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Thoracic Outlet Syndrome: Assessing the Elevation Chain

presented by Ann Porretto-Loehrke

Accreditation Check:

What do I do with patients that hurt all over? Why does the carpal tunnel symptoms seem to keep coming back? This course continues with the examination process for disputed neurogenic thoracic outlet syndrome with emphasis on joint-specific testing for compressors.

CHTs, when submitting this for recertification through HTCC, this course can be used for CAT B (hand therapy courses < 3 hours in length); however, if this course certificate is submitted with the following course certificates listed below (or any combination totaling 3 hours or more), they can be submitted under CAT A (hand therapy courses > 3 hours in length).

  • Identification & Evaluation of Thoracic Outlet Syndrome (2 hours)
  • Thoracic Outlet Syndrome: Assessing the Elevation Chain (1.25 hours)
  • Treatment of Thoracic Outlet Syndrome: Where to Begin (1.75 hours)
  • Treatment of Thoracic Outlet Syndrome: Addressing Shoulder and Upper Thoracic Limitations (1.5 hours)


  • Meet Your Instructor

    • Ann Porretto-Loehrke, PT, DPT, CHT, COMT, CMTPT

      Ann Porretto-Loehrke is a skilled clinician and dynamic instructor. She is the therapy manager of a large department at the Hand to Shoulder Center. Ann is a Certified Hand Therapist (CHT) and a Certified Orthopedic Manual Therapist (COMT) for treatment of the upper quadrant through the International Academy of Orthopedic Medicine (IAOM). She has extensive training in the evaluation and treatment of the upper quadrant. Ann completed a post-professional Doctorate in Physical Therapy (DPT) degree from Drexel University with a specialty in hand and upper quarter rehabilitation. Most recently, Ann has become certified in dry needling through Myopain Seminars, as a Certified Myofascial Trigger Point Therapist (CMTPT). She previously served as the Vice-Chair of the Examination committee for the Hand Therapy Certification Commission (HTCC). Ann also previously served as the Northeast District chair for the Wisconsin Physical Therapy Association from 2004 to 2008. She is a lead instructor who developed the Hand & Upper Extremity Track through IAOM, a set of six manual therapy courses designed specifically for hand and upper extremity specialists. Ann has presented at American Society of Hand Therapists (ASHT) annual conferences, Canadian Hand Conferences, Philadelphia meeting, and Teton Hand Conference.

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    Chapters & Learning Objectives

    Download Learning Objectives
    1. Scapular & Elevation Chain Assessment

      1. Scapular & Elevation Chain Assessment

      Poor scapular alignment and limited mobility in the upper extremity elevation chain can contribute to TOS, especially with compressors. This chapter covers how to assess resting scapular position and dynamic control as well as performing the Passive Elevation Test to determine if further joint-specific testing is indicated at the acromioclavicular joint (ACJ) or sternoclavicular joint (SCJ).

    2. Glenohumeral Joint Assessment

      2. Glenohumeral Joint Assessment

      Posterior glenohumeral joint (GHJ) tightness can contribute to poor scapular mechanics. In addition, end-range GHJ limitations can contribute to TOS “compressor” symptoms. This chapter covers how to assess posterosuperior and posteroinferior GHJ with the arm at the side as well as how the Passive Elevation Test can determine if further joint-specific testing is indicated at the GHJ at end-range.

    3. Cervicothoracic Assessment

      3. Cervicothoracic Assessment

      Stiffness in the upper thoracic spine can be a culprit with poor scapular mechanics and brachial plexus issues. This chapter covers how to assess upper thoracic extension and rotation mobility.