Good article-

this part really applied in my case- probably for many of us...

[Exam is where most practitioners miss the diagnosis. The problem seems to be due to a “compartmentalization” of the body by musculoskeletal specialists. Most MD and DO physicians view the body as disconnected areas. A common problem is the axial and peripheral mindset. For example, many doctors without significant soft-tissue training will limit their exam to the areas of complaint. Since many patients complain of hand symptoms, the exam is often focused from the elbow down. This poses a problem in rendering a correct diagnosis, since the cause in the shoulder and thorax, not in the hand. Because of this over focused exam strategy, the diagnoses of carpal tunnel syndrome or ulnar entrapment at the elbow are frequently made in error. Millions of dollars are paid by insurers each year to doctors treating a shoulder-thorax problem with wrist or elbow surgery. Each year in my practice, I see a hundred or more patients who have had unnecessary carpal tunnel surgery or ulnar releases who are treated successfully without any additional surgery simply by applying the correct treatment to the problem.

The clinician’s exam will reveal much about whether or not proper care has been taken to rule out this diagnosis. First, an exam with only elements such as Phalen’s, Tinnels at the wrist and/or elbow, Carpal or Wrist Compression Test, Sensation, Deep Tendon Reflexes or DTR’s is not adequate to detect this diagnosis. Tests such as the Upper Limb or Brachial Plexus Tension Test (ULTT), Spurling’s Maneuver, Adson’s Maneuver, Scalene Compression Test, First Rib Compression, and/or Shoulder Range of Motion (ROM) should be included. Again, the focus of the exam in a patient that presents with hand paresthesias must include the neck and shoulder, and not just be limited to the wrist. Despite this reality and in some part due to the pressures placed on physicians by managed care, many physicians simply don't’ check anything beyond the area of complaint. This causes massive under-diagnosis of this particular condition.

In general, conservative treatment for TOS is very poor in this country. This is largely due to an over-emphasis on orthopedic and surgical conditions and a de-emphasis on soft-tissue conditions in American PT schools. It’s very common for a patient to be placed in an orthopedic based physical therapy program where lifting weights or work hardening are a focus of treatment. While a few patients respond to this sort of treatment, most are made worse by the increased activity. This does not usually represent malingering or symptom magnification on the patient’s part, but rather the wrong treatment applied to the condition. ]