Thoracic Examination

Welcome to Temple University's Evidence-Based Practice project. This project was created by and for the students at Temple University in Philidelphia, and is part of the Orthopaedic curriculum. Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!!

Let me know if you need any assistance.Be the first to edit this page and have your name permanently included as the original editor, see the editing pages tutorial for help.

Original Editor - Your name will be added here if you created the original content for this page. Lead Editors - Your name will be added here if you are a lead editor on this page.  Read more.

Subjective

Primary thoracic spine pain disorders comprise approximately 15% of all back/spine complaints. Compared to cervical and lumbar spine, the research is lacking for the thoracic spine. As a result there is less evidence available for the evaluation and management of thoracic spine disorders. What follows is an outline of a musculoskeletal examination for patients with primary thoracic spine disorders. Where evidence from the peer-reviewed literature is utilized, however more research is required for this region.

Patient Intake

Self report
The following are guiding questions that the clinician should consider to assist with formulating initial hypothesis as to the nature of the patient’s disorder.

• What is the patient’s profile? Age, gender, occupation, hobbies.
• What is the patient’s chief complaint: Symptoms could include pain, stiffness, weakness, or neurological symptoms.
• What is the area of the patient’s symptoms? A pain body diagram is useful
• What is the behavior of the patient’s symptoms?
  
• What are the aggravating and easing factors?
  
• Do dynamic or static activities alter symptoms?
  
• What is the duration of the symptoms?
  
• What is the 24-hour behavior of the symptoms?
• What is the history of the present condition?
• Is the injury from trauma or over use?
• What is the patient’s past medical history? A medical screening form is useful to collect this data.
  
  

Performance‐based outcome measures

There are no validated region specific outcome tools for the thoracic spine, the following are recommended but require validation for use with patients with primary thoracic disorders:

• Neck Disability Index (NDI) for upper thoracic complaints
• Oswestry Disability Index (ODI) for lower thoracic complaints
  
• Numeric Pain Rating Scale (NPRS) where patient is able to rate their pain on a scale of 0 (none) to 10 (severe).
• Patient Specific Functional Scale (PSFS) can be used to measure activity limitations and used to compare progress from the baseline measurement.
  
  

Region‐specific historical examination

The thoracic area is a common place for the cervical spine to refer symptoms, a screening examination of the cervical spine including assessing for previous neck pain or neck trauma is necessary to rule-out cervical spine involvement.
Wainner and Fritz developed questions to help determine if the patient has a cervical radiculopathy;

• “Do neck movements improve your symptoms?” If yes there is a positive likelihood ratio (+LR) of 2.2, if no there is a negative likelihood ratio (-LR) of .50.
  
• “Where is the pain most bothersome?” With the answer “shoulder/scapula area” has a +LR 2.3.

Using a pain diagram and follow up questioning the examiner should begin to differentiate, as best as possible, if the disorder involves the upper or lower thoracic spine, as well as, vertebral or rib pain.

See the special questions below to rule out red flag disorders for the thoracic spine region.

Special Questions

The use of a medical screening form is recommended to gather important data on the patient’s past medical history and to begin screening for the presence of red flags.

Red Flags

• Thoracic spine pain and visceral pain can mimic one and other due to the shared afferent innervation of the ANS sympathetics, which originate from T1-L2 afferents from the spinal cord.
  
• Segments T4-T7 have the potential to cause pseudoanginal pain as well as symptoms generated by a cough, sneeze, deep breath, movement of the trunk, palpation, and compression.
• Other potential red associated with thoracic spine pain are listed the following charts:
  

Cardiac Ischemia	Dissecting thoracic aneurysm	Peptic Ulcer	Cholecystitis	Renal Infection and Kidney Stones
- History of risk factors for CAD, MI - Angina - Nausea	- Sudden, severe and unrelenting chest pain that can radiate to the upper back. - Unrelieved with laying down.	- Boring pain from epigastric area to middle thoracic spine. Triggered or relived with meals. - History of NSAID use. - Perforated ulcer can refer pain to shoulder with irritation of the diaphragm.	- Right upper quadrant and scapular pain. Fever, nausea and vomiting. 1-2 hours after a fatty meal.	- Renal colic/flank pain. - Fever, nausea, and vomiting. - Increased risk for kidney infection with ongoing UTI.

Fracture	Neoplastic Conditions	Inflammatory Disorders	Inflammatory or Systemic Disease
- Traumatic: blunt trauma or injury. - Compression Fractures: Caucasian race, history of smoking, early menopause, thin body build, sedentary lifestyle, steroid treatment, and excessive consumption of caffeine or alcohol. - Acute thoracic pain from trivial strain or trauma in males or females > 60 years.	- Age over 50 years. - Previous history of cancer. - Unexplained weight loss. - Constant pain, no relief with bed rest. - Night pain.	- Ankylosing Spondylitis:limited chest expansion, less <2.5 cm measured at nipple line. - Sacroilitis. - Morning pain and stiffness. - Peripheral joint involvemnt. - HLA-B27	- Temperature > 100° - Blood Pressure >160/95mmHg - Resting Pulse > 100 bpm. - Resting Respiration > 25 bpm. - Fatigue. - Osteomyelitis, diskitis, epidural infection, pericarditis.

Yellow Flags

• Fear Avoidance Beliefs Questionnaire (FABQ) can be used to screen for behaviors that may require a consult or an increase in treatment duration.
• Patients involved in on-going litigation have been found to have reduced changes in quality of life and higher rates of disability with the physical gains made in therapy.
• Research has found that patients with work related low back pain and covered by workman’s compensation are at risk for psychosocial issues and negatively affecting treatment outcomes. This relationship has not been studied in the thoracic spine pain population, but should be taken into consideration.
  
  

Investigations

• Diagnostic imaging Considerations- Patients that present with acute thoracic spine pain with risk factors for osteoporotic compression fractures should have standard thoracic spine radiographs.
• Radiographs are general sensitive to assess for acute compression fractures however, if the patient’s initial radiographs were read as normal and they are still experiencing extreme pain or symptoms consider a referral for advanced imaging such as CT or MRI.
• Patients with red flags for cancer should be referred for imaging to rule out cancer.
• Patients with suspected Ankylosing Spondylitis are typically referred for radiographs of the sacroiliac joints and lab studies including assessing for the presence of HLA-B27.
  

Objective

Observation

Posture

• The examiners observe the patient’s thoracic spine region and assesses for the presence of deviation from normal including the thoracic spine curvatures in the frontal and saggittal planes.
• The overall impression of inter-rater reliability for postural observation of kyphosis and label either excessive, normal or decrease ranges from moderate to substantial according to a study preformed by Cleland et al.
  

Movement Patterns

The examiner can ask the patient to perform the following movements to check for any change symptoms; looking up, transferring from sit to stand, lifting one or both arms overhead, and any other movements that aggravate or relieve symptoms. While the patient performs these movements watch for any deviations, compensations, or discrepancies between sides. If applicable, any of these movement patterns can be used as asterisk or comparable signs for reassessment after a trial intervention.

Palpation

To begin, palpate superficial structures and then move to the deeper structures of the thorax. Feel for any changes in temperature, texture, and moisture, as well as lymph node and soft tissue swelling. Check for symmetry between bony landmarks including the rib angles and attachments, this can also be done through observation.

• Supine- ternum, ribs, clavicle, sternocostal and costocondral joints
• Prone- spinous process, costotransverse and costovertebral -Note thoracic facet and costotransverse joints refer pain locally or 1 level above or below
• Seated- 1st rib anteriorly and posteriorly
  

Movement Testing

• AROM, PROM, and Overpressure
• Passive Intervertebral Motion
• Muscle Strength