Roos stress test: How to perform, interpret, and document

The Roos stress test is a provocative test for thoracic outlet syndrome (TOS).

The patient holds both arms at 90° abduction and external rotation. They then open and close their hands for up to three minutes. Symptom reproduction inside that window, or an inability to finish it, is a positive finding.

A 2019 study of microvascular responses to the test reported test-retest reliability that was good but not perfect. The authors attributed part of that to inconsistent symptom reproduction between the two trials. They recommend repeating the maneuver at least twice.

Physical therapists, osteopaths, chiropractors, and sports medicine clinicians meet this presentation often. Upper limb pain, numbness, and heaviness resist an obvious diagnosis, and TOS is easy to miss. This guide covers the procedure, how to read the findings, how it compares with the other TOS tests, and what to document.

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Key takeaways

The Roos stress test, also called the elevated arm stress test (EAST), screens for thoracic outlet syndrome.

The patient holds both arms at 90° abduction and external rotation, opening and closing the hands for three minutes.

Symptom reproduction within three minutes, or failure to complete the window, is a positive finding.

Reported sensitivity and specificity vary widely, so the result belongs in a cluster with the history and other provocative tests.

Onset timing, symptom type and laterality are what make the record useful later, so document all three.

What is the Roos stress test (EAST)?

The Roos stress test puts the neurovascular structures of the thoracic outlet under sustained mechanical stress. It is also called the elevated arm stress test, or EAST, and the two names are used interchangeably. D.B. Roos described it in the 1960s, and it remains the most widely used provocative test for TOS.

Thoracic outlet syndrome is not one pathology. Clinicians recognize three subtypes:

• Neurogenic TOS (nTOS): compression of the brachial plexus (C5-T1 nerve roots), accounting for over 95% of TOS cases.
• Arterial TOS (aTOS): compression of the subclavian artery, relatively rare but potentially serious.
• Venous TOS (vTOS): compression of the subclavian vein, presenting with arm swelling, cyanosis, and effort thrombosis.

The test is sensitive across all three subtypes, though a positive presentation looks different depending on whether the compression is neural or vascular. Which subtype you suspect changes how you read the findings.

Anatomy and mechanism: Why the test provokes symptoms

The thoracic outlet is a triangular space bounded by the first rib below, the clavicle in front, and the scalene muscles behind. The brachial plexus and subclavian vessels pass through it before running under the pectoralis minor toward the axilla. In TOS, one or more of those structures is compressed.

Compression comes from a cervical rib, a hypertrophied scalene, or postural narrowing of the costoclavicular space. Elevating the arms to 90° abduction and external rotation tightens that space and stretches the plexus across the first rib.

Repeated hand opening and closing raises metabolic demand in the distal muscles. Where flow is already compromised, symptoms come on faster than positioning alone would produce them.

The pectoralis minor adds a second compression point where the bundle passes under the coracoid process. Patients with a hypertrophied pectoralis minor from overhead sport often show earlier onset. Swimmers, baseball pitchers, and volleyball players are the usual examples.

How to perform the Roos stress test, step by step

Positioning decides the result. Small deviations in abduction angle or forearm rotation can fail to provoke TOS at all, or produce a false positive from rotator cuff impingement. A purpose-built physical therapy EMR lets you store the procedure as a checklist, so technique stays consistent across practitioners.

1. Position the patient upright, seated or standing. Avoid a slouched posture, which narrows the costoclavicular space before the test begins.
2. Abduct both shoulders to 90° in the coronal plane. The upper arm stays parallel to the floor, not angled forward or back.
3. Externally rotate the shoulders so the forearms are vertical and the elbows flexed to about 90°. The palms face forward.
4. Ask the patient to open and close their hands at a steady pace of roughly one cycle every two seconds. Keep it going for a maximum of three minutes.
5. Record the exact onset time, the symptom type, and the side or sides affected. Pain, numbness, tingling, heaviness and weakness are all worth distinguishing.
6. Stop the test if the patient reports severe pain, pallor, or pulselessness in the hand. Stop it too if they cannot continue, and note the point of cessation in seconds.

Common positioning errors to avoid

Shoulder elevation is the most frequent error. Patients instinctively shrug as fatigue builds, which unloads the costoclavicular space and reduces provocation. Remind them to keep the shoulders relaxed and level throughout.

Insufficient external rotation comes second. If the forearms rotate inward, the test loads the rotator cuff instead of the thoracic outlet. Any pain that follows points at the subacromial space, and the test result carries no TOS information. For a quick visual check, the elbows should point posteriorly instead of laterally.

Cadence matters too. Some patients perform slow, deliberate fist clenches instead of rapid alternating cycles. That lowers metabolic demand and delays or prevents provocation in borderline cases. A two-second cadence is the clinical standard.

Taken together, the four parameters below are what a reader of the note is trusting when they see a positive or negative result.

Interpreting the result: Positive and negative findings

A positive result reproduces the patient’s characteristic symptoms within the three-minute window. It also counts as positive when symptom severity stops the patient short of three minutes.

New pain on its own, such as localized shoulder fatigue, does not qualify. The reproduced symptoms have to match what the patient reports in daily life.

Positive indicators vary by TOS subtype:

• Neurogenic TOS: arm pain radiating into the medial forearm and fourth and fifth fingers, ulnar-distribution numbness or tingling, and progressive arm heaviness.
• Arterial TOS: pallor or cyanosis of the hand, coldness, and loss of radial pulse. Check the radial pulse at baseline and again at three minutes or at cessation.
• Venous TOS: arm swelling, venous distension in the forearm, or a sense of pressure and fullness.

A negative result does not exclude TOS. Mild or intermittent compression can present negatively if provocation is insufficient. Recent corticosteroid treatment can also reduce inflammatory compression enough to mask the finding.

Grading severity by symptom onset timing

No established guideline maps onset timing to severity, so treat the table below as clinical reasoning rather than a validated rule. Earlier onset generally suggests more significant compression. That relationship is not linear, and the timing belongs alongside the rest of the examination.

Diagnostic accuracy: Sensitivity, specificity, and evidence

Reported accuracy for the Roos stress test varies widely across studies, which reflects how loosely TOS itself is defined. Physiotutors cites a 2001 study by Gillard and colleagues, reporting 84% sensitivity and 30% specificity. Other studies report lower sensitivity, and no universally accepted reference standard exists to compare them against.

Key points from the evidence base:

• Sensitivity is generally higher for neurogenic TOS than for vascular TOS. Neurogenic symptoms such as tingling, numbness and arm heaviness are more reliably reproduced by sustained elevation.
• Specificity drops in mixed populations with shoulder pathology. Rotator cuff disease and cervical radiculopathy both produce arm symptoms during elevation that mimic a positive finding.
• The 30% specificity figure is the practical warning. A positive result raises suspicion without confirming a diagnosis.

The Physiopedia clinical reference recommends using the test as part of a cluster. A decision to investigate further should rest on several positive provocative tests, the history, and imaging.

Comparing TOS provocative tests: Roos, Adson, Wright, and Halstead

The Roos stress test is the most widely used of the TOS provocative tests, and most clinicians run a battery. Each one stresses the thoracic outlet by a different mechanism, which changes what it detects best.

The Adson test has relatively low specificity on its own, because pulse diminution occurs in many asymptomatic people. The Roos test is generally more useful for neurogenic TOS, since it targets functional limitation and not vascular occlusion alone. If you run the Adson test alongside it, record both results in the same note.

The Wright test is the one to add when hyperabduction reproduces the symptoms, because it points at the subcoracoid space instead of the first rib.

When to use the test in clinical practice

Reach for the test when upper limb symptoms are positional, activity-related, or provoked by overhead work. Three presentations come up most often:

• Unilateral arm pain or heaviness during overhead activity.
• Medial forearm and ulnar-side numbness without a clear cervical origin.
• A history of repetitive overhead sport or prolonged static neck posture.

Screen for red flags before you test. Acute hand pallor, pulselessness, or signs of arterial thrombosis make provocative testing inappropriate. Refer urgently instead.

The test earns its keep inside a cluster. One positive provocative test raises suspicion. Two or more, in a clinically consistent presentation, move TOS up the differential substantially. The Morley test adds a direct palpation check over the brachial plexus in the supraclavicular fossa.

Limitations and contraindications

The test has limitations worth understanding before you lean on it as a primary diagnostic tool.

False positives are the known concern. Rotator cuff pathology, subacromial impingement, and C8-T1 cervical radiculopathy all produce arm pain and paresthesia during sustained elevation. A cervical screen and a rotator cuff assessment beforehand reduce the misclassification risk. The arm squeeze test is one quick way to separate cervical radiculopathy from shoulder pathology.

False negatives turn up in mild or intermittent compression. A recent corticosteroid injection or manual therapy can temporarily reduce tissue irritability enough to suppress the response. A negative result in a patient with a suggestive history is a reason for combination testing, and it does not exclude TOS.

Patient compliance limits the test too. Significant shoulder pain from any cause, or restricted mobility after surgery, can stop a patient holding 90° abduction for three minutes. In those cases the test is inconclusive, and recording it as negative is a documentation error.

Contraindications include:

• Suspected acute arterial or venous occlusion in the upper limb, which needs urgent vascular referral.
• Recent shoulder surgery where abduction is restricted by the surgical protocol.
• Acute glenohumeral instability, or a dislocated shoulder within the previous six weeks.
• Severe cervical myelopathy, where sustained arm positioning may provoke cord symptoms.

None of these are unique to the Roos test. They follow from the same safety reasoning that governs any sustained provocative position.

What to document after the test

A vague note reading “Roos test positive” throws away the signal that onset timing, laterality and symptom character carry. Write down the procedure parameters and the patient’s exact response alongside the verdict.

A complete entry covers:

• Test name and alias: Roos stress test (EAST).
• Position confirmed: abduction angle, and whether external rotation was achieved or limited.
• Duration completed: seconds or minutes before cessation, or the full three minutes.
• Symptom reproduced: the exact description, such as tingling along the ulnar border of the fourth and fifth fingers, bilateral, onset at 90 seconds.
• Sides affected: unilateral or bilateral, dominant or non-dominant.
• Result interpretation: positive, borderline or negative, with the reasoning.
• Follow-on action: further tests performed, referral decision, or conservative plan.

How Pabau turns a provocative test battery into a structured note

Free-text notes are the default for this, so every practitioner records it slightly differently. Six months later, comparing the first Roos test with the third means reading three paragraphs of prose.

Practice management software like Pabau lets you build the entry once as a custom clinical form. You define the fields for onset in seconds, symptom type, laterality and interpretation. Every practitioner then fills the same ones.

The same template can carry the Adson and Wright fields, so a cluster assessment lands in one note instead of three. That note attaches to the client record the appointment already sits in, which is what makes the referral letter quick to write.

Pabau Scribe, our AI scribe, can draft the narrative part of the note during the appointment, so it is finished before the patient leaves.

Document provocative test findings as you observe them

Pabau’s custom clinical forms capture Roos test onset timing, symptom type and laterality as structured fields. The note lands in the client record with no transcription step.

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Conclusion

The Roos stress test is quick, cheap and easy to perform badly. Getting the position right, then writing down what happened and when, is what separates a useful record from a line that says positive.

Low specificity keeps a positive result in the category of suspicion. Pair it with the Adson or Wright test, weigh the history, and refer when the vascular picture demands it.

If your TOS assessments live in free text today, a structured template is the cheapest change you can make. Book a demo to see how Pabau structures musculoskeletal assessment notes.

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