Clinical Evaluation
The clinical examination is essential in aiding the practitioner in ruling out other relative conditions. The exam will involve observation of posture in different positions. First examine the patient in the waiting room, if at all possible, to assess for forward head, rounded shoulders or a kyphotic posture. When seated in the exam room and thereafter with the patient in standing, the therapist will examine the alignment and positioning of the patient’s head, arms, shoulders, and scapular movement. Clinical presentation can be variable: paresthesias (along the medial arm) aggravated with overhead positioning, pain along the cervical region or upper arm, sensation of heaviness, intrinsic hand muscle atrophy, the patient easily fatigued by upper extremity exertion, and pale color or reduced temperature unilaterally in one hand. Symptoms will vary in accordance with severity of the compression. Note that patient might present with supraclavicular fullness, possibly representing a first rib prominence versus a soft tissue swelling (Hooper 2010).
After obtaining a full history, with the patient describing symptom onset and situational changes or complaints, visually inspect upper extremities for edema, circumferential differences, moisture or temperature variation, cyanosis at the nailbeds (venous issues), or pale, colorless skin (vascular compromise) in one upper extremity. With the patient’s neck in flexion, percuss the lumbar, thoracic, and cervical spine along the spinous processes.
Also monitor the following signs or abnormalities:
What questions are appropriate to ask the patient?
After obtaining a full history, with the patient describing symptom onset and situational changes or complaints, visually inspect upper extremities for edema, circumferential differences, moisture or temperature variation, cyanosis at the nailbeds (venous issues), or pale, colorless skin (vascular compromise) in one upper extremity. With the patient’s neck in flexion, percuss the lumbar, thoracic, and cervical spine along the spinous processes.
Also monitor the following signs or abnormalities:
- Variation in blood pressure between either upper extremity (significant if difference is more than 20 mmHg; suggesting compromised subclavian artery)
- Neck and upper extremity active range of motion; how does patient move?
- An elevated first rib on the involved side
- Unilateral cavernous reduction in the supraclavicular fossa
- Pain on palpation of the supraclavicular fossa
- Atrophy of hand musculature
- Distal numbness or tingling of the upper extremity
- Excessive mobility of the first rib
- Mobility deficits in the thoracic or cervical spine
- Mobility of the clavicle during arm elevation
- Assess movement of the thoracic spine, especially for any lack of extension
- Assess glenohumeral end-range mobility
- Manual muscle testing of both upper extremities and thereafter assess muscles innervated by the median or ulnar nerves separately
- Note if patient has unilateral triceps weakness (common with TOS)
What questions are appropriate to ask the patient?
- Are you experiencing any pain? Could you describe the: location, how often you feel the pain, how long the pain lasts, the intensity on a scale of 0 to 10 (with zero being no pain and 10 being the worst pain imaginable), and areas where you experience any referral?
- What makes the pain worse? What makes the pain better?