Perhaps the best test for thoracic outlet syndrome is with overhead exercises consisting of slow, repetitive opening and closing of the hand in the elevated position looking for reproduction of symptoms.9 In addition, several maneuvers have been described to detect the neurovascular symptoms that result from compression of the thoracic outlet.
This is accomplished by palpating the patient's radial pulse in a seated position with the arm at the side (Fig. 16-29). The patient is instructed to hold his or her breath while the arm is extended and the head rotated toward the side being examined. The examiner documents a diminution in the radial pulse, which is recorded as a positive finding for vascular compression (Fielding's modification). We modify this test by turning the patient's head away from the side being examined5,9 and deem a positive test not only by a decrease in pulse, but by reproduction of symptoms.
In this test, the radial pulses are again monitored for change with the arms brought from resting to a hyperabducted position. It should be noted that 20% of individuals will demonstrate a diminution of the radial pulse in this position, so attention should be paid to asymmetry.5
This test is performed by abducting, extending, and externally rotating the arm.47 It is traditionally a test to monitor decrease in radial pulse, but we again modify this for reproduction of the patient's specific symptoms to call the test positive.
In addition to these findings, thoracic outlet syndrome can rarely present with vascular symptoms like engorgement and increased arm circumference, raising suspicion of thrombosis as described previously.
It is important to note that although burners and brachial neuritis more commonly present as pain and dysesthesias, some patients have a difficult time describing their symptoms, so that such complaints should illicit some suspicion of these diagnoses.
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