Roos stress test: How to perform and interpret the EAST test

The Roos stress test is a provocative orthopedic assessment that screens for thoracic outlet syndrome (TOS).

The patient holds both arms abducted and externally rotated at 90 degrees, opening and closing the hands for three minutes. Reproducing the patient’s own symptoms inside that window is a positive result. Plain arm fatigue is not.

Research published in Frontiers in Physiology (PMC6393400) found the maneuver reliable, though not perfectly so, and recommends performing it at least twice. The test is also known as the Elevated Arm Stress Test (EAST). This guide covers how to position the patient, how to read the result, what the accuracy data supports, and how to document findings.

Found our content helpful?

Key takeaways

The Roos stress test (EAST) screens for thoracic outlet syndrome by loading the neurovascular structures for three minutes of arm abduction and repeated hand movement.

A positive result is reproduction of heaviness, pain, tingling, numbness, or arm weakness within the three-minute window, not general fatigue.

Sensitivity for neurogenic TOS is high, but specificity varies widely, so treat the test as a screen rather than a diagnosis.

Record the minute mark at which symptoms start, because onset inside 60 seconds suggests more significant outlet compromise.

Practice management software like Pabau captures onset timing, reproduced symptoms, and laterality in structured fields at the point of care.

What is the Roos stress test and why do clinicians use it?

The Roos stress test is a provocative orthopedic special test for thoracic outlet syndrome. It puts the brachial plexus and subclavian vessels under sustained mechanical stress. Vascular surgeon David Roos developed it. The position it uses is the one that most reliably reproduces a patient’s symptoms, which matters in neurogenic TOS, where imaging is often unremarkable.

Its formal alternative name, the Elevated Arm Stress Test (EAST), describes the mechanism. Elevation combined with external rotation narrows the thoracic outlet and compresses the neurovascular bundle running through it. Static position tests such as the Adson maneuver stop there. The EAST adds repetitive hand opening and closing, which brings symptoms on faster in patients with genuine neurovascular compromise.

Clinicians in physical therapy, chiropractic, and sports medicine reach for it often. The trigger is upper limb pain, paresthesia, or fatigue that worsens with overhead activity. It answers one question. Does holding the arm abducted and externally rotated reproduce the complaint the patient came in with?

Anatomy of the thoracic outlet: Why this position is provocative

The thoracic outlet is a narrow corridor. The first rib bounds it below, the clavicle in front, and the scalene muscles behind and to the side. The brachial plexus, subclavian artery, and subclavian vein all pass through it on the way to the upper limb.

Abducting the shoulder to 90 degrees and externally rotating it tightens the scalene triangle and compresses the costoclavicular space at the same time. Flexing the elbow to 90 degrees tethers the brachial plexus further upstream.

Repeated fist opening and closing then raises blood demand in the forearm. Arterial flow through the compressed outlet cannot keep up. In neurogenic TOS the nerve roots take the load first. In arterial TOS the radial pulse fades. In venous TOS, congestion produces arm heaviness and cyanosis.

Knowing why the position provokes symptoms changes how you use it. You can explain the test to a patient, adapt the positioning for a restricted shoulder, and reason through an atypical result instead of discarding it. For physical therapists, that reasoning belongs in the notes and the referral letter. A purpose-built physical therapy EMR holds it better than free text does.

Types of thoracic outlet syndrome: What the test screens for

TOS is three conditions, not one. Each subtype needs different management, and the Roos stress test carries different weight for each.

Neurogenic TOS accounts for the large majority of clinical presentations. That is why the Roos stress test turns up so often in musculoskeletal physical therapy and chiropractic practice. Acute arterial or venous TOS can be a contraindication to provocative testing, which is covered further down.

How to perform the Roos stress test: Step-by-step

Consistent technique is non-negotiable. Variation in arm angle, elbow position, or instruction quality introduces measurement error. It also reduces sensitivity and makes repeat assessments harder to compare.

Patient positioning

Seat the patient in a supported upright posture with the spine neutral. Then instruct them to assume the EAST position:

1. Abduct both shoulders to 90 degrees (upper arms horizontal, parallel to the floor).
2. Flex both elbows to 90 degrees (forearms vertical, palms facing forward).
3. Externally rotate the shoulders so the hands sit behind the plane of the trunk, not in front of it.

The resulting posture resembles a hands-up or cactus position. Check that the shoulders are not shrugged. A shrugged posture reduces the provocative load and commonly produces false negatives in patients with significant TOS.

Examiner role during the test

The examiner’s job does not end once the patient is positioned. Responsibilities during the three-minute window include:

• Verbal cueing: instruct the patient to open and close their hands slowly and repeatedly, at about one cycle per second. Rushing reduces neurovascular stress, and stopping early invalidates the test.
• Timing: note the minute mark at which symptoms first appear. Onset before 60 seconds correlates more strongly with significant neurovascular compromise than onset between two and three minutes.
• Visual observation: watch for arm fatigue, color change in the hand or forearm, and early abandonment of the test.
• Pulse monitoring: where arterial TOS is suspected, palpate the radial pulse on both sides at baseline and at one-minute intervals. A weakening or absent pulse during the test suggests arterial compromise.

Recording both the onset timing and the nature of the symptoms is what makes a repeat assessment meaningful. Multi-clinician practices should standardize the recording protocol across the team. One clinician’s baseline is then directly comparable to another’s follow-up finding.

Interpreting the results: What is a positive Roos stress test?

A positive Roos stress test means the patient’s presenting symptoms are reproduced inside the three-minute window. Reproduction is the operative word. General arm fatigue or muscular discomfort from holding an unusual posture does not count.

Symptoms that count as a positive finding include:

• Heaviness or aching in the arm or forearm that mirrors the chief complaint
• Pain radiating from the shoulder, neck, or axilla into the arm or hand
• Tingling or numbness in the hand, typically ulnar in distribution for neurogenic TOS (C8/T1 territory)
• Weakness or loss of hand dexterity during the opening-and-closing phase
• Inability to complete the full three minutes because symptoms were reproduced
• Pallor or cyanosis of the hand during the test (vascular pattern)

Onset timing adds clinical nuance, and the three bands below are what a recorded minute mark buys you. Symptoms appearing inside the first 60 seconds suggest a more significant degree of outlet compromise. Symptoms appearing between two and three minutes are still positive, but may reflect milder or position-dependent compression. A patient who completes three minutes with no reproduction has a negative result.

Diagnostic accuracy: Sensitivity and specificity

The Roos stress test performs well as a screening instrument and poorly as a confirmatory one. Published sensitivity and specificity figures vary across study designs, patient populations, and TOS subtype definitions.

The clinical takeaway is straightforward. A positive Roos stress test raises suspicion for TOS and warrants further investigation, while a negative result does not rule it out. That matters for overhead athletes, whose TOS can present without classic paresthesia. Combine the Roos stress test with at least two other provocative tests, such as the Wright test, before forming a clinical impression.

Roos test vs other thoracic outlet syndrome tests

The Roos stress test sits within a family of TOS provocative tests. Knowing what each one stresses prevents redundant or inappropriate test selection during assessment.

The Adson test is the better choice when arterial TOS from scalene compression is suspected. The Roos stress test captures the demand-supply mismatch that mimics overhead activity. For swimmers, throwers, and manual workers it is usually the highest-yield first choice. If you run both in the same session, an Adson test template keeps the two records in a comparable format.

Differential diagnosis: Conditions that mimic a positive result

Several conditions produce upper limb pain and paresthesia during provocative testing and can yield a false positive. Clinical reasoning after a positive result has to account for them before TOS is presumed.

• Cervical radiculopathy: C6, C7, or C8 root compression produces dermatomal paresthesia that can worsen with sustained arm elevation. Neck rotation and Spurling’s test help differentiate. Radiculopathy pain usually carries a proximal cervical component that TOS does not.
• Carpal tunnel syndrome: median nerve compression at the wrist produces palmar and radial-sided finger paresthesia. The Roos position loads the proximal nerve too, which can aggravate a distal entrapment. Tinel’s sign and the Phalen test at the wrist separate the two.
• Double crush syndrome: proximal (TOS) and distal (carpal or cubital tunnel) nerve compression together. Both findings can be positive at once, and electrodiagnostic studies are needed to quantify each level.
• Rotator cuff pathology: significant cuff disease may stop the patient holding 90 degrees of abduction, producing pain before any neurovascular symptom appears. The result is then uninterpretable.
• Disputed or non-specific TOS: patients with chronic pain syndromes, fibromyalgia, or occupational strain may report diffuse arm discomfort in the EAST position. No clear dermatomal or vascular pattern, plus inconsistency across repeat testing, points away from structural compression.

Note the differential diagnoses you considered and the reasoning that moved you toward or away from each. This matters most when you refer for vascular surgery assessment or nerve conduction studies. A cervical screen that includes Spurling’s test is the quickest way to rule the neck in or out first.

Limitations and clinical considerations

The Roos stress test is a useful screening tool with clear boundaries. Several scenarios limit its reliability or rule it out altogether.

• Acute arterial or venous TOS: sustained arm elevation is contraindicated where acute subclavian thrombosis or significant arterial occlusion is suspected. These presentations usually involve dramatic color change, pulselessness, or limb swelling at rest. Refer urgently instead of testing.
• Restricted shoulder range of motion: rotator cuff tears, glenohumeral arthritis, or significant impingement prevent accurate positioning. The test cannot be administered validly without 90 degrees of pain-free abduction.
• Poor cooperation or understanding: the test needs sustained effort and accurate reporting. Cognitive limitations, language barriers, or pain that prevents stillness all compromise validity.
• Bilateral positive findings: some patients without TOS produce bilateral symptoms from arm fatigue alone. Check that the reproduced symptoms match the chief complaint before recording a positive.

Best practice is a cluster approach. Combine the Roos stress test with at least two other TOS provocative tests, a cervical spine screen, and an appropriate neurological and vascular examination. A standalone positive or negative result carries limited diagnostic weight.

Documenting and communicating your findings

A well-performed Roos stress test generates information that has to be recorded accurately to be useful later. A note that reads “EAST positive” gives the next clinician almost nothing to work with.

A complete entry captures:

• Laterality: right, left, or bilateral symptoms reproduced
• Onset timing: the minute mark at which symptoms first appeared, for example “onset at 45 seconds”
• Symptom quality: pain, paresthesia, heaviness, weakness, or vascular changes such as pallor or cyanosis
• Distribution: specific fingers, forearm, or diffuse upper limb involvement
• Test tolerance: whether the patient completed three minutes or stopped early
• Pulse findings: whether the radial pulse was monitored, and any change noted

Structured digital assessment forms enforce these fields better than free-text recall does. Practices running several practitioners and frequent repeat assessments usually get there through physiotherapy practice management software rather than a template pinned above the desk.

For a multi-clinician practice, standardized documentation means a follow-up assessment by a different therapist is still comparable to the baseline. Inconsistent recording between clinicians is a common reason why repeat assessments fail to show progress clearly.

How Pabau keeps special test findings in the record

In many practices a special test gets recorded twice. The therapist notes it on paper or holds it in their head during the session, then types it up afterward, often hours later. Onset time is the first detail to go.

Practice management software like Pabau removes that second step. Structured clinical notes give the Roos stress test its own fields for laterality, onset time, symptom quality, distribution, and pulse findings. Pabau Scribe, our AI scribe, can also capture what you say during the assessment and file it against the patient record.

The result is a baseline the next clinician can compare against, without chasing anybody for what they meant by “EAST positive”. The same fields feed the referral letter, so a vascular surgery or nerve conduction request goes out with the timing and distribution already in it.

Document special test findings the moment you find them

Structured clinical notes in Pabau capture onset timing, reproduced symptoms, and laterality at the point of assessment. The record is complete before the patient leaves.

Book a demo

Conclusion

The Roos stress test earns its place because it reproduces the arm position that provokes symptoms during overhead activity. It does not settle the diagnosis. Treat a positive result as a reason to keep investigating, and a negative one as weak evidence against TOS.

What changes the outcome is the detail you write down. Onset time, laterality, symptom quality, and distribution turn a single assessment into a baseline. Six weeks later, that baseline is what tells you whether treatment worked.

Build the recording format once and the whole team works from it. Book a demo to see how Pabau structures special test documentation for physical therapy and chiropractic teams.

Continue your research

Comparing TOS provocative tests? Halstead maneuver covers the traction-based test that sits alongside the Roos and Adson tests in the same cluster.

Need a supraclavicular screen too? Morley test explains the brachial plexus compression test used alongside the elevated arm stress test.

Opening or scaling a musculoskeletal practice? Opening a physiotherapy clinic walks through the compliance, staffing, and software decisions that affect clinical workflow from launch day.

Frequently asked questions