A succinct and in-depth subjective assessment is essential to identify specific symptoms and triggers, allowing for differentiation between the subsets of TOS. A comprehensive and meticulous objective assessment is paramount to pinpoint the involvement of anatomical structures. Physical tests to confirm the involvement of nerves, veins, or arteries to guide diagnosis and treatment are also pivotal during assessment (Povlsen & Povlsen, 2018).

SUBJECTIVE ASSESSMENT

Subjective assessments for TOS should comprise questions regarding pain onset, duration, and intensity. Specific questioning should be centred around where symptoms are occurring, how intense the pain is, and how long the pain takes to settle. Questions should also be structured around attempting to identify any tightness, heaviness, tingling, numbness, cramping, discomfort, weakness, or fatigue in the upper limb after excessive lifting or repetitive overhead activity (Ferrante, 2012).

The Northwick park neck pain and Mcgill pain questionnaires may also provide invaluable understanding regarding the onset and duration of symptoms as part of the patient’s history (Li et al., 2021).

OBjective assessment

posture assessment

A forward head posture with anterior displacement of where the head rests relative to the shoulders should be assessed. This posture increases the pressure on the thoracic outlet.

Shoulder positioning should also be assessed to observe whether the shoulders are protracted, which can narrow the pectoralis minor muscle and costoclavicular space.

Next the medial border prominence of the scapula should be assessed to indicate serratus anterior weakness.

Furthermore, excessive shoulder elevation or depression may identify hypertonicity in the levator scapulae or anterior scalene muscles, causing thoracic outlet compression.

Finally, it is imperative to assess for thoracic kyphosis which can cause compression at the thoracic outlet.

(Jones et al., 2019)

Palpation

The supraclavicular fossa, scalene muscles, clavicle and first rib, pectoralis minor, interscalene triangle, costoclavicular, and subcoracoid space must be palpated during an initial assessment. Physiotherapists assess for tenderness, tightness, or reproduction of pain, paraesthesia, or pins and needles down the ulnar nerve distribution (Chang & Kim, 2021).

Shoulder Range of motion (ROM) and

manual muscle testing (MMT)

ROM and MMT assessments of the shoulder, including the movements of flexion, extension, abduction, internal rotation, and external rotation can identify any specific muscle imbalances that may be causing compression at the thoracic outlet.

Cervical ROM

Assessments of the neck should be completed to identify any restrictions in the muscles surrounding the neck including scalenes, upper trapezius, and pectoralis minor (Jones et al., 2019).

Subjective Assessment Example videos

Neurological examination

Upper limb tension test (ULTT) at the ulnar nerve assesses the sensitivity of the brachial plexus by placing it under stress and determining whether symptoms are reproduced. Furthermore, a myotome assessment depicts the motor function at the nerve roots of the spine (C5-T1), weakness in each nerve root can provide an accurate representation of where compression is occurring in the thoracic outlet (Chang & Kim, 2021).

Examples of neurological examination

Provocation tests FOR NTOS

ROOS test - Assessing for numbness tingling or pain reproduction.

Upper limb tension test - Assessing for numbness, or tingling along the ulnar nerve distribution.

Wright’s test - Assessing for numbness or paraesthesia.

PROVOCATION TEST FOR VTOS

ROOS test - assessing for heaviness, or swelling in the arm.

PROVocation Test for ATOS

Adson’s test - Assessing for a diminished radial pulse or pallor and coldness in the upper limb.

Wright’s test - Assessing for cyanosis or numbness in the upper limb.

(Kuhn et al., 2015).

EXAMPLES OF PROvocation tests for TOS