Adsons Test

Original Editor­ - Rachael Lowe

Top Contributors - Rachael Lowe, Evan Thomas, Oyemi Sillo, Kai A. Sigel and Naomi O'Reilly

Purpose

Adson's test is a provocative test for Thoracic Outlet Syndrome accompanied by compression of the Subclavian artery by a cervical rib or tightened anterior and middle scalene muscles.[1]

Technique

Starting Position [2]

The test can be performed with the patient in either sitting or standing with their elbow in full extension

Procedure [2]

• The arm of the standing (or seated) patient is abducted 30 degrees at the shoulder and maximally extended.

• The radial pulse is palpated and the examiner grasps the patient's wrist.

• The patient then extends neck and turns the head toward the symptomatic shoulder and is asked to take a deep breath and hold it.

• The quality of the radial pulse is evaluated in comparison to the pulse taken while the arm is resting at the patient's side.

• Some clinicians have patients turn their heads away from the side tested in a modified test.

Positive Test [2]

The test is positive if there is a marked decrease, or disappearance, of the radial pulse. It is important to check the patient's radial pulse on the other arm to recognize the patient's normal pulse.

A positive test should be compared with the non-symptomatic side.


[3]

Evidence

There is minimal evidence of its interexaminer reliability according to existing literature. It has been noted to have a specificity ranging from 18% to 87%, and sensitivity of up to 94%. There is little documentation regarding the reliability of the Adson's test. [4][5][6]

Gillard (2001) reported that Adson’s test was one of the better performing tests of those commonly studied for TOS having a positive predictive value of 85% (79% sensitivity and 76% specificity). In this study, either loss of pulse or reproduction of symptoms was construed to be positive.[7]

A problem with the thoracic outlet tests on the whole is that many asymptomatic subjects will test positive, depending how a positive test is defined. In an asymptomatic population, Rayan (1998) found Adson’s to have a false positive rate of 13.5% for diminished/absent pulse but only 2% for neurological symptoms. Plewa (1998) found a comparable false positive rate of 11% for loss of pulse, a higher false positive rate for paresthesia (11%), but a very low rate of pain production (2%). Overall, Adson’s false positive rates were lower than those of either the hyperabduction and costoclavicular tests. Other studies have reported false positive rates (including isolated diminished pulse positives) to range as high as 53% (Rayan 1998) and even 92% (Malanga 2006).[8]

Although, overall, Adson’s test appears to be more useful than the costoclavicular or hyperabduction test, using a diminished radial pulse to determine a positive Adson’s test should be done with caution. Even symptom reproduction during the procedure must be correlated with other findings. At least one retrospective post surgical study fails to identify any “single preoperative diagnostic criterion” for thoracic outlet syndrome (Donaghy 1999).[9]

Rather, it is better to interpret the tests in combination (Nannapaneni 2003, Plewa 1998, Rayan 1998). Rayan (1998) and Nannapaneni et al. (2003) reported sensitivity of 94% using a combination of Adson’s, Eden’s, Wright’s and Roos tests with Tinel’s test or direct compression of the associated nerves. Likewise specificity appears to improve when multiple tests are combined. In Warrens’ study (1987), 58% of subjects given a battery of TOS tests (Adson’s, costoclavicular and hyperabduction) had at least one false positive, and only 2% had more than one test positive. Likewise, Plewa (1998) found that 2 or 3 positive tests dropped the overall false positive rate and improved the specificity.[10][11]

Unfortunately, most of the studies looking at specificity used asymptomatic patients rather than symptomatic patients with competing diagnoses, which tends to inflate test specificity values. Furthermore, because there is no gold standard to make a TOS diagnosis, most studies use the same orthopedic tests under investigation as part of the reference standard (incorporation bias), inflating the sensitivity values.

References

  1. Brotzman SB, Manske RC. Clinical Orthopaedic Rehabilitation: An Evidence-based Approach. 3rd ed. Philadelphia: Elsevier Health Sciences, 2011
  2. 2.0 2.1 2.2 Borenstein DG, Wiesel SW, Boden SD. Low Back and Neck Pain: Comprehensive Diagnosis and Management. 3rd ed. Philadelphia: Elsevier Health Sciences, 2004.
  3. Physiotutors. Adson Test | Thoracic Outlet Syndrome (TOS). Available from:https://www.youtube.com/watch?v=-7346RaEGKU
  4. Waldman SD. Pain Management: Expert Consult. 2nd ed. Philadelphia: Elsevier Health Sciences, Jun 9, 2011
  5. Malanga GA, Landes P, Nadler SF (April 2003). "Provocative tests in cervical spine examination: historical basis and scientific analyses". Pain Physician 6 (2): 199–205.
  6. Malanga GA, Nadler S. Musculoskeletal Physical Examination: An Evidence-based Approach. Philadelphia: Elsevier Health Sciences, 2006
  7. 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;68:416-24.
  8. Rayan GM. Thoracic outlet syndrome. J Shoulder Elbow Surg 1998;7(4):440-51.
  9. 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):602-6.
  10. Rayan GM, Jensen C. Thoracic outlet syndrome: Provocative examination maneuvers in a typical population. J Shoulder Elbow Surg 1995;4:113-17.
  11. Plewa MC, Delinger M. The false positive rate of thoracic outlet syndrome shoulder maneuvers in healthy individuals. Acad, Emerg Med 1998:5:337-42.