outlet syndrome is to verify the effects of the compression of the brachial plexus by attempting to reproduce the patient's symptoms. A variety of provocative thoracic outlet compression maneuvers may be used to reproduce the patient's symptoms, however, none of these tests are considered either highly sensitive or specific for the diagnosis of TOS. Some of the maneuvers are used to evaluate vascular symptoms and some to evaluate nerve compression. Nevertheless, these provocative maneuvers, along with a careful medical history and physical examination, improve the doctor's likelihood of arriving at an accurate diagnosis. Some of the more common provocative maneuvers include:

• Wright Hyperabduction Test - the radial and ulnar pulses of each wrist are measured at rest and then the radial pulse is measured when the arm is raised 90 degrees. The test is positive if the radial pulse weakens during the maneuver. However, the pulse changes are not definitively diagnostic for TOS since the same changes occur in approximately 7% of the normal population.

• EAST (Elevated Arm Stress Test) - also called the Roos Maneuver. This is considered one of the more reliable tests for the diagnosis of TOS. The patient stands with arms out and elbow bent at 90 degrees (surrender position) and opens and closes their hands slowly for 3 minutes. Usually, the only sensation is muscle fatigue but if a patient has TOS, the symptoms can be reproduced up to the point that the patient may not even be able to complete the test. Symptoms evoked by the test include:

  • gradual increase of pain in the neck and shoulder region
  • changes of sensation in the fingers
  • pain which radiates down the arm
  • arm pallor when the arm is elevated and hyperemia (abnormally high level of blood) when lowered (if there is arterial TOS)