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Textbook
Introduction
1. Cardiovascular system
2. Pulmonary system
3. Neuromuscular system
3.1 Central nervous system
3.2 Anatomy and function of spinal cord
3.3 Peripheral nervous system
3.3.1 Components and nerve structure
3.3.2 Dermatomes, myotomes, reflexes, and plexuses
3.3.3 Upper limb tension tests and thoracic outlet syndrome
3.4 Stroke deficits and recovery
3.5 Traumatic brain injury
3.6 Spinal cord injury
3.7 Neurodegenerative disorders and epilepsy
3.8 Peripheral nervous system conditions
3.9 Other neurological conditions
3.10 Interventions for neurological conditions
3.11 Vestibular system
4. Pediatrics
5. Musculoskeletal system
6. Other systems
7. Non-systems
Wrapping up
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3.3.3 Upper limb tension tests and thoracic outlet syndrome
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3. Neuromuscular system
3.3. Peripheral nervous system
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Upper limb tension tests and thoracic outlet syndrome

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Upper limb tension tests

Definitions
Upper limb tension test
Assists with identifying peripheral nerve injury by placing the upper limb in a position that will stress the nerve.

PTA scope of practice: The PTA collects data and recognizes and communicates changes in a patient’s status to the supervising PT; evaluating the patient, interpreting findings, and changing the plan of care remain the PT’s responsibility. When a PTA performs the upper limb tension tests and thoracic outlet tests in this chapter as part of data collection, a positive finding such as reproduced symptoms or a diminished radial pulse is reported to the supervising PT, not interpreted as a diagnosis. Supervision and delegation rules are covered in PTA responsibilities, research, and ADA.

  • Upper limb tension test 1 (ULTT 1) - median and anterior interosseous nerve
    • Cervical spine: contralateral lateral flexion
    • Shoulder: depression and abduction to 110 degrees
    • Elbow: extension
    • Forearm: supination
    • Wrist: extension
    • Fingers and thumb: extension
Upper limb tension test 1 demonstrating median nerve bias with shoulder abduction, elbow extension, and wrist extension.
ULTT 1: Median nerve
Achievable
  • Upper limb tension test 2 (ULTT 2) - median, axillary, and musculocutaneous nerve
    • Cervical spine: contralateral lateral flexion
    • Shoulder: depression and abduction to 10 degrees, lateral rotation
    • Elbow: extension
    • Forearm: supination
    • Wrist: extension
Upper limb tension test 2a showing median nerve bias with shoulder depression and abduction, elbow extension, and forearm supination.
(ULTT 2)- median, axillary, and musculocutaneous nerve
Achievable
  • Upper limb tension test 3 (ULTT 3) - radial nerve
    • Cervical spine: contralateral lateral flexion
    • Shoulder: depression and abduction to 10 degrees; internal rotation
    • Elbow: extension
    • Forearm: pronation
    • Wrist: flexion with ulnar deviation
    • Fingers and thumb: flexion
Upper limb tension test 2b demonstrating radial nerve bias with shoulder depression, elbow extension, and forearm pronation.
(ULTT 3)- radial nerve
Achievable
  • Upper limb tension test 4 (ULTT 4) - ulnar nerve
    • Cervical spine: contralateral lateral flexion
    • Shoulder: depression and abduction (10-90 degrees) with hand to ear
    • Elbow: flexion
    • Forearm: pronation
    • Wrist: extension and radial deviation
    • Fingers and thumb: extension
Upper limb tension test 3 showing ulnar nerve bias with shoulder abduction, elbow flexion, and wrist extension.
(ULTT 4)- ulnar nerve
Achievable

Thoracic outlet syndrome

Labeled diagram of the thoracic outlet showing the clavicle, first rib, brachial plexus, subclavian vessels, and surrounding muscles.
Thoracic outlet anatomy
Achievable
Definitions
Thoracic outlet syndrome
A condition caused by compression of the brachial plexus, subclavian artery, and/or subclavian vein as they pass through the thoracic outlet - the space bounded by the clavicle, the first rib, and the scalene muscles.

The following tests assess for structural damage to the nerves and arteries that pass through the thoracic outlet.

  • Adson’s test (compression of the subclavian artery and/or nerves as they pass through the interscalene space)
    • Patient seated with the radial pulse palpated; head rotated toward the extremity being tested while the shoulder is extended and externally rotated, then the head is extended
      • Positive: reproduction of neurological (pain, weakness, numbness, and loss of hand coordination) and vascular symptoms (loss of radial pulse)
Adson's test for thoracic outlet syndrome with the arm extended and the head rotated toward the tested side.
Thoracic outlet syndrome - Adson's test
Achievable
  • Roos elevated arm test (nerves and/or blood vessels in the space between the clavicle and the first rib are compressed)
    • Patient standing with shoulders fully externally rotated, 90 degrees abducted, elbows flexed to 90 degrees; the patient then rapidly opens and closes their hands for 3 minutes
      • Positive: reproduction of neurological (pain, weakness, numbness, and loss of hand coordination) and vascular symptoms (loss of radial pulse)
Roos test for thoracic outlet syndrome with both arms held in 90 degrees of shoulder abduction and external rotation while repeatedly opening and closing the hands.
Thoracic outlet syndrome - Roos test
Achievable
  • Wright’s test (compression at the space behind the pectoralis minor muscle)
    • Patient seated with passive movement of the arm into abduction and external rotation
      • Positive: reproduction of neurological (pain, weakness, numbness, and loss of hand coordination) and vascular symptoms (loss of radial pulse)
Wright's test for thoracic outlet syndrome with the arm hyperabducted and externally rotated overhead.
Thoracic outlet syndrome - Wright's test
Achievable
  • Costoclavicular test (compression of the neurovascular bundle between the clavicle and first rib)
    • Patient seated; the therapist assists the patient through 4 movements - scapular retraction, scapular depression, elevation, and protraction - holding each position for up to 30 seconds while resting their forearms on their thighs
      • Positive: reproduction of neurological (pain, weakness, numbness, and loss of hand coordination) and vascular symptoms (loss of radial pulse)
Costoclavicular test for thoracic outlet syndrome with the shoulders retracted and depressed in an exaggerated military posture.
Thoracic outlet syndrome - Costoclavicular test
Achievable

Upper limb tension tests (ULTT)

  • Purpose: stresses peripheral nerves via limb positioning to identify nerve injury
  • PTA role: collects data, reports positive findings (reproduced symptoms, diminished pulse) to supervising PT
    • PT retains responsibility for evaluation, interpretation, and plan of care changes

ULTT 1 - median and anterior interosseous nerve

  • Cervical contralateral lateral flexion
  • Shoulder depression/abduction to 110°
  • Elbow extension, forearm supination
  • Wrist, fingers, thumb extension

ULTT 2 - median, axillary, musculocutaneous nerve

  • Cervical contralateral lateral flexion
  • Shoulder depression/abduction to 10°, lateral rotation
  • Elbow extension, forearm supination, wrist extension

ULTT 3 - radial nerve

  • Cervical contralateral lateral flexion
  • Shoulder depression/abduction to 10°, internal rotation
  • Elbow extension, forearm pronation
  • Wrist flexion with ulnar deviation, fingers/thumb flexion

ULTT 4 - ulnar nerve

  • Cervical contralateral lateral flexion
  • Shoulder depression/abduction (10-90°), hand to ear
  • Elbow flexion, forearm pronation
  • Wrist extension with radial deviation, fingers/thumb extension

Thoracic outlet syndrome - overview

  • Compression of brachial plexus, subclavian artery, and/or subclavian vein
  • Occurs in space bounded by clavicle, first rib, and scalene muscles
  • Tests assess structural damage to nerves/arteries passing through outlet

Adson’s test

  • Tests subclavian artery/nerve compression in interscalene space
  • Seated; palpate radial pulse; rotate head toward tested side, shoulder extended/externally rotated, then extend head
  • Positive: reproduced neuro symptoms (pain, weakness, numbness, poor coordination) and/or vascular symptoms (lost radial pulse)

Roos elevated arm test

  • Tests compression between clavicle and first rib
  • Standing; shoulders externally rotated, 90° abducted, elbows flexed 90°; open/close hands rapidly for 3 minutes
  • Positive: same neuro/vascular symptom reproduction

Wright’s test

  • Tests compression behind pectoralis minor
  • Seated; passive arm abduction and external rotation
  • Positive: same neuro/vascular symptom reproduction

Costoclavicular test

  • Tests neurovascular bundle compression between clavicle and first rib
  • Seated; therapist guides through 4 positions (scapular retraction, depression, elevation, protraction), each held ~30 seconds, forearms resting on thighs
  • Positive: same neuro/vascular symptom reproduction

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Upper limb tension tests and thoracic outlet syndrome

Upper limb tension tests

Definitions
Upper limb tension test
Assists with identifying peripheral nerve injury by placing the upper limb in a position that will stress the nerve.

PTA scope of practice: The PTA collects data and recognizes and communicates changes in a patient’s status to the supervising PT; evaluating the patient, interpreting findings, and changing the plan of care remain the PT’s responsibility. When a PTA performs the upper limb tension tests and thoracic outlet tests in this chapter as part of data collection, a positive finding such as reproduced symptoms or a diminished radial pulse is reported to the supervising PT, not interpreted as a diagnosis. Supervision and delegation rules are covered in PTA responsibilities, research, and ADA.

  • Upper limb tension test 1 (ULTT 1) - median and anterior interosseous nerve
    • Cervical spine: contralateral lateral flexion
    • Shoulder: depression and abduction to 110 degrees
    • Elbow: extension
    • Forearm: supination
    • Wrist: extension
    • Fingers and thumb: extension
  • Upper limb tension test 2 (ULTT 2) - median, axillary, and musculocutaneous nerve
    • Cervical spine: contralateral lateral flexion
    • Shoulder: depression and abduction to 10 degrees, lateral rotation
    • Elbow: extension
    • Forearm: supination
    • Wrist: extension
  • Upper limb tension test 3 (ULTT 3) - radial nerve
    • Cervical spine: contralateral lateral flexion
    • Shoulder: depression and abduction to 10 degrees; internal rotation
    • Elbow: extension
    • Forearm: pronation
    • Wrist: flexion with ulnar deviation
    • Fingers and thumb: flexion
  • Upper limb tension test 4 (ULTT 4) - ulnar nerve
    • Cervical spine: contralateral lateral flexion
    • Shoulder: depression and abduction (10-90 degrees) with hand to ear
    • Elbow: flexion
    • Forearm: pronation
    • Wrist: extension and radial deviation
    • Fingers and thumb: extension

Thoracic outlet syndrome

Definitions
Thoracic outlet syndrome
A condition caused by compression of the brachial plexus, subclavian artery, and/or subclavian vein as they pass through the thoracic outlet - the space bounded by the clavicle, the first rib, and the scalene muscles.

The following tests assess for structural damage to the nerves and arteries that pass through the thoracic outlet.

  • Adson’s test (compression of the subclavian artery and/or nerves as they pass through the interscalene space)
    • Patient seated with the radial pulse palpated; head rotated toward the extremity being tested while the shoulder is extended and externally rotated, then the head is extended
      • Positive: reproduction of neurological (pain, weakness, numbness, and loss of hand coordination) and vascular symptoms (loss of radial pulse)
  • Roos elevated arm test (nerves and/or blood vessels in the space between the clavicle and the first rib are compressed)
    • Patient standing with shoulders fully externally rotated, 90 degrees abducted, elbows flexed to 90 degrees; the patient then rapidly opens and closes their hands for 3 minutes
      • Positive: reproduction of neurological (pain, weakness, numbness, and loss of hand coordination) and vascular symptoms (loss of radial pulse)
  • Wright’s test (compression at the space behind the pectoralis minor muscle)
    • Patient seated with passive movement of the arm into abduction and external rotation
      • Positive: reproduction of neurological (pain, weakness, numbness, and loss of hand coordination) and vascular symptoms (loss of radial pulse)
  • Costoclavicular test (compression of the neurovascular bundle between the clavicle and first rib)
    • Patient seated; the therapist assists the patient through 4 movements - scapular retraction, scapular depression, elevation, and protraction - holding each position for up to 30 seconds while resting their forearms on their thighs
      • Positive: reproduction of neurological (pain, weakness, numbness, and loss of hand coordination) and vascular symptoms (loss of radial pulse)
Key points

Upper limb tension tests (ULTT)

  • Purpose: stresses peripheral nerves via limb positioning to identify nerve injury
  • PTA role: collects data, reports positive findings (reproduced symptoms, diminished pulse) to supervising PT
    • PT retains responsibility for evaluation, interpretation, and plan of care changes

ULTT 1 - median and anterior interosseous nerve

  • Cervical contralateral lateral flexion
  • Shoulder depression/abduction to 110°
  • Elbow extension, forearm supination
  • Wrist, fingers, thumb extension

ULTT 2 - median, axillary, musculocutaneous nerve

  • Cervical contralateral lateral flexion
  • Shoulder depression/abduction to 10°, lateral rotation
  • Elbow extension, forearm supination, wrist extension

ULTT 3 - radial nerve

  • Cervical contralateral lateral flexion
  • Shoulder depression/abduction to 10°, internal rotation
  • Elbow extension, forearm pronation
  • Wrist flexion with ulnar deviation, fingers/thumb flexion

ULTT 4 - ulnar nerve

  • Cervical contralateral lateral flexion
  • Shoulder depression/abduction (10-90°), hand to ear
  • Elbow flexion, forearm pronation
  • Wrist extension with radial deviation, fingers/thumb extension

Thoracic outlet syndrome - overview

  • Compression of brachial plexus, subclavian artery, and/or subclavian vein
  • Occurs in space bounded by clavicle, first rib, and scalene muscles
  • Tests assess structural damage to nerves/arteries passing through outlet

Adson’s test

  • Tests subclavian artery/nerve compression in interscalene space
  • Seated; palpate radial pulse; rotate head toward tested side, shoulder extended/externally rotated, then extend head
  • Positive: reproduced neuro symptoms (pain, weakness, numbness, poor coordination) and/or vascular symptoms (lost radial pulse)

Roos elevated arm test

  • Tests compression between clavicle and first rib
  • Standing; shoulders externally rotated, 90° abducted, elbows flexed 90°; open/close hands rapidly for 3 minutes
  • Positive: same neuro/vascular symptom reproduction

Wright’s test

  • Tests compression behind pectoralis minor
  • Seated; passive arm abduction and external rotation
  • Positive: same neuro/vascular symptom reproduction

Costoclavicular test

  • Tests neurovascular bundle compression between clavicle and first rib
  • Seated; therapist guides through 4 positions (scapular retraction, depression, elevation, protraction), each held ~30 seconds, forearms resting on thighs
  • Positive: same neuro/vascular symptom reproduction

More from Peripheral nervous system

  • Components and nerve structure
  • Dermatomes, myotomes, reflexes, and plexuses