Which two tests have the highest sensitivity for non-traumatic (NTOS) and vascular (VTOS) thoracic outlet syndrome?

• A. ROOS test and Wright Hyperabduction test
• B. Adson's test and Wright Hyperabduction test
• C. Halstead maneuver and Allen maneuver
• D. Costoclavicular test and Adson's test

Answer: (A)

A provocative approach that loads the entire thoracic outlet is most effective for catching both non-traumatic neurogenic and vascular compression. The elevated arm stress test (ROOS) Provokes symptoms by having the patient hold the arms at 90 degrees of abduction with opening and closing of the fists for several minutes, which stresses the neurovascular bundle through the outlet and often reveals neurogenic and vascular compromise if present. The Wright hyperabduction test then targets compression specifically under the pectoralis minor or within the costoclavicular space by placing the arm in maximal abduction and external rotation; this maneuver tends to provoke vascular symptoms when the subclavian artery or vein, or the brachial plexus, is compressed. Together, these two tests have the highest sensitivity for detecting NTOS and VTOS because they actively widen the space and repeatedly challenge the outlet, making provocative compression more likely to occur if pathology exists. Other maneuvers like Adson’s, Halstead, Allen, or the costoclavicular test can be helpful but generally show lower sensitivity and can yield false positives or be inconsistent across examiners, so they’re less reliable as primary screening tests.