MSK I Unit 7: T-spine and ribs

what makes up the thorax

thoracic vertebrae

ribs

sternum

what is the function of the thorax

stability for the craniocervical region and shoulder girdle

protects vital organs

creates mechanics for breathing

what is the most stable portion of the vertebral column

SI joint

what makes up the upper thoracic spine

T1-T4

what makes up the middle t-spine

T5-T9

what makes up the lower T-spine

T10-T12

what are the properties of the thoracic vertebra body

equal anteroposterior and mediolateral diameters

what increases in the vertebral bodies of the thoracic vertebrae as you move cranially to caudal

height

end plate cross sectional area

bone mass

what are the properties of the spinous process of the thoracic vertebrae

long, slender, and angled obliquely down

what are the properties of the transverse process of the thoracic vertebrae

oriented anteriorly-posterior in frontal plane

what are the articular surfaces of the thoracic vertebrae

costal facets and demifacets (6)

inferior and superior facets

intervertebral facets

what ribs are the typical ribs

3-9

what are the components of typical ribs

head, neck, and tubercle

articular with two vertebrae

what are the Atypical ribs

1,2, 10-12

what are the components of atypical ribs

they articular with one vertebrae at the same level

what is unique about the first rib

it is the most curved and most inferiorly oriented

what does the first rib articulae with

T1 and manubrium

what does the second rib articulate with

T2 and the sternum at the manubriosternal joint

what is unique about the 10th rib

it has a single facet on the head of the rib

what is unique about ribs 11-12

they are the floating ribs as they ack a costotransverse joint

what are the posterior articulations of the ribs

costovertebral/costocorporeal joint

costotransverse joint

what is the costovertebral/costocorporeal joint

the superior and inferior costal demifacets on the vertebrae body of the same level and vertebra superior articulates with the head of the rib

what is the costotransverse joint

the facet on the transverse process articulates with the rib/costal tubercle

what are the anterior articulations of the ribs

the sternocostal joint

where is the true sternocostal joint found

at ribs 2-5

how are the ribs oriented

they are more horizontal at the upper levels then transition more downward obliquely at lower levels

what provides stability for the ribs

capsule

capsular ligaments

radiate ligament

costotransverse ligament

what is the cervicothoracic junction

the transition between mobile, lordotic cervical spine and the relatively stable, kyphotic thoracic spine

where is the location of the cervicothoracic junction and what does it include

C7-T2 including ribs 1 and 2 and the manubrium

what area of the spine is prone to significant stress and compression

the cervicothoracic function

what is CT junction hypomobility linked to

neck pain

headaches

UE/shoulder pain

what does normal mobility of the CT junction reduce

it reduces the demand at the mid and lower cervical spine

what muscles make up the superficial layer of the back (5)

trapezius

latissimus dorsi

rhomboids

levator scapula

serratus anterior

what muscle make up the intermediate layer of the back (2)

serratus posterior superior and inferior

what muscles make up the deep layer of back muscles

the erector spinae group

the transversospinal group

what muscles make up the erector spinae

spinalis

longissimus

iliocostalis

what muscles make up the transversospinal group

semispinalis

multifidus

rotatores

what are the respiratory muscles (7)

diaphragm

sternocostals

intercostals

scalenes

pec maj/min

serratus posterior

SCOM

what do the respiratory muscles influence

the shoulder girdle and cervical spine

what influences the thoracic kinematics

resting posture

apophyseal joint orientation

splinting action of rib cage

heights of IV discs (smallest disc to vertebral body height ratio)

what does decreased mobility of the thoracic spine lead to

increased mechanical stability

what is the normal flexion ROM of the thoracic spine

30-40 degress

what is the normal extension ROM of the thoracic spine

15-20 degrees

what is the normal rotation ROM of the thoracic spine

25-35 degrees

what is the normal lateral flexion ROM of the thoracic spine

25-30 degrees

what occurs at the facets of the thoracic spine with flexion

bilateral upglide

what can limit thoracic flexion (5)

apophyseal capsule

supraspinous ligament

interspinous ligament

posterior longitudinal ligament

anterior annulus fibrosus compression

where is there more flexion in the thoracic spine

the more caudal regions because of the floating ribs

what occurs to the ribs with thoracic flexion

anterior roll of rib head

what occurs at the facets with thoracic extension

bilateral facet downglide

what can limit thoracic extension (5)

apophyseal joint approximation

supraspinous processes

laminae

anterior longitudinal ligament

posterior annulus fibrosus compression

what occurs to the ribs with thoracic extension

rib heads roll posteriorly

inferior glide at costotransverse joint

what occurs at the facets with rotation at the upper thoracic region

ipsilateral downglide and contralateral upglide

what occurs with rotation at the facets of the mid-lower thoracic joints

ipsilateral gap

contralateral compression

why does thoracic rotation decrease in the lower regions

the facets become more vertical limiting rotation

what occurs at the facets of the thoracic vertebrae with lateral flexion

ipsilateral downglide and contralateral upglide

what limits lateral flexion of the thoracic vertebrae (4)

rib attachments

intertransverse ligament

approximation of ipsilateral facets

capsule of contralateral factes

what ribs joints allow motion and when

the costotransverse and costovertebral allow motion in relation to spinal movement and ventilation

what 5 articulations move and change the shape of the thorax during respiration

manubriosternal

sternocostal

interchondral

costotransverse

costovertebral

what occurs at the ribs during inspiration

the shafts of the rib elevate perpendicular to the axis of rotation between the costotransverse and costovertebral joints to increase intrathoracic volume

what occurs to the ribs during expiration

the muscles of inspiration relax and allow joints to return to resting position

what pleuritic conditions can cause thoracic pain (4)

pulmonary embolism

pericarditis

pleurisy

tracheabronchial pain

what pulmonary conditions can cause thoracic pain (2)

pleuritis

pulmonary embolism

what cardiac conditions can cause thoracic pain (5)

MI

aortic dissection

pericarditis

angina

mitral valve prolapse

what GI conditions can cause thoracic pain (4)

esophageal disorders

peptic ulcer disease

cholecystitis

pancreatitis

what renal conditions can cause thoracic pain (2)

nephrolithiasis (kidney stones)

acute pylenephritis

what chest wall conditions can cause thoracic pain (3)

herpes zoster

intercostal neuralgia

nerve entrapment

what viscerogenic conditions can cause thoracic pain (5)

neoplasms such as:

mediastinal tumor

metastatic lesions

pancreatic cancer

breast cancer

multiple myeloma

where are spinal fractures common

Thoracic (T1-T9)

thoracolumbar junction (T10-L2)

what are the red flags for a spinal fracture (4)

age over 50

osteoporosis

corticosteroid use

trauma

what is the osteoporotic compression fracture test cluster (5)

age over 52

no leg pain

BMI over 22

sedentary

female

how can visceral pain be screened

it tends to be vague and dull

can be accompanied by nausea and sweats

what are somatic condtions

cervical facet joint, muscles, and disc disorders

what should be included in the systems review for the thoracic spine

an examination of potential systemic disorders and MSK conditions that can refer pain there

what S/S may indicate an infection (5)

fever

night swears

underlying disease

penetrating wound

TB

what S/S may indicate a thoracic tumor (7)

history of cancer

age over 50

no improvement with treatment

unexplained weight loss

pain at multiple sites

pain at rest

night pain

what are mechanical conditions that can cause acute thoracic pain (^)

discogenic pain

disc protrusion

zygapophyseal joint pain

rib dysfunctions

muscle imbalances

postural deviations

if there is no MOI with thoracic pain what should be screeed

disease process

what does pain with respiration indicate

rib dysfunction or pleuritic pain

what does pain with coughing, sneezing, and deep inspiration indication

costovertebral joint involvement

what does pain with physical exertion indicate

the cardiopulmonary system needs to be cleared

how does thoracic neuropathic pain present

shooting, burning, and stabbing following sloping band along an intercostal space

what should be assessed in the cervical spine objective exam with thoracic pain (7)

Posture

AROM/POM

PIVM

Spurlings

Cervical distraction test

palpation

ULND if UE symptoms present

what objective exam tests should be done in the shoulder with thoracic pain (6)

posture

AROM/PROM

MMT

palpation

functional test/movement analysis

what should be assessed in a postural inspection for the thoracic spine (5)

symmetry of the thorax and rib cage

excessing of flattening spinal curves

Shoulder and scapular symmetry

muscle tone

integumentary

what are the ICF diagnoses for the thoracic spine (6)

thoracic mobility deficits

thoracic mobility deficits with UE referred pain

thoracic mobility deficits with neck pain

thoracic mobility deficits with shoulder pain

thoracic mobility deficits with low back pain

thoracic clinical instability

what are mobility deficits of the thoracic spine

impairments of facet joints and/or surrounding periarticular soft tissue

what can cause further stiffening of the thoracic spine

postural stress

overuse stress

injury

what population are thoracic mobility deficits seen

individuals who sit more than 7 hours a day and participate in less than 150 minutes of PA/wk

what are the pathoanatomical diagnoses associated with thoracic mobility deficits (2)

spondylosis

spran/strain

what is spondylosis

gradual progression of age related changes and/or adaptive shortening of connective tissue and periarticular soft tissue

what should be screened out with thoracic mobility deficits *6)

neoplastic conditions

inflammatory conditions

spinal infection

cardiopulmonary conditions

spinal/vertebral fracture

cervical myelopathy

what is often reported with thoracic mobility deficits in the subjective exam (7)

central or unilateral symptoms

possible referred pain along ribs and into UE

dull ache at rest that becomes sharp with movement

waking up painful/stiff and increased pain with inactivity

symptom reproduction with movements that load facets/tissues

ease of symptoms with changing position, progressive thoracic spine movement, and activity

pain with sleeping if high irritability

what will be reported for spondylosis

gradual onset with progressive worsening and mobility loss

what is reported in the subjective exam with a facet or ligament sprain/strain or a facet capsule entrapment

acute onset after recent unguarded/awkward movements or position with immediate onset of pain and loss of mobility

progressive onset with repetitive posture loading

what is reported in the subjective exam with a muscle strain

occurs after new/unaccustomed/overload activity

immediate pain onset

pain with contraction, stretch, and palpation

what is reported in the subjective exam with a rib dysfunction

costotransverse/costovertebral joints

pain with deep breathing

symptoms may be referred along the rib angle

what is seen in ROM and joint mobility with thoracic mobility deficits (3)

limited AROM with symptoms consistently at end range

symptoms with overpressure and/or combined motions

hypomobile joint mobility with local and/or somatic referred pain

what is seen in muscle performance testing with thoracic mobility deficits (2)

weak periscapular muscles, and deep neck flexor/extensors

tight pec/anterior chest, upper trap, scalenes, and suboccipitals

what is seen in neural testing of thoracic mobility deficits

no UE radicular symptoms

negative ULTT