Physiotherapy examination starts with the therapist assessing the posture of the patient, often before they have taken any of their clothes off. A rounded or slumped shoulder posture and a poking forward neck and head stretch the neck and shoulder blade muscles and may make this syndrome more likely to occur. Active range of movements of the neck will be examined and any restrictions noted. The neck may be placed in combined positions involving two or more pure movements plus downward pressure in an attempt to bring on symptoms. Range of motion of the shoulders is also assessed.

The examination will include the ability of the nervous and vascular system to supply the requirements of the arm, with most of the deficiencies involving the lower nerves of the brachial plexus. Compression of the veins in the armpit area results in an arm which is bluish in colour and swollen, whilst if the part of the vascular system which is compressed is an artery this makes the arm cooler, lacking in a pulse and often having a lower blood pressure of 20 mmHg or more compared to the normal arm.

In the case of thoracic outlet syndrome due to neurological compression the finding are often of weakness and wasting of the small muscles of the hand. There may also be reduced sensation in the areas supplied by the ulnar nerve, which again reflects the fact that the lower nerves of the brachial plexus are most often involved. The last type of this syndrome, that of non-specific thoracic outlet syndrome, has widespread but less precisely located pain, with less precise and clear examination findings, making the diagnosis unreliable at best.

Thoracic outlet syndrome can be brought on by a large number of neck and shoulder anatomical structures and this is reflected in the numbers of diagnostic tests which have been developed to investigate this problem. A significant problem with these tests is the occurrence of false positive and false negative tests. False negatives mean that the test shows the problem not to be present when it really is and false positives mean the test indicates the tested problem to be present when in reality it is not.

A typical test is Roos stress test, where the patient keeps their arms up in a "hands up" position, opening and closing the fist. If the symptoms come on or the arms feel heavy or tired then the test may be taken to have a positive result. The reasons for thoracic outlet syndrome can either be due to bony structures or soft tissue structures. Bony structures which might cause compression or obstruction include cervical ribs and bony outgrowths on the ribs or collar bone. Soft tissue structures involved include abnormal fibrous bands or abnormally large muscles in weight training athletes.

Trauma to the neck and mechanical stressors may combine with any abnormalities in neck anatomy such as cervical ribs to increase the likelihood of developing thoracic outlet syndrome. Obstruction of the blood supply is an emergency and should be speedily assessed and surgically decompressed with repair to the arteries or veins. Most people with this syndrome are however treated conservatively with anti-inflammatory drugs, transcutaneous electrical nerve stimulation (TENS) and assessment and mobilisation or exercise prescription by a physiotherapist.

Many patients are helped by conservative management and those whose pain continues to be troublesome may eventually be considered for surgery. Physiotherapists look at the postural attitude taken by patients and muscle imbalances which may be present around the neck and shoulders. Patients who maintain static postures for long periods or continually return to one particular posture may develop dysfunctions.

Abnormalities of posture can elevate local tension or compressive forces and cause chronic compression of the nerves in the area. Maintenance of muscles in a shortened position can cause them to shorten permanently and then react with pain when they are put on a stretch. The idea of muscle imbalance implies that some muscles are stretched by the person's function and become weaker whilst others become shorter in consequence and so stronger, perpetuating abnormal function. Management of these conditions starts with patient education as understanding is vital if they are to make long term postural changes.

Jonathan Blood Smyth, editor of the Physiotherapy Site, writes articles about Physiotherapists, physiotherapy, Physiotherapists in Coventry, back pain, orthopaedic conditions, neck pain and injury management. Jonathan is a superintendant physiotherapist at an NHS hospital in the South-West of the UK.