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DIAGNOSIS ARTERIAL COMPRESSION
ARTERIAL COMPRESSION SYNDROMES AT THE SHOULDER
PART 2: DIAGNOSTIC ARM MANOEUVRES BY CLAIRE STAPLETON, MCSP
INTRODUCTION Part 1 of this article (sportEX medicine 2009;39:22-25) presented a description of arterial compression syndrome at the shoulder. In brief, two compression sites at the subclavian artery and two compression sites at the axillary artery were described, as well as compression of the posterior humeral circumflex artery. This part of the article continues the theme of arterial compression syndrome at the shoulder but focuses on diagnostic arm manoeuvres used in the physical examination, discusses some diagnostic dilemmas, and highlights some areas that require further research. Upper-limb manoeuvres such as Adson’s test (1), the
hyperabduction manoeuvre (2), the elevated arm stress test (EAST) (3) and the costoclavicular manoeuvre (4) aid the diagnosis of arterial compression syndromes, either with or without advanced imaging techniques such as computed tomography (CT), magnetic resonance imaging (MRI), angiography and ultrasonography. It is assumed that these manoeuvres stress the vasculature to accurately reproduce the signs (eg. radial pulse disappearance, visible restriction or occlusion of blood flow, reduction in vessel diameter, doubling of or dampened peak systolic velocity (PSV) response) and symptoms (eg. ischaemic pain, paraesthesia, anaesthesia, heaviness) of vascular compromise. Alternatively, reproducing the arm position (usually an overhead-throwing arm position) that a specific athlete performs repeatedly is used as a diagnostic test position while pulse, blood pressure and blood flow are monitored. Unfortunately, in clinical practice, the diagnosis of vascular compromise remains a difficult challenge due to poor sensitivity and specificity of tests (5).
DIAGNOSIS WITHOUT ADVANCED IMAGING TECHNOLOGY Descriptions of these tests vary throughout the literature in terms of the movements incorporated and the terms used. However, most of the manoeuvres utilise several components that are capable of causing compression at more than one of the vulnerable sites (scalene triangle, costoclavicular space, retro-pectoralis minor space, anterior to the humeral head and the quadrilateral space syndrome), making localisation of the specific anatomical site of arterial compression difficult (Table 1). As has been reported, compression at the subclavian artery in particular is thought to result from bony anomalies such as cervical ribs and anomalous first ribs. However, symptoms do
This article covers one aspect of upper-limb vascular assessment. The outcome of diagnostic arm manoeuvres with or without advanced imaging equipment must be interpreted with the subjective history and other physical findings in order to exclude differential diagnoses and to determine whether a positive result should be considered clinically significant. The article focuses on diagnostic arm manoeuvres used in the physical examination, discusses some diagnostic dilemmas, and highlights some areas that require further research.
not present in these individuals early in life, suggesting that other factors are contributory to the condition. In addition, many patients benefit from conservative measures such as muscle stretches, soft-tissue releases, manual therapy, posture correction, acupuncture and taping to relieve symptoms from neurovascular compression syndromes, again suggesting that factors other than bony anomalies are at fault. It would, therefore, be valuable to physiotherapists to be able to locate the specific site of arterial compression in order to achieve effective results by targeting treatment at specific anatomical borders. With knowledge of the vulnerable sites for arterial compression and their respective anatomical borders, a step- by-step approach to diagnosis may prove more useful than a single ‘catch-all’ diagnostic arm manoeuvre. The author recommends assessing the effects of (1) deep inhalation, (2) scapula retraction and (3) cervical rotation/extension, in isolation and held for 10 seconds, and then (1) and (2) in combination, before undertaking any manoeuvre involving abduction. Abduction over 40o
becomes problematic as the
clavicle starts to elevate and rotate posteriorly, producing a scissor-like motion with the first rib; this results in less space for the underlying structures, such as the subclavian artery. As a consequence, when the arm is abducted, compression at the costoclavicular space cannot be differentiated from any other site. However, the performance of deep inhalation and scapula retraction in isolation, early in the assessment, would give a better indication of whether the site is the cause of symptoms.
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