Unit 7 - Thoracic Spine and Ribs

The Thorax Consists of…

• Rigid Rib Cage

• Thoracic Vertebrae

• Sternum

Rigidity provides:

• Stable base for muscles to control craniocervical region

• Protection for intrathoracic organs

• Mechanical bellows for breathing

Thoracic Articulations

• 24 Apophyseal Joints (12 pairs)

• Costocorporeal Joints

• Costotransverse Joints

24 Apophyseal Joints (12 pairs)

• Mild forward slope in frontal plane

• 15-25 degrees from vertical (65-75 from horizontal)

• Limited by immobility of costocorporeal and costotransverse joints (rib attachments)

• Ribs indirectly attach thoracic vertebrae to fixed sternum

Costocorporeal Joints

• Connect Head of Rib to Vertebral Body via demifacets

• Slightly ovioid with capsule and radiate ligaments

• Intervenes with adjacent Disc

Costotransverse Joints

• Articular Tubercle of most ribs to costal facet of transverse process of same T-vertebra

• Synovial joint —> capsule

• Costotransverse Ligament attaches neck of rib to transverse process of same T-vertebra

• Superior Costotransverse Ligament stabilizes by attaching superior neck of one rib to inferior margin of transverse process of above T-vertebra

• Ribs 11 & 12 lack these joints (“Floating”)

Thoracic Region

• Second only to sacroiliac joints as most mechanically stable portion of vertebral column

  • Attachments of thoracic vertebrae to rib cage to sternum

Thoracic Kinematics: Influenced by…

• Resting posture of region

• Orientation of apophyseal joints

• “Splinting” action of rib cage

• Relative heights of intervertebral discs

  • Smallest disc-to-vertebral body height ratio

Thoracic Kinematics: Decreased Mobility —>

Increased Mechanical Stability

Kinematics: Flexion

• 30-40 degrees

• Bilateral Facet Upglide (slide)

• Limited by:

  • Apophyseal joint capsule

  • Supraspinous ligaments

  • Interspinous ligaments

  • Posterior Longitudinal Ligament

  • Compression of anterior Annulus Fibrosus

• > Movement in caudal regions

  • Free-floating ribs 11 & 12

Kinematics: Extension

• 15-20 degrees

• Bilateral Facet Downglide (slide)

• Limited by:

  • Apophyseal joint approximation

  • Supraspinous Processes

  • Laminae

  • Anterior Longitudinal Ligament

  • Compression of posterior Annulus Fibrosus?

• Arthrokinematics same as Mid-Cervical region

Kinematics: Axial Rotation

• 25-30 degrees in horizontal plane

  • Cumulative throughout region

  • Very little slide at each facet

• Freedom of Axial Rotation decreases in lower regions

  • Orientation of Facets becomes more vertical and shift toward sagittal plane orientation

Kinematics: Lateral Flexion

• 25-30 degrees in region

• 45 degree thoracolumbar arc

• Ipsilateral downglide of inferior facet of superior vertebra ON superior facet of inferior vertebra; opposite for contralateral

• Limited by

  • Rib attachments

  • Intertransverse ligament

  • Approximation of ipsilateral facets

  • Joint capsule of contralateral facets

Pathoanatomy: Thoracic Spine Mobility Deficits

What is the proposed underlying cause for mobility deficits?

• Spondylosis

• Sprain/strain

Pathoanatomy: Thoracic Spine Mobility Deficits

What is the proposed underlying cause for mobility deficits?

Spondylosis

• Gradual progression of age-related joint changes

• Adaptive shortening of the joint connective tissue and periarticular soft tissue

Pathoanatomy: Thoracic Spine Mobility Deficits

What is the proposed underlying cause for mobility deficits?

Sprain/strain

• Acute onset sudden awkward movement

• Gradual onset repetitive postural loading

• Muscle strain and/or ligament sprain

Medical Screening: Thoracic Spine Mobility Deficits

What other conditions should be considered with this patient presentation?

Viscerogenic

• Neoplastic conditions

• Inflammatory or systemic disease

• Spinal infection

• Cardiopulmonary conditions

Medical Screening: Thoracic Spine Mobility Deficits

What other conditions should be considered with this patient presentation?

Neuromusculoskeletal

• Spinal fracture

• Cervical myelopathy

Differential Diagnosis: Thoracic Spine Mobility Deficits

What other conditions should be considered with this patient presentation?

Neuromusculoskeletal

• Neck pain with mobility deficits

• Neck pain with movement coordination deficits

• Neck pain with radiating pain

• Thoracic movement coordination impairments

• Thoracic outlet

Subjective Examination: Thoracic Spine Mobility Deficits

What system, structure, pain mechanism, and phases of healing are unique to this patient presentation?

• System

  • Neuromusculoskeletal

• Structure

  • Zygapophyseal joint and periarticular soft tissue

• Pain mechanism

  • Nociceptive

• Phase of healing

  • Muscle strain 2-4 weeks, ligament sprain and cartilage injuries 10-12 weeks

Subjective Examination: Thoracic Spine Mobility Deficits

What are common subjective reports for patients with mobility deficits?

General symptoms

• Central or unilateral symptoms

• Possible somatic referred along the ribs and into the upper extremity (T4 syndrome)

• Dull ache at rest that becomes sharp with movement

Subjective Examination: Thoracic Spine Mobility Deficits

What are common subjective reports for patients with mobility deficits?

Spondylosis

Gradual onset with progressive loss of motion

Subjective Examination: Thoracic Spine Mobility Deficits

What are common subjective reports for patients with mobility deficits?

Sprain/strain

• Immediate onset of pain and loss of motion

• Recent unguarded/awkward movement or position

• Progressive onset with repetitive postural loading

Subjective Examination: Thoracic Spine Mobility Deficits

What are common subjective reports for patients with mobility deficits?

Aggravating factors

• Dull ache and stiffness with inactivity

• Symptoms reproduced with active movements

Subjective Examination: Thoracic Spine Mobility Deficits

What are common subjective reports for patients with mobility deficits?

Easing factors

• Staying active and changing positions

• Progressive thoracic spine movement

Subjective Examination: Thoracic Spine Mobility Deficits

What are common subjective reports for patients with mobility deficits?

24-hour pain behavior

• Morning

  • May have pain and stiffness that upon waking that eases with activity and movement

• Noon to evening

  • Symptoms may vary throughout the day depending on the patient’s activities, may have increased pain and stiffness after being sedentary

• Night

  • Symptoms may disrupt sleep with changing positions depending on symptom irritability

Objective Examination: Thoracic Spine Mobility Deficits

What are the key examination procedures for patients with mobility deficits?

Systems Review: Cardiopulmonary

• Vitals – BP, HR, auscultate

• Assess for mechanical reproduction of symptoms and/or adverse response to movement

  • AROM, PIVM, compression/distraction

Objective Examination: Thoracic Spine Mobility Deficits

What are the key examination procedures for patients with mobility deficits?

Systems Review: Neuromusculoskeletal

• Reflexes/pathological reflexes

• Dermatomes/myotomes

Objective Examination: Thoracic Spine Mobility Deficits

What are the key examination procedures for patients with mobility deficits?

Movement and provocation examination

• Cervical clearing examination

• Neurodynamic testing

• Active range of motion

• Passive intervertebral motion (PIVM)

Objective Examination: Thoracic Spine Mobility Deficits

What are the key examination procedures for patients with mobility deficits?

Cervical clearing examination

• Active range of motion

• Passive intervertebral motion

Objective Examination: Thoracic Spine Mobility Deficits

What are the key examination procedures for patients with mobility deficits?

Neurodynamic testing

ULTTA/ULND1

Objective Examination: Thoracic Spine Mobility Deficits

What are the key examination procedures for patients with mobility deficits?

Active range of motion

• Thoracic range of motion limitations and symptom provocation consistently reproduced at end range

• Symptom provocation with the addition of overpressure and/or combined motions

Objective Examination: Thoracic Spine Mobility Deficits

What are the key examination procedures for patients with mobility deficits?

Passive intervertebral motion (PIVM)

• Hypomobility throughout the thoracic spine and ribs

• Hypomobility of the involved segment(s) with local and/or somatic referred symptom reproduction

Objective Examination: Thoracic Spine Mobility Deficits

What are the key examination procedures for patients with mobility deficits?

Muscle performance examination

• Muscle coordination, endurance, strength, and length testing

• Palpation

Objective Examination: Thoracic Spine Mobility Deficits

What are the key examination procedures for patients with mobility deficits?

Muscle coordination, endurance, strength, and length testing

• Deep neck flexors/extensors, middle/lower trapezius, rhomboids, serratus anterior

• Upper trapezius, levator scapulae, scalenes, suboccipitals, SCM, pec minor/major

Objective Examination: Thoracic Spine Mobility Deficits

What are the key examination procedures for patients with mobility deficits?

Palpation

Palpation of the cervicothoracic musculature may reveal active or latent myofascial trigger points and increase resting tone

Interventions: Thoracic Spine Mobility Deficits

What are interventions recommended for mobility deficits?

• Education

• Exercise

• Manual therapy

Interventions: Thoracic Spine Mobility Deficits

What are interventions recommended for mobility deficits?

Education

Active lifestyle and general exercise including aerobic and strength training

Interventions: Thoracic Spine Mobility Deficits

What are interventions recommended for mobility deficits?

Exercise

• Exercises that promote range of motion and mobility of the cervicothoracic spine and ribs

• Impairment-based approach to address cervicoscapulothoracic mobility, flexibility, endurance, neuromuscular control, and strength

Interventions: Thoracic Spine Mobility Deficits

What are interventions recommended for mobility deficits?

Manual therapy

Mobilization and manipulation of the cervicothoracic spine and ribs

Regional Interdependence: Thoracic Spine Mobility Deficits

What other conditions respond favorably to treatment in the thoracic spine?

• “Impairments in one region of the body can influence the musculoskeletal system and neuromuscular function and in symptoms in other, remote region of the body

• Biomechanical and anatomical relationships

  • “Kinetic chain”

• Regional neurophysiological effects

Regional Interdependence: Thoracic Spine Mobility Deficits

What other conditions respond favorably to treatment in the thoracic spine?

Thoracic mobility impairments with shoulder pain

• Mobility of the thoracic spine is necessary for full; shoulder range of motion

• Mechanisms of manual therapy in neurophysiologic effect that may help explain

  • Mintken et al. CPR 3/5 (+LR 5.3, 61% to 89%)

  • Pain free shoulder flexion <120*, shoulder internal rotation <53* at 90* abduction, not taking medications for shoulder pain, and symptoms <90 days

Regional Interdependence: Thoracic Spine Mobility Deficits

What other conditions respond favorably to treatment in the thoracic spine?

Thoracic mobility impairments with neck pain

• Thrust and non-thrust cervicothoracic manipulation combined active cervicothoracic range of motion exercises

• Impairment-based approach

Interventions: Thoracic Spine Mobility Deficits

When should we consider interprofessional or intraprofessional referral and what are other treatment options?

• Imaging

• Medications/injections

Interventions: Thoracic Spine Mobility Deficits

When should we consider interprofessional or intraprofessional referral and what are other treatment options?

Imaging

In the absence of red flag signs and for those classified as low risk, imaging is not indicated

Interventions: Thoracic Spine Mobility Deficits

When should we consider interprofessional or intraprofessional referral and what are other treatment options?

Medications/injections

• NSAIDs

• Facet joint injections

• Radiofrequency ablation

Pathoanatomy: Thoracic Outlet Syndrome

What is the proposed underlying cause for thoracic outlet?

Neurovascular entrapment

• Three sites of compression

  • Subclavian artery and lower roots between the anterior and middle scalene

  • Subclavian artery and vein and lower trunk in the costoclavicular space

  • Axially artery and vein and cords in subcoracoid tunnel

    

Pathoanatomy: Thoracic Outlet Syndrome

What is the proposed underlying cause for thoracic outlet?

Classification

• Vascular thoracic outlet; arterial TOS (aTOS)

• Vascular thoracic outlet; venous TOS (vTOS)

• Neurogenic thoracic outlet; true neurologic TOS (tnTOS)

• Neurogenic thoracic outlet; symptomatic TOS (sTOS)

Pathoanatomy: Thoracic Outlet Syndrome

What is the proposed underlying cause for thoracic outlet?

Vascular thoracic outlet; arterial TOS (aTOS)

Compression of the subclavian-axillary artery

Pathoanatomy: Thoracic Outlet Syndrome

What is the proposed underlying cause for thoracic outlet?

Vascular thoracic outlet; venous TOS (vTOS)

Compression of the subclavian-axillary vein

Pathoanatomy: Thoracic Outlet Syndrome

What is the proposed underlying cause for thoracic outlet?

Neurogenic thoracic outlet; true neurologic TOS (tnTOS)

Traction or compression injury to the brachial plexus

Pathoanatomy: Thoracic Outlet Syndrome

What is the proposed underlying cause for thoracic outlet?

Neurogenic thoracic outlet; symptomatic TOS (sTOS)

Repetitive compression and tensioning causing neural irritation of the brachial plexus

Pathoanatomy: Thoracic Outlet Syndrome

What is the proposed underlying cause for thoracic outlet?

Double crush syndrome

• Nerve entrapment that occurs at multiple sites

  • Cervical, thoracic outlet, elbow, forearm, and wrist

Medical Screening: Thoracic Outlet Syndrome

What other conditions should be considered with this patient presentation?

Viscerogenic

• Neoplastic conditions

• Inflammatory or systemic disease

• Cardiopulmonary conditions

• Vascular occlusion

Medical Screening: Thoracic Outlet Syndrome

What other conditions should be considered with this patient presentation?

Neuromusculoskeletal

• Spinal fracture

• Cervical myelopathy

Differential Diagnosis: Thoracic Outlet Syndrome

What other conditions should be considered with this patient presentation?

Neuromusculoskeletal

• Neck pain with mobility deficits

• Neck pain with movement coordination deficits

• Neck pain with radiating pain

• Thoracic mobility deficits

• Rotator cuff related shoulder pain

• Medial epicondalgia

• Ulnar nerve palsy

Subjective Examination: Thoracic Outlet Syndrome

What system, structure, pain mechanism, and phases of healing are unique to this patient presentation?

• System

  • Neuromusculoskeletal, vascular

• Structure

  • Brachial plexus, subclavian-axillary artery and vein

• Pain mechanism

  • Neuropathic, nociceptive

• Phase of healing

  • Nerve 2-3mm/day

Subjective Examination: Thoracic Outlet Syndrome

What are common subjective reports for patients with thoracic outlet?

Vascular: Arterial

• Upper extremity fatigue/paresthesia with the use of the arm

• Cold sensitivity or Raynaud’s

Subjective Examination: Thoracic Outlet Syndrome

What are common subjective reports for patients with thoracic outlet?

Vascular: Venous

• Upper extremity pain, venous engorgement and edema

• Cyanosis and fatigability

• Feeling of stiffness

Subjective Examination: Thoracic Outlet Syndrome

What are common subjective reports for patients with thoracic outlet?

Neurogenic: Symptomatic

• Pain and paresthesia commonly in the ulnar distribution

• Provoked with repetitive use of the upper extremity and positioning arm above shoulder height

Subjective Examination: Thoracic Outlet Syndrome

What are common subjective reports for patients with thoracic outlet?

Neurogenic: True neurologic

• Pain and paresthesia in the neck chest and upper extremity

• Weakness and numbness in the distribution of the involved neural structure

Subjective Examination: Thoracic Outlet Syndrome

What are common subjective reports for patients with thoracic outlet?

24-hour pain behavior

• Morning

  • May have pain, paresthesia, edema, stiffness that upon waking

• Noon to evening

  • Symptoms may vary throughout the day depending on the patient’s activities, may have increased symptoms with overhead activities

• Night

  • Symptoms may disrupt sleep with changing positions depending on symptom irritability and sleeping position

Objective Examination: Thoracic Outlet Syndrome

What are the key examination procedures for patients with thoracic outlet?

Systems Review: Cardiopulmonary

• Vitals – BP, HR, auscultate

• Visual inspection and palpation

Objective Examination: Thoracic Outlet Syndrome

What are the key examination procedures for patients with thoracic outlet?

Systems Review: Neuromusculoskeletal

• Reflexes/pathological reflexes

• Dermatomes/myotomes

Objective Examination: Thoracic Outlet Syndrome

What are the key examination procedures for patients with thoracic outlet?

Movement and provocation examination

• Cervical clearing examination

• Shoulder examination

• Neurodynamic testing

• Thoracic spine and ribs

Objective Examination: Thoracic Outlet Syndrome

What are the key examination procedures for patients with thoracic outlet?

Cervical clearing examination

• Active range of motion

• Passive intervertebral motion

• Spurling A & distraction test

Objective Examination: Thoracic Outlet Syndrome

What are the key examination procedures for patients with thoracic outlet?

Shoulder examination

• Active range of motion

• Passive range of motion

Objective Examination: Thoracic Outlet Syndrome

What are the key examination procedures for patients with thoracic outlet?

Neurodynamic testing

• ULND test 1/ULTTA

• ULND test 2/ULTTB

• ULND test 3/ULTTC

Objective Examination: Thoracic Outlet Syndrome

What are the key examination procedures for patients with thoracic outlet?

Thoracic spine and ribs: Active range of motion

• Inhalation/exhalation

• Thoracic and rib range of motion limitations

Objective Examination: Thoracic Outlet Syndrome

What are the key examination procedures for patients with thoracic outlet?

Thoracic spine and ribs: Passive intervertebral motion (PIVM)

• Hypomobility throughout the thoracic spine and ribs

• Hypomobility and symptom relief with first rib depression

Objective Examination: Thoracic Outlet Syndrome

What are the key examination procedures for patients with thoracic outlet?

Muscle performance examination

• Muscle coordination, endurance, strength, and length testing

• Palpation

Objective Examination: Thoracic Outlet Syndrome

What are the key examination procedures for patients with thoracic outlet?

Muscle coordination, endurance, strength, and length testing

• Deep neck flexors/extensors, middle/lower trapezius, rhomboids, serratus anterior

• Upper trapezius, levator scapulae, scalenes, suboccipitals, SCM, pec minor/major, and diaphragm

Objective Examination: Thoracic Outlet Syndrome

What are the key examination procedures for patients with thoracic outlet?

Palpation

• Cervicothoracic musculature may reveal active or latent myofascial trigger points and increased resting tone

• Supra- and infra- clavicular spaces may present with tenderness, tone or muscle spasm and symptom reproduction

Objective Examination: Thoracic Outlet Syndrome

What are the key examination procedures for patients with thoracic outlet?

Orthopaedic examination tests

• Adson’s (+LR 3.29, -LR 0.27)

• Roos (+LR 1.2, -LR 0.53)

• Hyperabduction – pulse (+LR 1.49, -LR 0.56)

• Hyperabduction – symptoms (+LR 0.69, -LR 0.34)

• Tinel sign – supraclavicular space (+LR 1.04, -LR 0.96)

Adson’s Maneuver

Roos Stress Test

Hyperabduction Test

Tinel Sign

• It is performed by lightly tapping (percussing) over the nerve to elicit a sensation of tingling or "pins and needles" in the distribution of the nerve.^[3]

• The Tinel sign is elicited by the percussion of an injured nerve trunk at or distal to the site of the lesion.

• Positive test: The test is positive when a tingling or prickling sensation is felt in the distribution of the nerve.

• Sign indicates nerve regeneration.

Objective Examination: Thoracic Outlet Syndrome

What are the key examination procedures for patients with thoracic outlet?

Diagnostic test-item cluster

• 5/5 (+LR 5.25, -LR 0.19)

  • Adson’s

  • Roos

  • Hyperabduction – pulse

  • Hyperabduction – symptoms

  • Tinel signs (supraclavicular space)

Interventions: Thoracic Outlet Syndrome

What are interventions recommended for thoracic outlet?

• Education

• Exercise

• Manual therapy

Interventions: Thoracic Outlet Syndrome

What are interventions recommended for thoracic outlet?

Education

• Active lifestyle and general exercise including aerobic and strength training

• Temporary reduction of repetitive overhead movements

• Sleep hygiene, nutrition, stress reduction

• Diaphragmatic breathing

• Edema management

Interventions: Thoracic Outlet Syndrome

What are interventions recommended for thoracic outlet?

Exercise

• Exercises that promote range of motion and mobility of the cervicothoracic spine and ribs

• Impairment-based approach to address cervicoscapulothoracic mobility, flexibility, endurance, neuromuscular control, and strength

Interventions: Thoracic Outlet Syndrome

What are interventions recommended for thoracic outlet?

Manual therapy

• Mobilization and manipulation of the cervicothoracic spine and ribs

• Upper quarter nerve mobilization procedures

Interventions: Thoracic Outlet Syndrome

When should we consider interprofessional or intraprofessional referral and what are other treatment options?

• Imaging

• Medical Interventions

Interventions: Thoracic Outlet Syndrome

When should we consider interprofessional or intraprofessional referral and what are other treatment options?

Imaging

• Electromyography/nerve conduction

• Magnetic Resonance Imaging (cervical)

• Magnetic Resonance Angiography

• Venography

• Doppler ultrasound

• Brachial plexus block

• Chest x-ray

Interventions: Thoracic Outlet Syndrome

When should we consider interprofessional or intraprofessional referral and what are other treatment options?

Medical Interventions

• Medications/injections

  • NSAIDs, muscle relaxants

  • SSRIs/SNRIs, antiepileptics

  • Botulinum toxin injections

  • Anticoagulants

• Surgical

  • Decompression