Pathoanatomical Causes of Thoracic Pain

possible indications of red flags of thoracic pain

spinal metastases, infection, vertebral fractures, rib fractures, costochondritis, ankylosing spondylitis, thoracic disc herniation, T4 syndrome, CRPS

cancers that metastasize to the thoracic region/SC

breast, lung, colon, prostate

risk factors of thoracic pain that could be cancer

history of cancer, age above 50, unexplained weight loss, failure of conservative treatment

causes of infection in the spinal cord

osteomyelitis, diskitis, epidural infection

what to do if you suspect a spinal cord infection

refer because pt will need IV drugs

causes of vertebral fractures

traumatic and osteoporotic

characteristics of osteoporotic vertebral fractures

spontaneous, often asymptomatic and found incidentally on a CXR, pain occurs in lumbar region

classification of thoracolumbar vertebral fractures from mild to severe

compression → burst → seat-belt type → dislocation

what is the only stable vertebral fracture

compression

benefits of MRIs

differentiate between acute and chronic, differentiate between benign and malignant, evaluate neural compromise

best imaging to evaluate fractures

CT scan

causes of rib fractures

blunt force trauma, direct force to small area, violent muscle contraction

treatment of rib fractures

rest, ice, NSAIDs, rib belt

cause of rib stress fractures

overuse from trunk taking on more work capacity than arms and legs

signs of rib stress fracture

localized pain, pain with deep breathing and UE lifting

risk factors of rib stress fracture

low calcium and vitamin d, amennorrhea, low bone density, ED, high training volume with poor biomechanics

recovery timeframe of rib stress

heals in 4-6 weeks and RTS in 8-12 weeks

treatment of rib stress fractures

rest while healing and PT to address muscle imbalances and core strength that may be contributing to thoracic stress

sport with most rib fractures

rowing

typical location of costochondritis

ribs 2-5

signs of costochondritis

achy/sharp pressure in chest, long lasting pain, pain with movement and breathing, TTP

tietze’s syndrome

costochondritis of 1 joint with palpable swelling

causes of costochondritis

mostly idiopathic but can also be from direct blow, surgery, upper respiratory infection

what should also be evaluated in a pt with costochondritis who is above age 35

ECG to assess possible CAD or pneumothorax

treatment of costochondritis

impairment based (manips, taping, stretching, STM, acupuncture, injections, diaphragmatic breathing)

signs of ankylosing spondylitis

morning stiffness, pain better with exercise, awakening from pain later in the night, alternating buttock pain

exam findings that could lead to ankylosing spondylitis diagnosis

global loss of ROM, thoracic kyphosis, paraspinal muscle spasms, limited chest expansion

what should be included in treatment program for ankylosing spondylitis

breathing exercises, trunk endurance and functional exercises, energy conservation techniques, maintenance of ROM

medications for ankylosing spondylitis

NSAIDs → corticosteroids and DMARDs → tumor necrosis inhibitor therapy

signs of thoracic disc herniation

mostly asymptomatic, thoracic midline pain, radiculopathy/myelopathy sxs

how is thoracic disc herniation diagnosed

MRI

treatment of thoracic disc herniation

rest, anti-inflammatories, injections, PT (surgery is rare)

results of surgery of thoracic disc herniation

high chance of resolution of pain, hyperreflexia, and spasticity

symptoms of T4 syndrome

upper back/arm/head pain, glove-like distribution of numbness, intrinsic weakness, UE coldness, skin crawling sensation

exam findings of T4 syndrome

pressing on T3/T4 recreates sxs, positive neural tension test, kyphotic posture, TPs in shouler and upper trap

treatment of T4 syndrome

manipulation of T4, STM, stretching, postural exercises, injections

cycle of CRPS

injury → pain impulse causes increase in sympathetic response → causes vessel dilation and spasm → increases pain

how can joint manipulations help CRPS

relieve mechanical pressure (caused by hypomobility) in the area of the sympathetic chain ganglia

early treatment of CRPS

desensitization, edema management, gentle therapeutic exercises, nerve glides

location of thoracic facet pain referral

intrascapular (possible unilateral glove paresthesia and headaches)

treatment of facet joint pain

manipulations, medial branch blocks, ablation