Upper back and Ribs (thoracic)

Bilateral facet pain suggests what?

Degenerative process

Direction of facet referral pattern?

superior and inferior/lateral

What makes T3–T5 facet pain unique?

Can refer pain to anterior chest wall and can mimic cardiac or rib pain

The superior part of the 1st intercostal nerve (T1) forms…

part of the brachial plexus

the lateral cutaneous branch of the 2nd intercostal nerve (T2) is known as…

intercostal brachial nerve

intercostal brachial nerve supplies…

the floor of the axilla and joins the medial brachial cutaneous nerve to supply the medial side of the arm as far distal as the elbow region

1st/2nd rib syndrome presentation

pain in superior thoracic cage and lateralization into the axilla

• think about T1, T2 nerves and its supply

The cutaneous branches supply…

the skin on lateral and anterior aspect of the thorax and abdomen

the muscular branches of the 7th through 11th intercostals and the subcostal nerve innervate…

abdominal muscles

subcostal nerve supplies…

the skin of abdominal wall, the lateral hip region, and over the iliac crest

Primary functions of thoracic spine

• provides a stable base for muscles to work upon

• protection for intrathoracic organs

• serves as mechanical bellow for breathing

Normal thoracic sagittal plane motion

50-70 degrees

Normal thoracic horizontal/transverse plane motion

30 degrees to each side

Normal thoracic frontal plane motion

25 degrees to each side

Fryett’s First Law

when the spine is in neutral, side bending to one side will be accompanied by horizontal rotation to the opposite side. Type 1 mechanics.

Fryett’s Second Law

when the spine is flexed or extended (not neutral), side bending to one side will be accompanied by rotation to the same side. Type 2 mechanics.

Fryett’s Third Law

when motion is introduced in one plane, it will modify (reduce) in the other two planes

Diaphragm

• primary muscle of respiration, which comprises 70-80% of inspiratory force

• increases longitudinal dimension of the thoracic spine

• indirectly elevates the ribs

What type of joint is the costotransverse joint of the upper ribs (1–7)?

Concave/convex

What type of joint is the costotransverse joint of the lower ribs (8–12)?

Planar

What happens above rib 7?

More rotation

• because its concave/convex meaning more roll and slides

What happens to upper ribs during inspiration?

Rise in sagittal plane (pump handle)

What happens to lower ribs during inspiration?

Widen laterally (bucket handle)

effects of manipulation

• sympathetic response

  • accelerated heart rate

  • bronchial dilation (changes in breathing)

  • release of adrenaline and non-adrenaline

  • inhibits bladder contraction (it relaxes)

C2–C3 facet referral location?

Upper neck/head

C3–C4 facet referral location?

Mid cervical region

C4–C5 facet referral location?

mid neck to upper shoulder

C5–C6 facet referral location?

Top of shoulder

C6–C7 facet referral location?

Lower shoulder/scapular region

How does rib dysfunction referral behave?

Stays on the same side (unilateral)

How does rib pain typically spread?

Wraps around the thorax along the rib

Heart referral pattern?

Left chest, left shoulder, medial left arm, and upper thoracic area

Lung/diaphragm referral pattern?

Neck, upper shoulder (supraclavicular area)

Liver/gallbladder referral pattern?

Right upper abdomen (near epigastric) + right shoulder, below scapula

Stomach referral pattern?

Epigastric region; mid thoracic

Pancreas referral pattern?

Epigastric region + mid back/lower thoracic

Spleen referral pattern?

top of left shoulder

Small intestine referral pattern?

Central abdomen

Colon referral pattern?

Lower abdomen; into sides of hip region

Kidney referral pattern?

Low back/flank(sides)

Ureter referral pattern?

Groin region; inner thigh

Bladder referral pattern?

Suprapubic region; anus

Ovary referral pattern?

central abdomen

Flexion restriction

inability to rotate forward in sagittal plane

causes of flexion restriction

• impaired superior gliding of facets

• reduced anterior translation of the superior vertebral body on the inferior vertebral body

• restricted anterior rotation or internal torsion of the rib joints

• soft tissue restrictions

What motions are limited in unilateral flexion restriction?

• Flexion

• Contralateral rotation

• Contralateral side bending

What soft tissue factor can contribute to unilateral flexion restriction?

Ipsilateral muscle tightness

What joint structure can contribute to unilateral flexion restriction?

Unilateral rib dysfunction; facet dysfunction; vertebrae (lack of lateral translation ipsi)

Extension Restrictions

the inability of the thoracic segment to rotate backward in the sagittal plane

extension restrictions are common in….

upper thoracic spine and cervicothoracic junction (C7-T2)

• increased thoracic kyphosis often present

lower thoracic spine is commonly restricted in which direction?

extension

• tends to have increased lower + mid thoracic spine

fixed thoracic extension restrictions occurs with..

aging; due to disc height degeneration and change in shape and vertebral body

what are some causes of a unilateral extension restriction of a thoracic vertebral body?

• facet joint restriction (can’t glide inferiorly + laterally)

• posteriolateral disc protrusion (blocks movement)

• space-occupying lesion (like disc protrusion or osteophyte)

What motions are limited in unilateral extension restriction?

• Extension

• Ipsilateral rotation

• Ipsilateral side bending

  • tested in this combined motion

where can a rib be dysfunctional?

costotransverse or costovertebral joint articulations

thoracic sprain general presentation

• pain is unilateral (more often than bilateral)

• pain is in a distinct thoracic area without neurological signs

• pain may spread but is non-dermatomal; hard to localize

• pain increases at the end range of one specific motion

  • usually more symptomatic in extension or rotation

  • flexion and side-bending can be compromised as well

• palpable asymmetry of transverse processes in either T/S flexion or extension

• unilateral PAs reproduces symptoms on involved segment

thoracic sprain subacute presentation

• reproduction of pain at end range of one particular movement, with or without OP

• pain with resistance

• less tenderness and stiffness/restrictions than in the acute stage

thoracic sprain chronic presentation

patient’s unilateral symptoms are only reproduced with end range OP in either a combined extension and side bending motion OR a combined flexion and side bending motion

acute care and management of thoracic sprain

• electrical stimulation

• STM

  • primarily to multifidi and rotatores of involved segments

• joint mobs and manips

  • isometric mobs and contract/relax procedures to involved segments to reduce associated multifidi and rotatores muscle gaurding

• therex

  • passive stretching

costcochondritis description

considered a benign cause of chest pain from inflammation of the costochondral or costosternal joints

• diagnosis made through exclusion (meaning when everything else got ruled out, you consider this diagnosis)

costochondritis prevalence

• 30% of people complaining of chest pain

• > 40 years old

Key findings of costochondritis

• asymmetrical rib position

• AP or PA glides of involved rib mobility is limited and painful

• TTP of iliocostalis insertion ad/or intercostal myofascia

• costochondral junction of involved rib is TTP

• localized tenderness corresponding to site of injury

Objective assessment criteria for costochondritis

• pain and tenderness with palpation of costochondral joints (more common at 2-5th junctions)

• tenderness associated with heat, swelling, erythema may be a result of Tietze’s syndrome (rare genetic disorder)

SxS of costochondritis

• Intermittent Anterior chest pain (usually unilateral)

• Insidious onset or after repetitive trauma

• pain w/ trunk movements, deep inspiration (sharp, nagging, aching)

• may have edema

T4 syndrome description

a clinical pattern that involves UE paraesthesia and pain w/or without symptoms into the neck and/or head

• this is a term used to describe a condition with varied problems that seem to be derived from upper thoracic spine

• diagnosis of exculsion

symptoms of T4 syndrome include…

• constant or intermittent upper thoracic pain

  • may be accompanied w/ back stiffness and UE numbness/paresthesia

• numbness and/or paresthesia may be a GLOVE like distribution for one or both forearms/hands (pts say it feels like i’m wearing gloves)

• referred pain to the neck and scapular region

what is the competing diagnosis for T4 syndrome?

TOS

key objective assessment criteria for T4 syndrome

• PA accessory joint mob at T4 reproduces pt’s symptoms

• palpation at rib angles may reproducing symptoms

• observation of trophic changes (i.e. color & temp.)

• (+) ULTT

• radiographs are typically negative

subjective findings of T4 syndrome

• insidious onset

• new activity or physical demand

• hands are hot/cold

• swollen hands

• aches and pain in forearm

• neck or upper thoracic pain

prevalence of T4 syndrome

• unknown

• prone to injury >35 years

Scoliosis prevalence

• 12-14 years old

• 1- 1.4: 1 of females to males (curve <20)

• 5.4:1 of females to males (curve >21)

• R curve most common

scoliosis description

a lateral curve of the spine > than 10 degrees, as measured by the Cobb method on a standing radiograph

idiopathic scoliosis

a curve in the spine with no clear underlying cause

SxS of scoliosis

• back pain (uni- or bi-)

• leaning to one side

objective findings of scoliosis

• cobb angle >10 degrees

• presence of rib hump in forward lumbar spine flexion (on the side of convexity)

• lateral flexion can produce pain

• C or S-shaped curve

• uneven shoulders or hips

• one shoulder blade appears more prominent

• uneven waist, lateral shift

scoliosis severity: mild

cobb angle 10-20 degrees

scoliosis severity: moderate

21-40 degrees cobb angle

scoliosis severity: severe

cobb angle >40 degrees

scoliosis treatment

• stretch concavity

• strengthen convexity

• joint mobility

• HVLAT

  • remote to curvature, not at curvature

who’s likely to have dural type problems (dural entrapment)?

People with meningitis, spinal tap, epidurals (mothers), trauma with scar tissue building up

rib sprain prevalence

• trauma to rib cage

• after illness with a lot of coughing

rib sprain symptoms

• aching or sharp pain in rib cage

• sharp pains with deep breathing, coughing, sneezing, laughing

rib sprain signs

• end range positions cause pain

• pain with palpation to sternocostal, costochondral, and costotransverse joints

• pain at rib angles

• pain at intercostal/myofascia

1st rib dysfunction description

• Joint impairments can be minor, such as lack of mobility, or can be a gross fracture of the rib itself

• Joint impairments often result in upper quadrant symptoms that can be local or radicular

objective assessments criteria for 1st rib dysfunction

• cervical rotation and lateral flexion restriction (in supine or seated)

  • possible 1st rib subluxation

• limited or “blocked” CL cervical spine flexion

• radiographs may be needed to rule out fractures in cases of trauma

• first rib spring test

• cervical rotation lateral flexion test used to assess 1st rib hypomobility

TOS prevalence

• Neurologic 5-10% or vascular 85% origin

• males most affected

TOS symptoms (subjective)

• pain and heaviness in c/s and arms

• paresthesias on medial side

• overhead reach of arms aggravates symptoms

• change in color/temp of hands

• deep, boring toothache-like pain

TOS signs (objective)

• supraclavicular tenderness

• slight weakness of limb

• numbness of medial side

• UE edema, cyanosis, pallor

• + special tests

• MLT deficits of scalenes + pec minor

• entrapment sites - check (could be +)

T/S vertebrae fractures (compression fractures) prevalence

• 2-3 fold increase risk in women >60

• 16% white females

• 5% white males

T/S vertebrae fractures (compression fractures) symptoms

• insidous onset or after trauma

• constant back pain

• history of fracture or osteoporosis

• decrease disc height, PA

  • last two are risk factors for this

T/S vertebrae fractures (compression fractures) signs

• moderate decrease trunk ROM

• pain with palpation over SP