Adsons test

Adson’s test is a provocation maneuver used when thoracic outlet syndrome (TOS) is suspected – a condition in which structures in the scalene triangle compress the brachial plexus or the subclavian artery¹. The test primarily assesses vascular involvement, with radial pulse changes serving as an indirect indicator of compression.

Execution

Purpose of the test:

To identify potential compression of the subclavian artery between the scalene muscles and the first rib, as seen in scalene syndrome or in the presence of a cervical rib¹.

How to perform the test:

• The patient sits or stands upright with the arm in a neutral position and the elbow fully extended.

• The examiner palpates the patient’s radial pulse.

• The arm is abducted approximately 30°, maximally extended at the shoulder, and held in that position.

• The patient is instructed to:

  • Extend the neck.

  • Rotate the head toward the tested side.

  • Take a deep breath and hold it.

• The examiner monitors the quality and strength of the radial pulse compared to the starting position.

Modified variant:

In some versions, the patient rotates the head away from the tested side instead of toward it, to alter the mechanical load on the thoracic outlet².

Interpretation

Positive test:

• Marked reduction or disappearance of the radial pulse, with or without paresthesia or other upper-limb symptoms³.

• Findings must always be compared with the contralateral side.

Clinical considerations:

• A positive result suggests vascular compression but should always be interpreted alongside other tests and symptoms.

• Many asymptomatic individuals may experience reduced pulse. Symptom reproduction (numbness, tingling) has higher specificity than pulse changes alone⁷.

What the Test Assesses

• Subclavian artery: Compression by scalenus anterior, scalenus medius, first rib, or cervical rib.

• Brachial plexus: Secondary involvement if nerve roots are compressed simultaneously.

• Thoracic outlet: Indirect functional assessment of this anatomical passage.

Common Errors

• Failure to compare findings with the opposite side.

• Unstable arm position or insufficient shoulder extension.

• Inaccurate palpation of the radial pulse.

• Incorrect head rotation or inability to hold breath².

Evidence and Validity

• Sensitivity: 32–94% (large variation among studies)³⁴⁵

• Specificity: 18–87% (low if only pulse reduction is used)³⁴⁵

• Positive predictive value: Up to 85% in some reports⁶

• False positives: 2–53%, depending on criteria and study population⁷⁸⁹

Adson’s test has low inter-rater reliability and a high false-positive rate if used alone. Therefore, it is recommended as part of a test battery rather than a stand-alone diagnostic tool.

Combination with Other Tests

Diagnostic value increases substantially when Adson’s test is combined with:

• Roos test

• Wright’s test (hyperabduction)

• Eden’s test (costoclavicular maneuver)

• Tinel’s test over nerve roots

• Direct pressure over brachial plexus (compression test)

Studies by Wainner (2003) and Rayan (1998) showed that sensitivity rose to 94% and false positives decreased when at least two tests were positive simultaneously⁹.

Criticism and Clinical Relevance

Despite its frequent use, recent systematic reviews have questioned the diagnostic value of Adson’s test as a single tool for TOS¹¹. Reasons include:

• Low specificity

• High rate of false positives

• Weak methodological quality of supporting studies

Pulse changes alone have been particularly criticized as unreliable markers.

Clinical implication:

Adson’s test should never be used in isolation. It is best applied in conjunction with other clinical tests and imaging to support the diagnosis of TOS.

Sources:

1. Brotzman SB, Manske RC. Clinical Orthopaedic Rehabilitation: An Evidence-Based Approach. 3. utg. Philadelphia: Elsevier Health Sciences; 2011.

2. Borenstein DG, Wiesel SW, Boden SD. Low Back and Neck Pain: Comprehensive Diagnosis and Management. 3. utg. Philadelphia: Elsevier Health Sciences; 2004.

3. Waldman SD. Pain Management: Expert Consult. 2. utg. Philadelphia: Elsevier Health Sciences; 9. juni 2011.

4. Malanga GA, Landes P, Nadler SF. Provocative tests in cervical spine examination: historical basis and scientific analyses. Pain Physician. 2003 apr;6(2):199–205.

5. Malanga GA, Nadler S. Musculoskeletal Physical Examination: An Evidence-Based Approach. Philadelphia: Elsevier Health Sciences; 2006.

6. Gillard J, Perez-Cousin M, Hachulla E, et al. Diagnosing thoracic outlet syndrome: Contribution of provocation tests, ultrasonography, electrophysiology, and helical computed tomography in 48 patients. Joint Bone Spine. 2001;68:416–424.

7. Rayan GM. Thoracic outlet syndrome. J Shoulder Elbow Surg. 1998;7(4):440–451.

8. Donaghy M, Matkovic Z, Morris P. Surgery for suspected neurogenic thoracic outlet syndromes: A follow-up study. J Neurol Neurosurg Psychiatry. 1999 nov;67(5):602–606.

9. Rayan GM, Jensen C. Thoracic outlet syndrome: Provocative examination maneuvers in a typical population. J Shoulder Elbow Surg. 1995;4:113–117.

10. Plewa MC, Delinger M. The false positive rate of thoracic outlet syndrome shoulder maneuvers in healthy individuals. Acad Emerg Med. 1998;5:337–342.

11. Hixson KM, Horris HB, Valovich McLeod TC, Welch Bacon CE. The diagnostic accuracy of clinical diagnostic tests for thoracic outlet syndrome. J Sport Rehabil. 2017 sep;26(5):459–465. doi: 10.1123/jsr.2016-0051.