Careful history and physical examination are essential keys to suspect thoracic outlet syndrome. Throughout examination with provocative tests is an essential part of patient evaluation. Clinical examination may reveal pain and tenderness in the supraclavicular area. Neurological examination of the arm and hand is of paramount importance and may demonstrate hypesthesia (numbness) as well as muscle paresis (weakness) and even atrophy (wasting). The presence of muscle weakness is particularly important since it is an indicator of disease severity.
Provocative testing is an essential part of clinical examination. The purpose of these tests is to elicit TOS symptoms using specific clinical maneuvers in order to establish diagnosis. Elevated arm stress tests (EAST or Roos test), upper limb tension tests (ULTTs), and Adson tests are most commonly used.
Radiographic examination plays an important role in diagnosing TOS. X-ray, CT scan, MRI, and Doppler USG are commonly used radiological tools.
Above, there is a 3-dimensional CT angiographic reconstruction from a patient with TOS. Note that the subclavian artery narrows as it passes over the accessory rib. The accessory rib makes an abnormal joint with the first rib (white circle).
Nerve conduction studies like EMG and ENG may be helpful, but in the majority of cases, they do not provide a definitive diagnosis. Thus, the diagnosis is mainly made by careful clinical examination.
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