What is Adson's maneuver?

Adson's Maneuver: A Diagnostic Test for Thoracic Outlet Syndrome

Adson's maneuver is a provocative test used to evaluate for arterial thoracic outlet syndrome (TOS), though it has limited diagnostic value due to high false-positive rates and poor specificity. 1, 2

Technique for Performing Adson's Maneuver

• Patient positioning: The patient sits upright with arms at their sides
• Examiner position: The examiner palpates the radial pulse on the side being tested
• Execution:
  1. Ask the patient to extend their neck
  2. Have the patient rotate their head toward the side being examined
  3. Instruct the patient to take and hold a deep breath
  4. Monitor for diminishment or disappearance of the radial pulse
  5. Observe for reproduction of the patient's symptoms

Diagnostic Value and Limitations

• False positive rate: High in both normal subjects (9-20%) and patients with other conditions like carpal tunnel syndrome (42-45%) 3
• Clinical utility: The American College of Radiology states that Adson's test has been shown to be of "no clinical value" for diagnosing TOS 2
• Specificity: Poor, as many asymptomatic individuals can have a positive test 4, 5
• Sensitivity: Low, as many patients with confirmed TOS have a negative test 2

Interpretation of Results

• Traditional interpretation: A positive test (diminished or absent radial pulse) was historically thought to indicate compression of the subclavian artery at the thoracic outlet
• Modern understanding: Pulse changes alone are not diagnostic of TOS without corresponding symptoms 1, 2
• Clinical correlation: Must be interpreted in context of the patient's clinical presentation, as isolated positive findings are not reliable 5

Alternative Diagnostic Tests for TOS

More reliable tests for diagnosing thoracic outlet syndrome include:

• Elevated arm stress test (Roos test): Patient holds arms in abduction and external rotation for 3 minutes
• Wright's test: Hyperabduction of the arm with observation for pulse changes and symptom reproduction
• Halstead maneuver (costoclavicular maneuver): Shoulders are drawn downward and backward
• Supraclavicular pressure test: Direct pressure applied to the supraclavicular fossa

Clinical Applications

• Diagnostic algorithm: Adson's maneuver should not be used in isolation but as part of a comprehensive evaluation for suspected TOS 2, 5
• Imaging correlation: Some studies suggest that duplex scanning during Adson's maneuver may help predict surgical outcomes in non-specific TOS 6
• Practical considerations: When evaluating for arterial flow changes, examination should continue for at least 20 seconds, as flow arrest may be temporary 4

Pitfalls to Avoid

• Overreliance on pulse changes: Diminished pulse without symptom reproduction has little diagnostic value
• Misdiagnosis: Using Adson's test alone to diagnose "vascular TOS" without proper classification (arterial, venous, or neurogenic)
• Failure to classify TOS: Always specify the type of TOS being evaluated (arterial, venous, or neurogenic), as each has distinct clinical features 2

Adson's maneuver has historically been part of the physical examination for TOS but should be interpreted with caution given its limited diagnostic accuracy and high false-positive rate in the general population.