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orthopedic assessment as "stress and assess." If we believe a structure is unhealthy and causing the client to experience the signs or symptoms of a condition, then the goal of our assessment test is to increase the stress on that structure to see if it reproduces or increases the client's characteristic pattern of signs and symptoms. To do this, we need to understand the underlying mechanics of the condition we are assessing. With anterior scalene syndrome, the underlying mechanism is tight anterior/middle scalene musculature; with costoclavicular syndrome, the underlying mechanism is a decreased costoclavicular space between the clavicle and first rib; and with pectoralis minor syndrome, the underlying mechanism is a tight pectoralis minor. Each of these cases results in compression on the brachial plexus of nerves (or the subclavian/axillary artery or vein). Therefore, our orthopedic assessment tests for these conditions involve increasing the physical stress on the structures involved. For whom would we perform these TOS orthopedic assessment tests? Most often, it would be for any client who presents with upper extremity paresthesia or motor dysfunction. The most common symptom of TOS is tingling or numbness in the hand. The three orthopedic assessment tests for TOS are Adson's, Eden's, and Wright's. Adson's Test Adson's test for anterior scalene syndrome places a tension stress on the scalene musculature by stretching it, thereby pulling it taut and hard against the neurovascular contents. Given that the anterior/middle scalenes are flexors of the neck in the sagittal plane, lateral flexors in the frontal plane, and contralateral rotators in the transverse plane, they would be stretched by asking the client to move the neck into extension, lateral flexion to the opposite side, and rotation to the same side (Image 3A). It should be noted that if the client is experiencing TOS due to the presence of a cervical rib, then because the compression caused by the cervical rib occurs at the scalene musculature, Adson's test would usually show positive. Therefore, Adson's test assesses TOS due to both anterior scalene syndrome and a cervical rib. Cervical ribs can often be palpated, but definitive assessment of a cervical rib would be made by X-ray. Eden's Test Eden's test for costoclavicular syndrome is performed by asking the client to assume a posture that stresses the body by decreasing the costoclavicular space. This is accomplished by asking the client to push their chest out and pull their shoulder girdles back, as if standing at attention in front of a commanding military officer (Image 3B). This pushes the first rib anteriorly against the clavicle as the clavicle is pulled posteriorly against the first rib. Wright's Test Wright's test for pectoralis minor syndrome stresses the pectoralis minor by stretching it. Because the pectoralis minor is a protractor and depressor of the scapula, the client's scapula is brought back into retraction and elevation, using the client's arm as the contact (Image 3C). This tautens and hardens the pectoralis minor, as it is pulled posteriorly against the neurovascular contents. There is an alternative position for Wright's test that involves stretching and tethering the brachial plexus of nerves around the pectoralis minor by simply bringing the arm into abduction with the elbow joint flexed to approximately Orthopedic assessment tests for TOS. 3A: Adson's test for anterior scalene syndrome. 3B: Eden's test for costoclavicular syndrome. 3C: Wright's test for pectoralis minor syndrome. 3D: Alternate Wright's test position for pectoralis minor syndrome. A B M P m e m b e r s e a r n F R E E C E a t w w w. a b m p . c o m / c e b y r e a d i n g M a s s a g e & B o d y w o r k m a g a z i n e 63 3B 3A 3C 3D