Roos Test

The Roos Test is primarily used to identify neurogenic TOS, where patients typically report arm pain, numbness, tingling, or heaviness with overhead or sustained arm positions.

Involved Structures

The thoracic outlet is bordered by the first rib inferiorly, the clavicle anteriorly, and the scalene muscles laterally. The key structures susceptible to compression include:

• Brachial plexus — the network of nerves supplying the arm and hand
• Subclavian artery — the primary arterial supply to the upper extremity
• Subclavian vein — the primary venous drainage of the upper extremity
• Scalene muscles — the anterior and middle scalenes can entrap the brachial plexus
• First rib and clavicle — the bony boundaries of the costoclavicular space

How to Perform the Roos Test

Starting Position

The patient is positioned in standing or sitting with both arms elevated to 90 degrees of shoulder abduction and full external rotation. The elbows are flexed to 90 degrees, resembling a “hands up” position. Both arms are tested simultaneously.

Test Movement

The patient slowly opens and closes their hands repeatedly for up to three minutes while maintaining the starting position. The examiner observes for symptom onset, asymmetry in hand movement, or the patient’s inability to maintain the position.

Positive Test

A positive Roos Test is indicated when the patient reproduces their familiar symptoms of pain, heaviness, paresthesia, or vascular changes in the arm or hand before the three-minute mark, or is unable to complete the full three minutes due to symptom reproduction. Simple fatigue or mild discomfort without symptom reproduction is not considered a positive result.

Diagnostic Accuracy

The clinical accuracy of the Roos Test for thoracic outlet syndrome is variable and difficult to interpret, largely because there is no widely accepted gold standard diagnostic test for TOS — particularly neurogenic TOS. Published studies report sensitivity values generally between 82% and 90%, suggesting the test is reasonably good at identifying patients who have the condition. Specificity is considerably lower, typically in the range of 30% to 40%.

False positives are common. The sustained overhead position is inherently fatiguing, and many people without TOS will experience discomfort within three minutes. This is why symptom reproduction, not just inability to complete the test, is the key criterion for a positive result.

The Roos Test should not be interpreted in isolation. A positive result should be considered alongside the patient’s history, symptom pattern, and findings from other provocative tests before a clinical diagnosis is made.

Related Tests

Several other tests are used in the clinical assessment of thoracic outlet syndrome. No single test is diagnostic on its own, and combining multiple tests improves diagnostic confidence:

• Adson’s Test — assesses for arterial TOS by monitoring radial pulse changes with cervical rotation and deep inspiration
• Allen Test — evaluates arterial patency; used to rule out vascular involvement distal to the wrist
• Wright Test (Hyperabduction Test) — assesses subclavian artery compression with full arm hyperabduction
• Costoclavicular Maneuver — compresses the costoclavicular space by retracting and depressing the shoulder girdle
• Upper Limb Tension Test (ULTT) — assesses neural tension in the brachial plexus; useful when neurogenic TOS is suspected

Clinical Pearls

• Early symptom onset (within 60 seconds) is more clinically significant than symptoms appearing late in the test.
• Compare both sides. Asymmetric symptom reproduction is more meaningful than bilateral fatigue.
• Neurogenic TOS is a diagnosis of exclusion. Rule out cervical radiculopathy and peripheral nerve entrapment first.
• False positives are common in patients with poor shoulder girdle endurance — consider this in athletes and overhead workers.
• Use this test as part of a cluster alongside a thorough history, not as a standalone screen.

Related Tests for Thoracic Outlet Syndrome

• Adson’s Test: vascular TOS assessment targeting the subclavian artery; commonly combined with the Roos Test
• Allen Test for TOS: additional vascular assessment for thoracic outlet compression
• Thoracic Outlet Syndrome: clinical overview of TOS subtypes, anatomy, and management

Frequently Asked Questions

What is the Roos Test used for?

The Roos Test is used to help identify thoracic outlet syndrome (TOS), particularly the neurogenic subtype, where the brachial plexus is compressed as it passes through the thoracic outlet. It is one of the most commonly used screening tests for this condition in clinical practice.

What does a positive Roos Test mean?

A positive result means the patient reproduced their familiar symptoms of pain, numbness, tingling, or arm heaviness during the elevated arm stress position. It suggests neurovascular compression may be occurring at the thoracic outlet with the arm in this position. It is not diagnostic on its own and should be interpreted alongside the patient’s history and other clinical findings.

How accurate is the Roos Test?

The Roos Test has moderate-to-high sensitivity (approximately 82–90%), meaning it is reasonably good at detecting TOS when present. However, its specificity is low (approximately 30–40%), which means false positives are common. Many people will experience fatigue or discomfort in this position without having TOS, which limits its ability to confirm a diagnosis on its own.

What is the difference between the Roos Test and the EAST Test?

They are the same test. EAST stands for Elevated Arm Stress Test. Both names refer to the same procedure: 90 degrees of shoulder abduction and external rotation with repeated hand opening and closing for up to three minutes. It is also sometimes called the “Hands Up” test.

Can you have thoracic outlet syndrome with a negative Roos Test?

Yes. A negative result does not rule out TOS. While the test has reasonable sensitivity, patients with mild or intermittent TOS may not reproduce symptoms during the test. If clinical suspicion remains high, other tests, imaging, and specialist referral should be considered.

How is thoracic outlet syndrome treated?

Most cases of neurogenic TOS are managed conservatively with physiotherapy. Treatment typically focuses on improving thoracic and cervical posture, strengthening the periscapular and deep neck muscles, stretching the scalene muscles and pectoral region, and addressing contributing factors such as poor ergonomics or overhead loading. In cases where conservative treatment fails, surgical options such as first rib resection may be considered.

Video Demonstration