Adson's Test Research Articles

Torasik Outlet Sendromunda Cerrahi Tedavinin Etkinliği

Aim: In this study, we aimed to evaluate the effectiveness of surgical treatment in patients diagnosed with thoracic outlet syndrome. Patients and Methods: This study was conducted by analyzing the age, sex, occupational distribution, anamnesis and physical examination findings, symptoms, preoperative examinations, operation findings, postoperative complications, postoperative hospital stay and operation results of thirty seven patients who were diagnosed with Thoracic Outlet Syndrome, and were operated on between 1991 and 2004. Results: Most of the patients were in the 15-35 age group (72.97%) and female (91.9%). Most of these cases were housewives (51.4%). The most common symptoms were pain (94.6%) and numbness (78.4%). The most commonly used test in physical examination was the Adson test, which provided an 86% positive rate. The most common pathology encountered in radiological tests was cervical rib anomaly (37.8%). It was found that EMG of upper extremity supported TOS with a rate of 48.6% and arterial doppler of upper extremity supported TOS with a rate of 13,5%. We applied first rib and cervical rib resection scalenectomy and cutting of fibromuscular bands as a surgery by transaxillary approach. A 78.4% complete recovery was observed in the early period after surgery and there was no mortality in any of the cases. Conclusion: In this study, the results were satisfactory in TOS patients on suitable cases and with good surgical technique. Surgical success rate can reach up to 97%.

Chronic Shoulder Pain Secondary To Trampolining Injury

HISTORY: 14 year old female with right shoulder pain and arm paresthesias after trampolining injury 17 months prior to visit. Her right arm was yanked down and she heard a pop. Pain initially improved but recurred during basketball tryouts 6 months later. At presentation she noted right shoulder “spasm” pain rated 2/10 at rest and worsened to 5/10 with repetitive activities. Most bothersome symptoms were achy, tingling sensation on the medial aspect of her right arm radiating into the 3rd-5th digits with hand weakness. PHYSICAL EXAMINATION: Right first rib was elevated with tenderness. The right middle scalene was notable for spasm with tenderness. Right scapula winging noted. Positive right lift-off test. Weakness in the right abductor pollicis brevis, 3/5 on motor testing. No sensory or other strength deficits. Radiating symptoms reproduced with right shoulder mobility. Negative Neers, Hawkin’s and speed’s. Positive Roo’s maneuver on the right at 15 seconds. Negative Adson's test bilaterally, Negative Tinel's test at the right elbow and wrist. Negative Spurling’s and Lhermitte’s. DIFFERENTIAL DIAGNOSIS: #1-Neurogenic thoracic outlet syndrome #2-Brachial plexopathy #3-Vascular thoracic outlet syndrome TEST AND RESULTS: MRI Right brachial plexus - No mass or focal abnormality along right brachial plexus. Diminutive appearance of right internal jugular vein of uncertain clinical significance. MRI of cervical spine - No evidence of neural compromise. Electrodiagnostic exam - There was a 25% decrease in the right median motor amplitude compared to the left. No side to side difference in ulnar nerve studies. The scapular stabilizers were not evaluated. Vascular Doppler Evaluation - Dampened plethysmography waveforms in the right arm in the Adson maneuver when compared to the left. FINAL/WORKING DIAGNOSIS: Arterial thoracic outlet syndrome TREATMENT AND OUTCOMES:Dry-needling of the right anterior and middle scalene muscles were performed. Physical therapy was prescribed with focus on stretching the scalenes and pectoralis muscles. She is no longer having symptoms at rest and her strength is significantly improved. She continues to have right 3rd-5th digit paresthesias with prolonged activities despite focused physical therapy and is undergoing surgical evaluation.

Provocative tests in the diagnosis of thoraсic outlet syndrome

Objective — to study the reliability, expediency and informational content of provocative tests in the diagnosis of thoraсic outlet syndrome.Methods and subjects. The study involved 82 patients with complaints of pain in the shoulder girdle and/or upper limb. All patients underwent a complex set of examinations, which consisted of radiography and magnetic resonance imaging of the cervical spine, ultrasound diagnostics of the neck soft tissues, shoulder girdle and upper extremity vessels, stimulating electroneuromyography and needle electromyography of upper extremity. In order to identify vessel or nervous fiber involvement we performed provocative tests.Results. After the careful history taking, clinical examination, data of instrumental methods of examination, thoracic outlet syndrome was diagnosed in 23 patients. The sensitivity of the Adson test for TOS was identified in 43 % of patients, the specificity was in 80 %, the sensitivity of the EAST test was in 53 %, and the specificity was in 75 %. Patients with TOS during the EAST test had symptoms of one‑sided type or symptoms were more expressed on a particular side. In addition, in patients with TOS, the numbness in most cases localized on the ulnar edge, whereas in practically healthy individuals it was diffuse. In patients with TOS, numbness was observed after the first minute.Conclusions. The results of Adson and EAST test for the diagnosis of neurogenic TOS should be confirmed by instrumental methods of examination, due to the low sensitivity and specificity of individually applied provocative tests. During the EAST test it is important to pay attention to the time when symptoms occur and which symptoms are present, especially the feeling of numbness and pain with typical for TOS localization, which may be a marker for neurogenic TOS or mixed forms of TOS if signs of vascular component involvement is determined by instrumental examination methods and provocative tests.

A New Anatomical Variation in the Brachial Plexus Roots and its Implications for Neurogenic Thoracic Outlet Syndrome

Neurogenic thoracic outlet syndrome (TOS), compression of proximal portions of the brachial plexus as they course through the superior thoracic outlet, is the most common type of TOS, and often results in pain, paresthesia, and paresis in the upper extremity. Typically impingement occurs as the neurovasculature passes between the anterior and middle scalene muscles, and this classic relationship is the foundation for clinical diagnosis. Positional testing, such as Adson's test, relies on vascular compromise of the subclavian artery in this space. Here we report an anatomical variant in which the superior trunk of the brachial plexus pierces the anterior scalene, while the subclavian artery travels without entrapment. Thirty cadavers at Midwestern University were assessed to determine the frequency of this variant. Twelve variations from classic anatomy were observed. In 10 (33.3%), the superior trunk pierced the anterior scalene muscle, and in one, the middle trunk also pierced the muscle belly. All cases occurred unilaterally, and almost exclusively on the left side. The high frequency of this variation and its potential to predispose patients to neurogenic TOS by compressing the superior and/or middle trunk suggests that current diagnostic methods may be insufficient to identify those who suffer from TOS symptoms. Due to a lack of vascular compromise, patients with this variant would likely not display a positive Adson's sign. Ultrasound may be used to determine whether this variation is present in patients who suffer from TOS symptoms but are without a diagnosis based on traditional positional testing.

Tratamiento fisioterápico mediante terapia manual en el síndrome compresivo del músculo escaleno: a propósito de un caso

Thoracic outlet syndrome referring to brachial plexus entrapment within the anterior and medium scalene muscle is under debate. The case of a 70-year old woman, with progressive neck and hand pain since 3 years ago is reported. She had received previous physiotherapy intervention (massage, microwave and TENS) without any effect. The Adson test was positive for the affected arm. Her treatment consisted of 8 physical therapy sessions including pressure release, mobilization of C5-T1 joints, nerve slider neurodynamic technique biased to the median nerve and cranio-cervical flexion motor control exercises. Spontaneous pain intensity at baseline was 6 points (0-10). Functionality was 40% according to the Michigan Hand Outcomes Questionnaire. One month after the last session, pain at rest was 1/10 and the Michigan Hand Outcomes Questionnaire showed 75% hand function. Physiotherapy focused on manual therapy approach represents a potential effective intervention for reducing symptoms and increasing function in individuals with thoracic outlet syndrome.

Diagnosis and treatment of a patient with bilateral thoracic outlet syndrome secondary to anterior subluxation of bilateral sternoclavicular joints:A case report

Thoracic outlet syndrome may result from a posterior sternoclavicular (SC) joint subluxation, or an anterior SC joint subluxation after surgical fixation. This case report presents the physical therapy management of a patient with bilateral thoracic outlet syndrome (TOS) secondary to bilateral idiopathic anterior SC joint subluxation. A 16-year-old female presented with a 2-year history of numbness, tingling, and coldness in bilateral upper extremities, and intermittent headaches with occasional vision loss. Ipsilateral upper extremity symptoms were reproduced with cervical rotation and shoulder flexion and abduction from 90° to end of the range. All TOS tests were positive. Passive horizontal abduction, through the plane of scaption, produced anterior subluxation of the ipsilateral SC joint. Sustained posterior glides to the medial clavicle relieved all symptoms during shoulder flexion and the Adson's test. Interventions consisted of manual therapy, therapeutic exercise, and the trial of two orthoses. After 12 treatment sessions, the patient's symptoms resolved and she improved by 10 points on the Upper Extremity Functional Index. She had no reproduction of symptoms with the thoracic outlet special tests. She maintained a static hold for 90 sec at 90° shoulder flexion, 90° shoulder abduction, and full shoulder flexion without symptoms. The outcomes describe a successful intervention for a patient with bilateral TOS secondary to idiopathic bilateral anterior SC joint subluxation. This case suggests that SC joint dysfunction should be considered as a cause of TOS and should be screened during the initial examination.

ADSON'S TESTの問題点;深吸気が脈管テストに与える影響

ADSON'S TESTの問題点;深吸気が脈管テストに与える影響

Chiropractic care of a patient with thoracic outlet syndrome and arrhythmia

Objective The purpose of this article is to describe a case report and discuss a possible anatomical explanation of the occurrence of arrhythmias in patients with thoracic outlet syndrome (TOS). Clinical Features A 60-year-old man experienced arrhythmia when he turned his head to the left and had these symptoms for 7 years. The patient attributed his symptoms to TOS. The arrhythmia was triggered while performing an Adson test during the clinical evaluation. Intervention and Outcome The Grostic procedure as a measure of analysis of the biomechanical relationship of C1 to C0 and the lower cervical spine was performed. According to this analysis, the patient had a right laterality malposition of the atlas. High-velocity, low-amplitude manipulations (adjustments) were applied. The patient's symptoms improved after one visit and demonstrated resolution upon evaluation at the third visit. In the year following the initial presentation, he has had minor recurrent short-lived episodes of arrhythmia that abated with the atlas manipulation/adjustment. Conclusion There is a paucity of published reports describing the management of patients with arrhythmias through manipulative methods. This appears to be the first case that describes the successful amelioration of an arrhythmia associated with TOS using chiropractic adjustment of the atlas vertebra as the sole intervention.

Arm Swelling And Axillary Pain-non-competitive Older Athlete

HISTORY: A 60 year old right handed, recreational athlete presented with 6 months of progressive arm swelling and discoloration, with associated axillary discomfort. These symptoms began after she increased her upper body weight lifting program. Symptoms now occur post exercise and nocturnal. The right arm is not involved. The left axillary pain, located near the left chest wall is described as tightness. She denied warmth, weakness and paresthesia. Past medical history was significant for osteopenia, Raynaud's phenomenon and cervical spine disc bulges found after an MVA in 1998. PHYSICAL EXAMINATION: The patient is a well developed female in no distress. Blood pressure 126/70 both arms, capillary refill 1 second, pulses 2+and equal, 76 bpm. Cervical spine exam revealed moderately reduced extension and lateral flexion; Spurling test negative. Dilated veins noted over the left anterior chest wall and upper arm with telangectasia; no cords. Left arm circumference was larger than right (upper arm 2 cm, forearm 4 cm). Neurological exam motor 5/5, DTR's 2+,gait normal, Babinski response downgoing, sensation intact. Axilla was nontender; no palpable adenopathy. Cardiopulmonary exam normal. DIFFERNTIAL DIAGNOSIS: 1. Thoracic outlet syndrome 2. Paget-Schroetter syndrome 3. Cervical arthritis 4. Cervical radiculopathy 5. Cervical disc disease 6. Brachial plexus neuritis TESTS AND RESULTS: Provocactive maneuvers: Adson Test (-), Allen test (-), overhead exercise test (+) with plethora/pain/increase venous engorgement. Cervical spine X ray: C5-6: discogenic disease and uncovertebral joint arthropathy with mild bilateral neuroforaminal narrowing, left >right.. CXR normal. Vascular consultation and upper extremity duplex venous ultrasound (-)thrombosis. Lab data: CBC/EKG -normal. FINAL/WORKING DIAGNOSIS: Thoracic outlet syndrome causing isolated venous flow restriction symptomology without thrombosis (previously not reported). The cervical spine DJD was the suspected trigger in the setting of a progressive weight resistance program. TREATMENT AND OUTCOMES: 1. Referral to occupational therapist. 2. Avoidance of overhead weight lifting positions. 3. Six week follow up revealed near complete resolution of symptoms and venous engorgement.

Neurogenic Thoracic Outlet Syndrome and Pectoralis Minor Syndrome: A Common Sequela of Whiplash Injuries

Thoracic outlet syndrome (TOS) presents with pain and paresthesia in the neck and upper extremity, weakness in the arm, and occipital headaches. Over 80% of cases are a result of compression of the brachial plexus after hyperextension neck injuries such as whiplash. The diagnosis is often missed because it cannot be made by x-ray or nerve tests; diagnosis requires clinical evaluation by history and physical examination. The popular Adson test is misleading and should be replaced by more specific provocative maneuvers that elicit symptoms. In addition, many patients with neurogenic TOS also have chest pain that often is from an associated pectoralis minor (PM) compression syndrome. Because PM syndrome is easily treated by a no-risk outpatient procedure, its distinguishing features and recognition are important. The clinical diagnostic features of both conditions are the focus of this article.

Shoulder Pain-Weight Lifting

HISTORY: 22yo male recreational weightlifter and triathlete p/w several month h/o progressive L shoulder pain of insidious onset. He reported weakness in his shoulder, particularly with weight training, and described intermittent numbness and paresthesias radiating from the shoulder into the forearm and hand. He denied swelling or discoloration of the LUE. PMH: (+)RLE DVT with PE, approx. 1 year earlier, after immobilization in CAM walker following RLE injury. Extensive hypercoagulability work-up was (−). Meds: coumadin 5 mg daily, ASA 81 mg daily. (+)rare ETOH use. (−) tobacco/recreational drug/anabolic steroid use. FH: (−) thromboembolic/neurologic disease. ROS: no constitutional sx. PHYSICAL EXAMINATION: Gen: healthy-appearing, muscular, young male. No LUE edema/discoloration. L shoulder: no atrophy/deformity, (+)full ROM, (+)pain with shoulder elevation >130°, (+)Hawkin's test, (−)apprehension test. RUE strength 5/5, including RTC. Sensation intact to soft touch/pinprick. Reflexes +2 symmetric. Normal pulses LUE. (−)Spurling's maneuver, (−)Adson's test, (−)Roos test, (−) costoclavicular maneuver. DIFFERENTIAL DIAGNOSIS: Shoulder impingement syndrome Cervical radiculopathy Thoracic outlet syndrome Upper extremity deep vein thrombosis Brachial plexopathy TEST AND RESULTS: Shoulder MRI: small fluid collection in subdeltoid bursa and subcoracoid region, small effusion in glenohumeral joint, small subcortical cysts in posterior humeral head laterally. Os acromiale present. LUE EMG/NCS: abnormal insertional activity, denervation potentials and membrane instability c/w with active C6 radiculopathy. C-spine x-rays: normal C-spine MRI: normal Brachial plexus MRI: thrombosis of L subclavian vein with inflammation of nearby brachial plexus in cervical vascular and subclavicular regions. FINAL WORKING DIAGNOSIS: C6 radiculopathy secondary to subclavian vein thrombosis TREATMENT AND OUTCOMES: Given duration of sx, pt not considered candidate for thrombolytic tx. INRs in preceding months had been in 2.0-2.4 range. Hematology consultant who had been involved with pt's prior care for DVT/PE. advised increasing coumadin dosing to achieve INR in 2.5-3.0 range. Pt referred for surgical evaluation for consideration of thoracic outlet decompression.

Facteurs prédictifs des résultats à long terme de la rééducation fonctionnelle des syndromes de la traversée thoracobrachiale : à propos de 85 patients

Introduction Thoracic outlet syndromes are expressed by various clinical manifestations. Treatment is mainly rehabilitation. We aimed to identify factors predicting long-term functional rehabilitation in patients with this treatment and recurrence of symptoms. Patients and methods We performed a descriptive retrospective analysis of 84 patients who underwent rehabilitation for thoracic outlet syndrome as defined by Revel and colleagues. Data collection involved a questionnaire exploring personal information, risk factors for developing thoracic outlet syndrome, clinical signs, and x-ray results. Long-term results of treatment were evaluated by telephone questionnaire. Data analysis involved use of Stata 6 software. Results Univariate analysis : predictive factors of negative results with treatment were ligament hypermobility, sensitive disturbances at the time of diagnosis, and a positive Adson's test result. Predictive factors of positive results were absence of paresthesia at the end of the treatment, and a negative “bell sign” at the end of the treatment. Predictive factors of nonrecurring symptoms were age younger than 34, bilateral positive Adson test result, and need for a supplementary number of sessions. Multivariate analysis : predictive factors of positive results with treatment were absence of sensitive impairment at the time of diagnosis, compliance with home exercises, initial negative Adson's test result, absence of hypermobility, and absence of paresthesia at the end of treatment. Predictive factors of recurring symptoms were age younger than 34, the need for a supplementary number of sessions and bilateral positive Adson's test result. Conclusion A larger number of subjects are needed to further explore the predictive factors of rehabilitation and recurring symptoms in thoracic outlet syndrome for better validity and significance.

Doppler Adson’s Test: Predictor of Outcome of Surgery in Non‐Specific Thoracic Outlet Syndrome

Outcome of surgery in non-specific thoracic outlet syndrome (TOS) is variable. Duplex imaging of the subclavian artery during Adson's maneuvre may help predict outcome. A retrospective study of 16 cases of non-specific TOS who had pre-operative duplex imaging of the subclavian artery during Adson's maneuvre was done and their outcomes following surgical decompression of the thoracic outlet studied. Of the eight cases with a positive Adson's test, seven (87.5%) had a complete response of symptoms following surgery while in the eight cases with a negative test, only four (50%) had a favorable response to surgery. Duplex scanning of the thoracic outlet during Adson's maneuvre may help predict outcome of thoracic outlet decompression surgery in cases of non-specific TOS.

Provocative Tests in Cervical Spine Examination: Historical Basis and Scientific Analyses

The majority of the provocative tests described for physical examination of the neck and cervical spine relate to identification of radiculopathy, spinal cord, or brachial plexus pathology. These tests are often performed routinely by many providers with variable methods and interpreted in a variety of ways. Several commonly performed provocative tests include Spurling's Neck Compression Test, Shoulder Abduction (Relief) Test, Neck Distraction Test, L'hermitte's Sign, Hoffmann's Sign and Adson's Test. This review describes some specialized provocative tests with comprehensive literature review. The goal of this review is to develop standardization in the performance and clinical use of these tests. Each of the tests described in this manuscript apparently originated from the anecdotal observations of experienced, well respected clinicians. However, only few studies have been performed addressing the interexaminer reliability or validity of these tests. The existing literature appears to indicate high specificity, low sensitivity, and good to fair interexaminer reliability for Spurling's Neck Compression Test, the Neck Distraction Test, and The Shoulder Abduction (Relief) Test when performed as described. For Hoffman's Sign, the existing literature does not address interexaminer reliability but appears to indicate fair sensitivity and fair to good specificity. For L'hermitte's Sign and Adson's Test, not even tentative statements can be made with regard to interexaminer reliability, sensitivity, and specificity, based on the existing literature. It is concluded that more research is indicated to understand the clinical utility of all the provocative tests employed in the physical examination of the neck and cervical spine.

Diagnosing thoracic outlet syndrome: contribution of provocative tests, ultrasonography, electrophysiology, and helical computed tomography in 48 patients

Objective. To evaluate the diagnostic usefulness of provocative tests, Doppler ultrasonography, electrophysiological investigations, and helical computed tomography (CT) angiography in thoracic outlet syndrome (TOS). Patients and methods . We prospectively evaluated 48 patients with a clinical suspicion of thoracic outlet syndrome. Standardized provocative tests, an electromyogram and somatosensory evoked responses, a Doppler ultrasonogram, and a helical CT arterial and/or venous angiogram with dynamic maneuvers were done on each patient. The final diagnosis was established by excluding all other causes based on all available data. The agreement between the results of each investigation and the final diagnosis was evaluated. Results. Provocative tests had mean sensitivity and specificity values of 72% and 53%, respectively, with better values for the Adson test (positive predictive value 〚PPV〛, 85%), the hyperabduction test (PPV, 92%), and the Wright test. Using several tests in combination improved specificity. Doppler ultrasonography visualized vascular parietal abnormalities and confirmed the diagnosis in patients with at least five positive provocative tests. Electrophysiological studies were useful mainly for the differential diagnosis or for detecting concomitant abnormalities. Although helical CT angiography provided accurate information on the location and mechanism of vascular compression, the usefulness of this investigation for establishing the diagnosis of TOS and for obtaining pretherapeutic information remains unclear.

Neurovascular Injuries to the Shoulder

The throwing athlete is at risk for neurovascular injuries of the shoulder because of the excessive demands placed upon the shoulder by repetitive throwing motions. The most commonly recognized neurovascular compression syndromes are axillary artery occlusion, effort thrombosis, quadrilateral space syndrome, and thoracic outlet syndrome. Diagnosis is aided by the use of the Adson's test, costoclavicular maneuver, and hyperabduction maneuver. Initial treatment usually is nonoperative. Anticoagulation or thrombolytic therapy can be used for vascular occlusion. Surgery usually is reserved for patients suffering acute or chronic symptoms despite nonoperative treatment. With proper treatment, most patients are able to resume their previous athletic activities in a timely manner with minimal disability.

Popliteal artery entrapment syndrome: Report of a case and study of 18 cases in Japan

A case of entrapment of the popliteal artery is reported in a 15 year old girl who was treated successfully by resection of a thrombosed segment of the artery and interposition of the autovein. Adson's test gave positive results in both arms, suggesting the coexistence of anomalies of either artery or muscle in the shoulder or the neck. Histologically, abnormal longitudinal muscle layers were observed both inside and outside the normally arranged circular muscle of the media. There have been 18 cases reported in the literature in Japan. Although embryologic disposition of the popliteal artery is much the same, the manifestation of symptoms is more apparent among the Japanese. The Japanese daily manner of living on straw matting without the use of chairs may be partly responsible.

Mechanism of Vascular Tests in Thoracic Outlet Syndrome

Vascular tests for thoracic outlet syndrome are considered to be one of the important diagnostic aid in order to determine the localization and the severity of neurovascular lesion at the thoracic outlet region. However, the mechanism and significance of vascular tests are still unclear.This is to report our clinical and autopsial study to try to clarify the exact meanings of each vascular test.Materials are 72 cases in 48 patients with thoracic outlet syndrome (46 cases in 39 patients recieved first rib resection) and 21 cases of exploration in autopsy.Positive Adson's test, although the incidence is quite low, may suggest severe lesion at the scalen triangle. Eden's test indicate lesions at the costo-clavicular space. In this positive the clavicle moves most to the posteromedial direction among the various positions. Abduction-external rotation test and Wright's test show neurovascular compression mainly at the costo-clavicular region and partly at the scalen triangle. These positions make the neurovascular bundle tracted foward the lateral. Compression at the subcoracoideal region is not the main cause in Wright's test.

Disparity in Blood Pressure Between Arms

To the Editor.— While the consultants in QUESTIONS AND ANSWERS (237:1871, 1977) are correct in stating that the most common cause of dissimilar blood pressure readings in the arms of a 77-year-old man is arteriosclerotic occlusion of the subclavian artery, they make no mention of alternative explanations that may be responsible or contributory. Asymmetrical sphygmomanometric recordings can occur with the scalenus anticus syndrome, a cervical rib, or other forms of the thoracic outlet syndrome. Adson's test is usually positive in these cases.1 Anesthesiologists as myself occasionally give anesthesia to these patients for unrelated surgery, and often positioning them on the operating table can incur a spurious hypotension in the affected arm. Contralateral normalrange Korotkoff sounds delineate the discrepancy, and repositioning amends it. Unilaterally diminished arterial pulsations may also be seen status after open heart surgery or cardiac catheterization. Checking the blood pressure in both arms is worthwhile not only

Results of Surgical Treatment for Thoracic Outlet Syndrome

First rib resection for thoracic outlet syndrome had been performed on 35 cases (29 patients) for 4 years (Jan. 1972-Dec. 1975).In this report we analyzed the postoperative clinical status in 27 cases (22 patients) of these patients who were able to be followed up.Synthetic evaluation are classified as excellent 11 cases (41%), good 9 (33), fair 5 (19) and poor 2 (7).Subjective symptoms of upper limbs seem to improve more than that of scapular regions.Improvement of vascular signs was observed highly in Adson's test and abduction-external rotation test.