History and exam
Key diagnostic factors
common
history of repetitive jobs or overhead hobbies/activities
For example: computer operators, linotype operators, mail sorters, pump operators, athletes (particularly, football, baseball, tennis, and volleyball players, swimmers and divers, weightlifters, gymnasts).
pain in upper extremity and adjacent areas
Can occur in all types of thoracic outlet syndrome (TOS).
Pain can occur in the head, neck, upper back, anterior chest, shoulder, arm, forearm, and/or hand.
Tenderness to palpation may be present in the supraclavicular region, anterior chest wall, scalene muscles, trapezius, or pectoralis minor muscles.
May be described as a dull ache in arterial TOS.
Exacerbated by exertion in both arterial and venous TOS.
paraesthesias in arms, hands, and/or fingers
Common complaint in neurological thoracic outlet syndrome (TOS).
Numbness may also be described in arterial TOS.
May be bilateral or unilateral.
circulatory changes in upper extremity
Raynaud's phenomenon can be seen in neurological and arterial thoracic outlet syndrome (TOS).
Cyanosis, pallor, or coolness of the upper extremity can be seen in arterial TOS. Acute ischaemia or gangrene is an emergent complication of arterial TOS.
Cyanosis, erythema, or dusky appearance of the upper extremity can be seen in venous TOS.
Sympathetic compression symptoms include excessive cold or warm and sweaty upper extremities. Can sometimes mimic atypical chest pain (pseudoangina).
Sympathetic and arterial compression results in more severe symptoms of excessive upper extremity warmth or cold or sweating because of the additive or synergistic sympathetic stimulation.
upper extremity fatigue
Described in both arterial and venous thoracic outlet syndrome (TOS).
Fatigue is often exacerbated by activity.
Dead arm sensation has been reported in arterial TOS.
Other diagnostic factors
uncommon
history of clavicular fracture
Neurovascular/combined (traumatic) types of thoracic outlet syndrome is associated with a clavicle fracture, which can cause compression of the neurovascular structures in the costoclavicular space.
palpation of cervical rib
Presence of a cervical rib in the concurrent setting of repetitive stress can predispose people to thoracic outlet syndrome.
Cervical ribs can sometimes be palpated on physical examination of the neck.
subcutaneous venous collateral distention around shoulders (Urschel's sign)
Sometimes present in venous thoracic outlet syndrome.
motor weakness
Present primarily in true neurological thoracic outlet syndrome.
May occur in shoulder girdle and hand.
hyperhidrosis
Present primarily in neurological or arterial thoracic outlet syndrome when there is sympathetic nerve stimulation.
thenar eminence muscle atrophy
Hand muscle atrophy is seen in true neurological thoracic outlet syndrome.
Consistent with median motor nerve conduction velocity abnormality.
exertional pain/claudication
Feature of arterial and venous thoracic outlet syndrome.
Symptoms of upper extremity pain can worsen with activity and improve with rest.
supraclavicular systolic bruit
Can sometimes be auscultated on physical examination in arterial or venous thoracic outlet syndrome.
May only be present with shoulder abduction.
blood pressure difference between extremities
A blood pressure difference (e.g., of up to 20 mmHg) may be seen on physical examination between the thrombosed upper extremity and the contralateral normal upper extremity in arterial thoracic outlet syndrome.
positive Adson's (scalene) test
Tightens the anterior and middle scalene muscles, thus decreasing the interspace and magnifying pre-existing compression of the subclavian artery and brachial plexus. The patient takes and holds a deep breath, extends the neck fully, and turns the head toward the side.[128] Obliteration or decrease of the radial pulse in addition to production of symptoms and hand pallor suggests compression.[Figure caption and citation for the preceding image starts]: The Adson maneuver tightens the anterior and middle scalene muscles, decreasing interspace and magnifying pre-existing compression of the brachial plexus and subclavian artery. The patient takes and holds a deep breath, extends the neck fully, and turns the head toward the affected side. Obliteration or decrease in the radial pulse indicates neurovascular compression at the thoracic outletReprinted with permission from Netter Images [Citation ends].
positive costoclavicular test
Also known as the Halsted test or military brace.
Shoulders are drawn downwards and backwards. This narrows the costoclavicular space by approximating the clavicle to the first rib and thus tends to compress the neurovascular bundle.[129]
Obliteration of the radial pulse with production of symptoms indicates compression.
positive hyperabduction test
Hyperabduction of the arm to 180° pulls the components of the neurovascular bundle around the pectoralis minor tendon, the coracoid process, and the head of the humerus.[129]
If the radial pulse is decreased, compression should be suspected.
positive elevated arm stress test (Roos test)
Both arms are placed at right angles to the shoulder, and the forearms are at right angles to the upper arms. Both hands are opened and closed as fast as possible to see if symptoms occur.[130]
Performed during the physical examination to determine what symptoms the patient is experiencing with reference to their thoracic outlet (e.g., arms start to hurt, hands become numb, hands change colour).
positive stretch test
The arm is abducted 90° with elbow extension, palm facing forwards, and thumb pointing up to the ceiling. This stretches the plexus. A positive test is an uncomfortable pulling sensation of the inner arm, sometimes extending into the forearm or hand, on abduction. The patient may develop paraesthesias or heaviness of the extremity.
The patient then laterally flexes the head to the opposite side. A positive test of lateral flexion is exacerbation of the symptoms.
positive upper limb tension tests
A series of tests of all tissues in the upper limb with a preferential focus on the median nerve and its associated plexus and roots. They involve shoulder abduction, wrist suspension and extension, shoulder lateral rotation, elbow extension, and neck lateral flexion away from or toward the test side. Symptoms may be reproduced with shoulder abduction alone, and expected to be aggravated with wrist extension and alleviated with wrist flexion.[1][64][100]
Provides physical evidence of stretch of median, radial, and ulnar nerves. Allows side-to-side comparison and comparison of response with normal extremity movement.
positive Wright's manoeuvre
The arm is externally rotated and abducted to 180° while the elbow is flexed (simulating a lazy hand raise).
Can recreate a patient’s paraesthesia symptoms in neurological thoracic outlet syndrome.
oedema/swelling of upper extremity
Can be seen acutely in venous thoracic outlet syndrome.
Upper extremity swelling (and concurrent pain) may develop suddenly following an increase in the causative activity.
Risk factors
strong
cervical ribs (partial or complete)
abnormal (hypoplastic) first rib or bony abnormalities
anomalies of muscular development (interdigitation, scalene minimis muscle)
fibro-fascial or ligamentous bands
fractures of clavicle or first rib
over-development of muscles (bodybuilding, heavy labour with upper extremities)
Decreases the normal aperture of the thoracic outlet.
traumatic injuries (whiplash, upper extremity distraction injuries)
Hyperextension injuries resulting from rapid acceleration or deceleration of the neck or arm (e.g., whiplash-like injury or falls on the outstretched arm) are well known to be contributing factors in neurogenic thoracic outlet syndrome. These types of injury may result in microscopic alterations in scalene and pectoralis minor muscles, with fibrosis and varying degrees of chronic muscle spasm.These factors may lead to compression and irritation of the brachial plexus in the interscalene triangle, costoclavicular space, and/or subcoracoid space.[11][12][63][64][65]
Use of this content is subject to our disclaimer