Halstead maneuver: How to perform, interpret, and document TOS testing

Key takeaways

The Halstead maneuver applies downward arm traction while the patient extends and rotates the neck, stressing the costoclavicular space.

A positive result needs both pulse diminishment and symptom reproduction, because pulse change alone appears in healthy arms too.

Run the test that matches the presenting pattern first, and clear cervical radiculopathy before you reach for a TOS battery.

Marked pallor, cyanosis, dizziness, or ischemic pain during traction are stop signs, not findings to note and continue past.

Practice management software like Pabau lets physical therapy and chiropractic practices record every test field the same way across visits.

The Halstead maneuver is a provocative test for thoracic outlet syndrome, and a positive result needs two findings at once. The radial pulse has to drop, and the patient’s familiar arm symptoms have to return. Performing it takes under two minutes. Reading it correctly takes more judgment, because this test has the weakest specificity of the standard test battery.

Thoracic outlet syndrome is both over-diagnosed and under-diagnosed in musculoskeletal practice. Technique and documentation are what separate a finding you can act on from one that misleads the next clinician.

This guide covers the anatomy the test stresses, the technique, and how to read a positive finding. It also sets out what the accuracy data supports, which test to run first, and the signs that mean stopping mid-test. It is written for physical therapists, chiropractors, and other musculoskeletal (MSK) clinicians who want a reference they can return to between patients.

What is the Halstead maneuver and what does it test?

The Halstead maneuver is a provocative orthopedic test that screens for thoracic outlet syndrome (TOS) by narrowing the costoclavicular space. You will also see it written as Halstead’s test, and as the Reverse Adson’s test. All three names describe the same maneuver.

TOS describes compression of the neurovascular bundle as it passes through the thoracic outlet. That bundle is the brachial plexus plus the subclavian artery and vein. The outlet is bounded by the clavicle anteriorly, the first rib inferiorly, and the scalene muscles laterally.

The Halstead maneuver stresses one specific part of that outlet. That part is the costoclavicular space, the interval between the first rib and the clavicle. Downward traction on the arm depresses the shoulder girdle and narrows the interval. Cervical extension and rotation add soft-tissue tension on top.

Three TOS subtypes exist. Neurogenic TOS involves the brachial plexus, arterial TOS the subclavian artery, and venous TOS the subclavian vein. The Halstead maneuver screens mainly for the arterial and neurogenic subtypes. There, radial pulse change and upper limb symptom reproduction are the findings that count.

Anatomy and clinical rationale behind the test

The Halstead maneuver works by shrinking a space that is already tight in most people. Four structures define what happens when you do it.

• Subclavian artery: passes over the first rib and beneath the clavicle. Caudal arm traction pulls the clavicle down toward the first rib, narrowing the interval and pressing the artery against bone.
• Brachial plexus: runs alongside the artery through the same space. Traction plus cervical rotation stretches the plexus, reproducing paresthesia, weakness, or heaviness where compression already exists.
• First rib and clavicle: form the costoclavicular interval. Drooped shoulders and forward head posture narrow it chronically. The maneuver applies a dynamic stress that reveals latent narrowing.
• Scalene muscles: contralateral neck rotation tightens the anterior and middle scalenes on the test side. That adds soft-tissue compression to the mechanical traction already applied.

This anatomy explains the test’s logic and its main weakness. The costoclavicular space narrows under downward traction in nearly everyone, so asymptomatic arms can lose radial pulse during the maneuver. Symptom reproduction, rather than pulse change, is what makes a positive result clinically meaningful.

How to perform the Halstead maneuver: Step-by-step

Seat the patient upright and find the radial pulse. Apply steady caudal traction to the arm, then have them extend and rotate the neck away from the test side. Technique is consistent across sources apart from rotation direction, which some texts describe as ipsilateral. The version below is the most widely cited.

1. Patient position: Seat the patient upright with arms resting at their sides and shoulders relaxed. Check for shoulder guarding or shrugging, which alters the costoclavicular relationship.
2. Locate the radial pulse: Palpate the radial pulse on the test side before applying any force. Establish a baseline for pulse quality, so you have something to compare against.
3. Apply caudal traction: Grasp the wrist or distal forearm and apply steady downward traction. Use enough force to gently depress the shoulder girdle, but not enough to cause pain from the traction itself.
4. Instruct cervical movement: Ask the patient to extend the neck and rotate the head away from the arm being tested. Maintain that position throughout.
5. Monitor for response: Keep palpating the pulse while watching for symptom reproduction. Hold for up to 60 seconds, asking the patient to report changes in sensation, heaviness, or pain.
6. Compare bilaterally: Repeat on the opposite side. Unilateral findings carry more clinical weight than bilateral ones.

Interpreting a positive result

A positive Halstead maneuver requires two findings at the same time, not one.

• The radial pulse diminishes or disappears on the test side while the position is held.
• The patient’s familiar symptoms return. That means paresthesia, heaviness, aching, or weakness in the upper limb or hand.

Pulse diminishment without symptom reproduction does not count as positive. Studies measuring radial pulse obliteration during similar TOS maneuvers report rates between 30% and 60% in healthy volunteers. Treating pulse change alone as positive is how patients end up in unnecessary investigation.

Symptom reproduction without pulse change can still matter clinically. In neurogenic TOS the brachial plexus is the structure under load, not the subclavian artery. There, the symptom pattern carries more diagnostic weight than the vascular finding. Look at distribution, and at how symptoms track with posture and activity history.

Sensitivity, specificity, and clinical limitations

Reported sensitivity for the Halstead maneuver sits around 72%, with specificity near 26%. Those figures come from small study populations using varied TOS criteria across the literature. Treat them as indicative rather than definitive.

The specificity figure of roughly 26% is the false-positive problem in one number. Clinical reviews of thoracic outlet syndrome make the same point. No single provocative TOS test is specific enough to confirm or exclude the condition on its own. The same logic drives the Ottawa Ankle Rules, where combined criteria beat any single finding.

Two practical limitations are worth naming. Examiner variation in traction force changes the mechanical stress on the costoclavicular space from one clinician to the next. And patient-reported symptoms during the test are influenced by anticipation, plus the ordinary discomfort of any applied traction. Standardizing your technique and recording findings the same way each session reduces both.

How the test compares to other TOS special tests

No provocative test is used in isolation for TOS. The standard approach is a battery, with each test stressing a different anatomical compartment. Knowing what separates them is what lets you pick a sequence and read combined findings without over-calling the result.

Adson’s test vs. the Halstead maneuver

Both tests palpate the radial pulse during a provocative cervical position. They rotate the head in opposite directions, and they load different compartments.

• Adson’s test (also called the Adson maneuver): the patient rotates the head toward the test side and inhales deeply while you monitor the radial pulse. This tightens the ipsilateral scalenes against the subclavian artery. Loss of the pulse on that inhalation is the Adson sign.
• Halstead maneuver: the patient rotates the head away from the test side while you apply caudal traction. This loads the costoclavicular space instead of the interscalene triangle.

So the choice between the two comes down to which compartment the history points at. A patient positive on Adson’s but negative on the Halstead maneuver suggests scalene-level compression. The reverse pattern points at a costoclavicular mechanism. Positive on both raises suspicion of multi-level compression or a structural anomaly, such as a cervical rib.

Adson’s test is the more familiar of the two names, and that familiarity creates a documentation problem. An entry reading “Adson test positive” does not say whether the pulse dropped, whether symptoms returned, or which way the head was turned. Record all three, or the note is unusable at the next visit.

Roos test, or the elevated arm stress test

The Roos test asks the patient to hold both arms overhead and open and close their fists for three minutes. It is also called the elevated arm stress test, or EAST. Rather than monitoring the radial pulse, it looks for symptom reproduction under sustained effort.

1. The patient abducts both arms to 90 degrees, externally rotates, and flexes the elbows to 90 degrees. This is the surrender position.
2. The patient opens and closes both fists slowly for three minutes.
3. A positive result is failure to complete three minutes, or reproduction of arm fatigue, paresthesia, or ischemic pain within that time.

The Roos test is more sensitive than the Halstead maneuver for neurogenic TOS, at roughly 84% against 72%, with similarly low specificity. Its advantage is that it replicates sustained overhead activity. That is the exact context in which many TOS patients report their worst symptoms. Pairing passive vascular provocation with active functional provocation tells you more than either test alone.

Wright test and hyperabduction syndrome

The Wright test checks whether hyperabduction of the arm is what compresses the neurovascular bundle. It is also called the Wright maneuver, or the hyperabduction test.

With the patient seated, take the arm into 90 degrees of abduction and external rotation while you palpate the radial pulse. Then move the arm further into hyperabduction. The neck stays relaxed in neutral throughout, since head rotation belongs to Adson’s test and the Halstead maneuver rather than this one. Hold for up to a minute, then compare with the other arm.

A positive Wright test reproduces the patient’s arm symptoms, with or without a drop in the radial pulse. That points at the retropectoral space, where the pectoralis minor and the coracoid process can pin the bundle against the chest wall. Pulse loss alone is especially unreliable here, since hyperabduction reduces the pulse in many healthy shoulders.

This is why the Wright test earns its place beside the other two. The Halstead maneuver loads the costoclavicular space, the Roos test loads the plexus under sustained effort, and the Wright test loads the retropectoral space. Between them, the battery covers all three common compression sites.

Sequencing the TOS test battery: Order, safety, and when to stop

Start with the test that matches the presenting pattern, not the one you perform most often. Vascular complaints, neurogenic complaints, and cervical radiculopathy each call for a different opening move. Getting the order right saves time, and it stops you provoking a patient you should have referred instead.

Two ordering rules matter more than the rest. Clear cervical radiculopathy first, because a positive TOS finding in a radiculopathic arm is close to uninterpretable. And run the least provocative test first, so a patient who reacts badly reacts to the mildest stimulus you had planned.

Stop signs that mean releasing the traction immediately

Release the traction and end the test as soon as any of the following appears.

• Marked pallor or cyanosis in the hand or forearm.
• Dizziness, vertigo, or visual disturbance while the neck is extended and rotated.
• Ischemic pain, meaning a deep ache or cramp that keeps building rather than settling.
• Pulse loss with symptoms that do not clear within seconds of releasing the arm.

None of these are findings you record and then carry on with. Dizziness during cervical extension and rotation raises the question of vertebrobasilar involvement, which is a referral decision rather than a TOS one. Marked pallor or cyanosis suggests arterial compromise significant enough to warrant vascular assessment.

After a full battery, an ambiguous or positive result is a reason to escalate rather than to start treating. Duplex ultrasound with positional provocation is the usual first-line vascular study. MR angiography or CT angiography follows where the ultrasound is equivocal, or where surgical opinion is being sought. Nerve conduction studies help where neurogenic TOS is the working diagnosis.

When a test stops early for one of these reasons, the note matters more than usual. Record which sign appeared, how long into the hold it appeared, how quickly it settled, and what you did next.

When to use the test in clinical practice

Use the Halstead maneuver when the history points at a positional, load-related upper limb problem that the cervical spine does not explain. No single item below justifies the test on its own. The cluster is what should trigger a TOS battery.

• Upper limb pain, paresthesia, or heaviness with a positional or postural component.
• Symptoms reproduced or worsened by overhead activity or sustained arm elevation.
• Occupation or training history involving prolonged shoulder-girdle loading, such as swimmers, overhead athletes, or manual workers with drooped posture.
• A cervical examination that does not fully explain the upper limb symptoms.
• Asymmetric hand or forearm wasting, color change, or temperature difference suggesting vascular involvement.

Where cervical radiculopathy is the leading differential, start with the cervical exam instead, as set out above. Use the Halstead maneuver once the history and initial examination point toward a thoracic outlet mechanism specifically.

Documenting why you chose a test, and not only what it showed, protects you later and stops a colleague repeating the whole workup. Where the patient is an athlete, the staged-loading thinking behind a return-to-running protocol transfers well to reloading the shoulder girdle once symptoms settle.

Documenting and managing TOS assessment in practice

A TOS assessment is only as useful as the note it leaves behind. An entry reading “TOS tests performed, some positive” cannot support a treatment decision or a referral letter three months later.

A structured entry for the Halstead maneuver captures seven things.

• Test performed and side: “Halstead maneuver, right side”
• Baseline pulse: “Radial pulse strong and regular pre-test”
• Traction applied: “Moderate caudal traction, patient tolerated well”
• Cervical position: “Full extension and contralateral rotation achieved”
• Vascular finding: “Radial pulse markedly diminished at 15 seconds”
• Symptom reproduction: “Paresthesia in fourth and fifth digits, consistent with presenting complaint”
• Interpretation: “Positive Halstead maneuver, consistent with right-sided costoclavicular compression”

Free text will not produce all seven consistently across a busy list. A form that prompts each field will. Guidance on safer clinical notes and writing effective clinical notes covers how structured SOAP entries cut documentation errors in assessment-heavy specialties.

Practice management software like Pabau lets a physical therapy or chiropractic practice build the whole TOS battery as one reusable assessment form. Pabau’s digital forms prompt the clinician for baseline pulse, traction grade, cervical position, and symptom response on every side tested. The completed form lands in the patient’s structured client records, so the next clinician opens one screen instead of reading back through free text.

That structure pays off most in serial testing. Tracking Halstead maneuver findings across a course of care gives you something objective to point at when you discharge, progress, or refer onward. Pairing them with a patient-reported measure such as the global rating of change gives you two independent lines of evidence.

Practices comparing physical therapy software should check whether custom assessment forms feed the patient record directly, rather than saving as a loose PDF.

Screening earlier helps too. A chiropractic intake form template that asks about occupation, overhead loading, and symptom triggers arrives completed before the patient reaches the table. The examiner then starts the physical assessment with the relevant history already documented.

Practices running chiropractic software or a physical therapy EMR can pull those fields into a progress summary. That beats re-reading every note before a review appointment.

Keep every special test documented the same way

Pabau helps physical therapy and chiropractic practices build structured assessment forms, track MSK test findings across visits, and keep clinical notes complete. Nothing gets lost between sessions.

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Conclusion

The Halstead maneuver earns its place in a TOS workup, but never on its own. Its specificity is too low to confirm anything, and its sensitivity too moderate to exclude anything. What it does well is tell you whether the costoclavicular space is part of the story.

So the decision that changes outcomes is the order you test in. Clear the cervical spine first, then run the test that matches the presenting pattern. Stop the moment the hand changes color or the patient gets dizzy. An ambiguous battery is a reason to image, not a reason to start treating.

One trade-off is worth remembering. A thorough battery takes 10 minutes, and a note that captures it properly takes two more. Skipping the second part wastes the first. Book a demo to see how Pabau keeps MSK assessment findings structured and comparable across a course of care.

Continue your research

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Looking at lateral hip and IT band tightness? Ober’s test explains the positioning that keeps the result reproducible between examiners.

Want better clinical note quality across your practice? Safer clinical notes covers the documentation principles that reduce medico-legal risk in MSK practice.

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