Anatomy, Biomechanics and Regional Interdependence of the Thorax: Difference between revisions

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<div class="editorbox"> '''Original Editor '''- [[User:Jess Bell|Jess Bell]] based on the course by [https://members.physio-pedia.com/course_tutor/tanja-bell-jenje/ Tanja Bell-Jenje]<br>
<div class="editorbox"> '''Original Editor '''- [[User:Jess Bell|Jess Bell]] based on the course by [https://members.physio-pedia.com/course_tutor/tanya-bell-jenje/ Tanya Bell-Jenje]<br>
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[[Category:Course Pages]]
[[Category:Course Pages]]
[[Category:Physioplus Content]]
[[Category:Plus Content]]
[[Category:Thoracic Spine]]
[[Category:Thoracic Spine]]
[[Category:Musculoskeletal/Orthopaedics]]
[[Category:Musculoskeletal/Orthopaedics]]


== Introduction ==
== Introduction ==
The thorax is an area of the spine that has, historically, been under-explored. It can, however, be a silent contributor to many presentations in clinical practice.
The [[Thoracic Anatomy|thorax]] is an area of the spine that has, historically, been under-explored. It can, however, be a silent contributor to many presentations in clinical practice.<ref name=":0" />


One cross-sectional survey in Denmark looked at the prevalence of spinal pain. It found that in one year:<ref>Leboeuf-Yde C, Nielsen J, Kyvik KO, Fejer R, Hartvigsen J. [https://link.springer.com/article/10.1186/1471-2474-10-39 Pain in the lumbar, thoracic or cervical regions: do age and gender matter? A population-based study of 34,902 Danish twins 20–71 years of age]. ''BMC Musculoskelet Disord''. 2009;10(39).</ref>
One cross-sectional survey in Denmark<ref name=":4">Leboeuf-Yde C, Nielsen J, Kyvik KO, Fejer R, Hartvigsen J. [https://link.springer.com/article/10.1186/1471-2474-10-39 Pain in the lumbar, thoracic or cervical regions: do age and gender matter? A population-based study of 34,902 Danish twins 20–71 years of age]. ''BMC Musculoskelet Disord''. 2009;10(39).</ref> looked at the prevalence of spinal pain. It found that in one year<ref name=":4" />:


* 13 percent of respondents had thoracic pain
* 13 percent of respondents had [[Thoracic Back Pain|thoracic pain]]
* 43 percent had low back pain
* 43 percent had [[Low Back Pain|low back pain]]
* 44 percent had neck pain
* 44 percent had [[Mechanical Neck Pain|neck pain]]


However, 36 to 41 percent of individuals have thoracic pain which co-exists with neck or back pain.<ref>Roquelaure Y, Bodin J, Ha C, Le Marec F, Fouquet N, Ramond-Roquin A et al. Incidence and risk factors for thoracic spine pain in the working population: the French Pays de la Loire study. Arthritis Care Res (Hoboken). 2014;66(11):1695-702. </ref> Thus, four in ten patients will have an associated thoracic spine condition. This is, therefore, a region that should not be ignored in physiotherapy practice.<ref name=":0">Bell-Jenje T. The Thorax Simplified - Anatomy, Biomechanics and Regional Interdependence Course. Physioplus, 2021.</ref>  
However, between 36 to 41 percent of individuals who present with neck or back pain will also have thoracic pain (i.e. around 4 in 10 patients).<ref>Roquelaure Y, Bodin J, Ha C, Le Marec F, Fouquet N, Ramond-Roquin A et al. [https://onlinelibrary.wiley.com/doi/10.1002/acr.22323 Incidence and risk factors for thoracic spine pain in the working population: the French Pays de la Loire study]. Arthritis Care Res (Hoboken). 2014;66(11):1695-702. </ref> This is, therefore, a region that should not be ignored in physiotherapy practice.<ref name=":0">Bell-Jenje T. The Thorax Simplified - Anatomy, Biomechanics and Regional Interdependence Course. Plus , 2021.</ref>  


== Anatomy ==
== Anatomy ==
The [[Thoracic Anatomy|thoracic spine]] includes 136 joints and 112 muscle attachments. The orientation of the thoracic joints and ribs limit flexion, extension and lateral flexion, but facilitate rotation.<ref name=":0" />
There are 136 joints in the [[Thoracic Anatomy|thoracic spine]] and 112 [[muscle]] attachments. The orientation of the thoracic joints and ribs limit flexion, extension and lateral flexion, but facilitate rotation.<ref name=":0" />
 
{{#ev:youtube|3mniZ_zQuRE}}<ref>Kenhub - Learn Human Anatomy. Thoracic Spine - Definition & Components - Human Anatomy | Kenhub. Available from: https://www.youtube.com/watch?v=3mniZ_zQuRE [last accessed 28/8/2021]</ref>  


=== Range of Motion ===
=== Range of Motion ===
The total rotation available in the thoracic spine is 85 degrees (+/- 14.8 degrees).<ref>Heneghan NR, Hall A, Hollands M, Balanos GM. Stability and intra-tester reliability of an in vivo measurement of thoracic axial rotation using an innovative methodology. Manual Therapy. 2009; 14(4):452-5.</ref> It contributes 80 percent of the total range of axial trunk rotation.<ref>Fujii R, Sakaura H, Mukai Y, Hosono N, Ishii T, Iwasaki M et al. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2223353/ Kinematics of the lumbar spine in trunk rotation: in vivo three-dimensional analysis using magnetic resonance imaging]. ''Eur Spine J''. 2007;16(11):1867-74. </ref> Each thoracic segment rotates between 6 and 8 degrees. This is significantly more than each lumbar segment, which only has 2 to 3 degrees of rotation.<ref name=":0" />  
The total rotation available in the thoracic spine is 85 degrees (+/- 14.8 degrees).<ref>Heneghan NR, Hall A, Hollands M, Balanos GM. Stability and intra-tester reliability of an in vivo measurement of thoracic axial rotation using an innovative methodology. Manual Therapy. 2009; 14(4):452-5.</ref> It contributes 80 percent of the total range of axial trunk rotation.<ref>Fujii R, Sakaura H, Mukai Y, Hosono N, Ishii T, Iwasaki M et al. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2223353/ Kinematics of the lumbar spine in trunk rotation: in vivo three-dimensional analysis using magnetic resonance imaging]. ''Eur Spine J''. 2007;16(11):1867-74. </ref> Each thoracic segment rotates between 6 and 8 degrees. This is significantly more than the [[Lumbar Anatomy|lumbar segments]], which only rotate 2 to 3 degrees.<ref name=":3">Lee LJ. A closer look at the thorax [Internet. Physical Therapy Web [cited 30 August 2021]. Available from: https://physicaltherapyweb.com/closer-look-thorax-lj-lee/</ref>  


Thoracic movement is critical for optimal performance in rotational sports and kinematically links the upper and lower quarters.<ref>Heneghan NR, Lokhaug SM, Tyros I, Longvastøl S, Rushton A. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7173996/ Clinical reasoning framework for thoracic spine exercise prescription in sport: a systematic review and narrative synthesis]. BMJ Open Sport Exerc Med. 2020;6(1):e000713. </ref><ref>Heneghan NR. Webb K, Mahoney T, Rushton A.  [https://www.researchgate.net/publication/334720891_Thoracic_spine_mobility_an_essential_link_in_upper_limb_kinetic_chains_in_athletes_A_systematic_review Thoracic spine mobility, an essential link in upper limb kinetic chains in athletes: A systematic review]. ''Transl Sports Med''.  2019;2:301-15.</ref> It also contributes 55 percent to total force during a throw.<ref>Kaczmarek PK, Lubiatowski P, Cisowski P, Grygorowicz M, Łepski M, Długosz J et al. [https://www.researchgate.net/publication/263207986_Shoulder_problems_in_overhead_sports_Part_I_-_biomechanics_of_throwing Shoulder problems in overhead sports. Part I - biomechanics of throwing]. Pol Orthop Traumatol. 2014;79:50-8. </ref>
Thoracic movement is critical for optimal performance in rotational sports and the thoracic spine kinematically links the upper and lower quarters.<ref>Heneghan NR, Lokhaug SM, Tyros I, Longvastøl S, Rushton A. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7173996/ Clinical reasoning framework for thoracic spine exercise prescription in sport: a systematic review and narrative synthesis]. BMJ Open Sport Exerc Med. 2020;6(1):e000713. </ref><ref>Heneghan NR. Webb K, Mahoney T, Rushton A.  [https://www.researchgate.net/publication/334720891_Thoracic_spine_mobility_an_essential_link_in_upper_limb_kinetic_chains_in_athletes_A_systematic_review Thoracic spine mobility, an essential link in upper limb kinetic chains in athletes: A systematic review]. ''Transl Sports Med''.  2019;2:301-15.</ref> It also contributes 55 percent of the total force during a throw.<ref>Kaczmarek PK, Lubiatowski P, Cisowski P, Grygorowicz M, Łepski M, Długosz J et al. [https://www.researchgate.net/publication/263207986_Shoulder_problems_in_overhead_sports_Part_I_-_biomechanics_of_throwing Shoulder problems in overhead sports. Part I - biomechanics of throwing]. Pol Orthop Traumatol. 2014;79:50-8. </ref>


=== Regions of the Thorax ===
=== Regions of the Thorax ===


* Verebromanubrial:
* [[File:Rib Cage.jpg|right|frameless|423x423px]]Vertebromanubrial:
** Includes: T1 and T2, ribs 1 and 2, the manubrium and clavicle
** Includes: T1 and T2, [[ribs]] 1 and 2, the manubrium and [[Clavicula|clavicle]]
* Vertebrosternal
* Vertebrosternal
** Includes: T3 to T7, true ribs 3 to 7 and sternum
** Includes: T3 to T7, true ribs 3 to 7 and [[sternum]]
* Vertebrochondral:
* Vertebrochondral:
** Includes: T8 to 10 and false ribs 8 to 10
** Includes: T8 to T10 and false ribs 8 to 10
* Thoracolumbar
* Thoracolumbar
** Includes: T11 and T12, floating ribs 11 and 12<ref name=":0" />
** Includes: T11 and T12, floating ribs 11 and 12<ref name=":0" />
NB: True ribs attach directly to the sternum via [[cartilage]], false ribs attach to the lowest true ribs and floating ribs only have posterior attachments to the spine.


==== Ribs ====
==== Ribs ====


* Ribs 1, 11 and 12 articulate with the named vertebra (i.e. rib 1 articulates with T1)
* Ribs 1, 11 and 12 articulate with the named vertebra (i.e. rib 1 articulates with T1)
* Ribs 2 to 10 articulate with the named vertebra, as well as the body above, the intervertebral disc and the anterior surface of the transverse process of the named vertebra
* Ribs 2 to 10 articulate with the named vertebra, as well as the body above, the [[intervertebral disc]] and the anterior surface of the transverse process of the named vertebra
* More information on the ribs is available [[Ribs|here]]
* More information about the ribs is available [[Ribs|here]]


==== The Thoracic Ring (T3-T9) ====
==== The Thoracic Ring (T3-T9) ====
“The “thoracic ring” consists of two adjacent vertebrae and the related intervertebral disc, the right and left ribs (attached to the vertebra-disc-vertebra complex at the costovertebral joints), and the anterior attachments to the sternum/ manubrium and related cartilages.”<ref name=":1">Lee LJ. Thoracic ring approach. Available from: https://ljlee.ca/teaching-models/the-thoracic-ring-approach/ (accessed 28 August 2021).</ref>  
<blockquote>'The "thoracic ring” consists of two adjacent vertebrae and the related intervertebral disc, the right and left ribs (attached to the vertebra-disc-vertebra complex at the costovertebral joints), and the anterior attachments to the sternum/manubrium and related cartilages.'<ref name=":1">Lee LJ. Thoracic ring approach. Available from: https://ljlee.ca/teaching-models/the-thoracic-ring-approach/ (accessed 28 August 2021).</ref></blockquote>There are 13 articulations per thoracic ring<ref name=":0" /><ref name=":1" />:
 
There are 13 articulations per thoracic ring:<ref name=":0" /><ref name=":1" />


* Zygapophyseal / facet = 2
* Zygapophyseal / facet = 2 articulations
* Costovertebral = 4
* Costovertebral = 4 articulations
* Intervertebral = 1
* Intervertebral = 1 articulation
* Costotransverse = 2
* Costotransverse = 2 articulations
* Costochondral = 2
* Costochondral = 2 articulations
* Sternocostal = 2
* Sternocostal = 2 articulations


Because of the strong anatomical connections between the ribs and the thoracic spine, mobilising the rib laterally will cause motion at the vertebral segments of that thoracic ring, as well as the ribs on the opposite side of the body.<ref name=":0" />
Because of the strong anatomical connections between the ribs and the thoracic spine, mobilising a rib laterally will cause motion at the vertebral segments of that thoracic ring, as well as the rib on the opposite side of the body.<ref name=":0" />


=== Thoracic Function ===
== Thoracic Function ==
Lee has described the thoracic spine as a “‘slinky’ or a shock-absorbing spring”.<ref name=":1" /> It consists of a dynamic stack of 10 thoracic rings<ref name=":1" /> and has the following functions:<ref name=":0" />
Lee<ref name=":1" /> has described the thoracic spine as a “slinky" or a "shock-absorbing spring”. It consists of a dynamic stack of 10 thoracic rings<ref name=":1" /> and has the following functions<ref name=":3" />:


* Force transmission
* Force transmission
** NB: many patients with chronic low back pain or cervical pain have a stiff thoracic spine
** NB: many patients with chronic low back pain or cervical pain have a stiff thoracic spine and increasing thoracic mobility allows for more even distribution of load through the spine with movement<ref>McConnell J. Recalcitrant chronic low back and leg pain--a new theory and different approach to management. Man Ther. 2002;7(4):183-92. </ref> <ref>Mohanty PP, Pattnaik M. Mobilisation of the thoracic spine in the management of spondylolisthesis. J Bodyw Mov Ther. 2016;20(3):598-603. </ref><ref>Cleland JA, Childs JD, McRae M, Palmer JA, Stowell T. Immediate effects of thoracic manipulation in patients with neck pain: a randomized clinical trial. Man Ther. 2005;10(2):127-35. </ref>
** Increasing thoracic mobility allows more even distribution of load through the spine with movement<ref>McConnell J. Recalcitrant chronic low back and leg pain--a new theory and different approach to management. Man Ther. 2002;7(4):183-92. </ref> <ref>Mohanty PP, Pattnaik M. Mobilisation of the thoracic spine in the management of spondylolisthesis. J Bodyw Mov Ther. 2016;20(3):598-603. </ref><ref>Cleland JA, Childs JD, McRae M, Palmer JA, Stowell T. Immediate effects of thoracic manipulation in patients with neck pain: a randomized clinical trial. Man Ther. 2005;10(2):127-35. </ref>
* Central area for [[Thoracolumbar Fascia|myofascial]] attachments
* Central area for myofascial attachments
* Protects heart, lungs, vessels and digestive tract<ref>Edmondston SJ, Singer KP. Thoracic spine: anatomical and biomechanical considerations for manual therapy. Man Ther. 1997;2(3):132-43. </ref>
* Protects of heart, lungs, vessels, digestive tract<ref>Edmondston SJ, Singer KP. Thoracic spine: anatomical and biomechanical considerations for manual therapy. Man Ther. 1997;2(3):132-43. </ref>
* Aids optimal [[Respiratory Assessment|respiratory function]] <ref>Kudzinskas A, Callahan AL. [https://www.ncbi.nlm.nih.gov/books/NBK557710/ Anatomy, Thorax.] InStatPearls [Internet] 2021 Jul 31. StatPearls Publishing.</ref>
* Aids optimal respiratory function
* Houses the autonomic nervous system
* Houses the autonomic nervous system
== Thoracic Asymmetry ==
It is normal for there to be thoracic asymmetry of the [[Facet Joints|facet]] orientation in the thoracic spine.<ref>Masharawi Y, Rothschild B, Dar G, Peleg S, Robinson D, Been E et al. Facet orientation in the thoracolumbar spine: three-dimensional anatomic and biomechanical analysis. Spine (Phila Pa 1976). 2004;29(16):1755-63.</ref> Asymmetrical anatomy may, however, cause changes in the coupled motion at a segment.<ref>Andriacchi T, Schultz A, Belytschko T, Galante J. A model for studies of mechanical interactions between the human spine and rib cage. J Biomech. 1974;7(6):497–507.</ref>
== Regional Interdependence ==
The [[Regional Interdependence|regional interdependence]] theory proposes that: “seemingly unrelated impairments in remote anatomical regions of the body may contribute to and be associated with a patient’s primary report of symptoms.”<ref>Sueki DG, Cleland JA, Wainner RS. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3649356/ A regional interdependence model of musculoskeletal dysfunction: research, mechanisms, and clinical implications]. ''J Man Manip Ther''. 2013;21(2):90-102.</ref> It has been proposed that there may also be central mechanisms involved in mediating regional interdependence.<ref>Ghamkhar L, Arab AM, Nourbakhsh MR, Kahlaee AH, Zolfaghari R. Examination of regional interdependence theory in chronic neck pain: interpretations from correlation of strength measures in cervical and pain-free regions. Pain Med. 2020;21(2):e182-e190.</ref>{{#ev:youtube|v4YXQgamW2Q}}<ref>FoundationPT. The truth about aches and pains - Regional Interdependence Overview. Available from: https://www.youtube.com/watch?v=v4YXQgamW2Q [last accessed 28/8/2021]</ref>
Examples of interdependency in the thoracic spine include the following:<ref name=":0" />
=== 1. Cervical spine ===
Tsang and colleagues<ref name=":2" /> found that motion of the thoracic spine, particularly the upper thoracic spine, contributes to neck mobility. The upper thoracic spine contributes:<ref name=":2">Tsang SM, Szeto GP, Lee RY. Normal kinematics of the neck: the interplay between the cervical and thoracic spines. Man Ther. 2013;18(5):431-7. </ref>
* 25 percent to cervical flexion and extension
* 10 percent to cervical rotation
Thoracic spine changes are, therefore, implicated in a loss of cervical range of motion, so this area should always be assessed in patients with neck dysfunction.<ref name=":2" />
Similarly, Engell and colleagues have found that when manual therapy techniques (e.g. high-velocity low-amplitude spinal manipulative therapy) are applied to the thoracic spine, forces can be transmitted to the neck.<ref>Engell S, Triano JJ, Howarth SJ. Force transmission between thoracic and cervical segments of the spine during prone-lying high-velocity low-amplitude spinal manipulation: A proof of principle for the concept of regional interdependence. Clin Biomech (Bristol, Avon). 2019;69:58-63. </ref>
=== 2. Shoulder ===
The [[scapula]] is a sesamoid [[bone]], which rests upon the thorax. It is influenced by the position of the thoracic spine elements and the ribs. [[Posture]]<nowiki/>s such as [[Thoracic Hyperkyphosis|thoracic kyphosis]], thoracic [[scoliosis]] or flattened / inverted thoracic spine, can change the resting position of the scapula.<ref name=":0" />
* Thoracic kyphosis is associated with a loss of [[Glenohumeral Joint|glenohumeral]] range of motion and [[Impingement / Instability Differentiation|impingement]] symptoms<ref>Barrett E, O'Keeffe M, O'Sullivan K, Lewis J, McCreesh K. Is thoracic spine posture associated with shoulder pain, range of motion and function? A systematic review. Man Ther. 2016;26:38-46. </ref>
* Treating the thoracic spine has been shown to alter shoulder symptoms<ref>Strunce JB, Walker MJ, Boyles RE, Young BA. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2813499/ The immediate effects of thoracic spine and rib manipulation on subjects with primary complaints of shoulder pain]. J Man Manip Ther. 2009;17(4):230-6.</ref><ref>Boyles RE, Ritland BM, Miracle BM, Barclay DM, Faul MS, Moore JH et al. The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement syndrome. Man Ther. 2009;14(4):375-80.</ref> <ref>Haider R, Bashir MS, Adeel M, Ijaz MJ, Ayub A. [https://jpma.org.pk/article-details/8600?article_id=8600 Comparison of conservative exercise therapy with and without Maitland Thoracic Manipulative therapy in patients with subacromial pain: Clinical trial]. J Pak Med Assoc. 2018 Mar;68(3):381-7. </ref>
=== 3. Other Relationships ===
* [[Sympathetic Nervous System|Sympathetic]] nerve blocks at the thoracic spine can improve chronic upper extremity [[Neuropathic Pain|neuropathic pain]]<ref>Yoo HS, Nahm FS, Lee PB, Lee CJ. Early thoracic sympathetic block improves the treatment effect for upper extremity neuropathic pain. Anesth Analg. 2011;113(3):605-9. </ref>
* 70 percent of patients with lateral [[elbow]] pain have co-existing thoracic pain (compared to 16 percent of the control group)<ref>Berglund KM, Persson BH, Denison E. Prevalence of pain and dysfunction in the cervical and thoracic spine in persons with and without lateral elbow pain. Man Ther. 2008;13(4):295-9.</ref>
== Postural and Positional Implications ==
Certain postural dysfunctions could result in compensatory thoracic dysfunction (i.e. ‘gives’):<ref name=":0" />
* Inextensible [[Hamstrings|hamstring]]<nowiki/>s force the thoracic spine to 'give' into flexion during stride, lunging and long sitting
* Inextensible hip flexors can cause [[Low Back Pain Related to Hyperlordosis|lordosis]] and kyphosis
* A [[Leg Length Discrepancy|leg length discrepancy]] and asymmetrical load can cause thoracic scoliosis
[[File:Bigstock Image - Forward Head Posture - ID302417506.jpg|thumb|Figure 1. Forward head position.|alt=|400x400px]]
Poor cervico-thoracic postures such as<ref name=":0" />:
* [[Forward Head Posture|Forward head position]] (Figure 1)
* Thoracic kyphosis
* Scoliosis
* [[Sway Back Posture|Flat / inverted thoracic spine]]
Can cause<ref name=":0" />:
* Muscle imbalances
* Joint incongruity
* [[Ligament]] laxity
* Altered neurodynamics
Thoracic scoliosis<ref name=":0" />:
* Even minor curves cause wedging of the vertebrae and discs<ref>Stokes IA, Aronsson DD. Disc and vertebral wedging in patients with progressive scoliosis. J Spinal Disord. 2001;14(4):317-22. </ref>
* 80 percent of athletes who experience asymmetrical loading on their trunk and shoulders (e.g. javelin throwers, tennis players) have thoracic scoliosis<ref>Swärd L. The thoracolumbar spine in young elite athletes. Current concepts on the effects of physical training. Sports Med. 1992;13(5):357-64. </ref>
* It could, therefore, be proposed that scoliosis provides a mechanical advantage in asymmetrical sports<ref name=":0" />
== Summary ==
* Potentially 40 percent of patients presenting for physiotherapy with back or neck pain will have an associated thoracic spine dysfunction which needs to be assessed and managed
* [[Biomechanics]] and knowledge of the clinical anatomy of the thorax will help you to better understand the underlying pathogenesis of these conditions
* Thoracic rotation is essential for optimal sports performance and functional activities
* Postural dysfunctions such as tight hamstrings or hip flexors may force compensatory 'gives' in the thoracic spine - it is essential to look for the source of the problem


== References ==
== References ==

Latest revision as of 16:17, 13 January 2023

Original Editor - Jess Bell based on the course by Tanya Bell-Jenje
Top Contributors - Jess Bell, Lucinda hampton, Kim Jackson, Olajumoke Ogunleye, Merinda Rodseth and Robin Tacchetti

Introduction[edit | edit source]

The thorax is an area of the spine that has, historically, been under-explored. It can, however, be a silent contributor to many presentations in clinical practice.[1]

One cross-sectional survey in Denmark[2] looked at the prevalence of spinal pain. It found that in one year[2]:

However, between 36 to 41 percent of individuals who present with neck or back pain will also have thoracic pain (i.e. around 4 in 10 patients).[3] This is, therefore, a region that should not be ignored in physiotherapy practice.[1]

Anatomy[edit | edit source]

There are 136 joints in the thoracic spine and 112 muscle attachments. The orientation of the thoracic joints and ribs limit flexion, extension and lateral flexion, but facilitate rotation.[1]

[4]

Range of Motion[edit | edit source]

The total rotation available in the thoracic spine is 85 degrees (+/- 14.8 degrees).[5] It contributes 80 percent of the total range of axial trunk rotation.[6] Each thoracic segment rotates between 6 and 8 degrees. This is significantly more than the lumbar segments, which only rotate 2 to 3 degrees.[7]

Thoracic movement is critical for optimal performance in rotational sports and the thoracic spine kinematically links the upper and lower quarters.[8][9] It also contributes 55 percent of the total force during a throw.[10]

Regions of the Thorax[edit | edit source]

  • Rib Cage.jpg
    Vertebromanubrial:
    • Includes: T1 and T2, ribs 1 and 2, the manubrium and clavicle
  • Vertebrosternal
    • Includes: T3 to T7, true ribs 3 to 7 and sternum
  • Vertebrochondral:
    • Includes: T8 to T10 and false ribs 8 to 10
  • Thoracolumbar
    • Includes: T11 and T12, floating ribs 11 and 12[1]

NB: True ribs attach directly to the sternum via cartilage, false ribs attach to the lowest true ribs and floating ribs only have posterior attachments to the spine.

Ribs[edit | edit source]

  • Ribs 1, 11 and 12 articulate with the named vertebra (i.e. rib 1 articulates with T1)
  • Ribs 2 to 10 articulate with the named vertebra, as well as the body above, the intervertebral disc and the anterior surface of the transverse process of the named vertebra
  • More information about the ribs is available here

The Thoracic Ring (T3-T9)[edit | edit source]

'The "thoracic ring” consists of two adjacent vertebrae and the related intervertebral disc, the right and left ribs (attached to the vertebra-disc-vertebra complex at the costovertebral joints), and the anterior attachments to the sternum/manubrium and related cartilages.'[11]

There are 13 articulations per thoracic ring[1][11]:

  • Zygapophyseal / facet = 2 articulations
  • Costovertebral = 4 articulations
  • Intervertebral = 1 articulation
  • Costotransverse = 2 articulations
  • Costochondral = 2 articulations
  • Sternocostal = 2 articulations

Because of the strong anatomical connections between the ribs and the thoracic spine, mobilising a rib laterally will cause motion at the vertebral segments of that thoracic ring, as well as the rib on the opposite side of the body.[1]

Thoracic Function[edit | edit source]

Lee[11] has described the thoracic spine as a “slinky" or a "shock-absorbing spring”. It consists of a dynamic stack of 10 thoracic rings[11] and has the following functions[7]:

  • Force transmission
    • NB: many patients with chronic low back pain or cervical pain have a stiff thoracic spine and increasing thoracic mobility allows for more even distribution of load through the spine with movement[12] [13][14]
  • Central area for myofascial attachments
  • Protects heart, lungs, vessels and digestive tract[15]
  • Aids optimal respiratory function [16]
  • Houses the autonomic nervous system

Thoracic Asymmetry[edit | edit source]

It is normal for there to be thoracic asymmetry of the facet orientation in the thoracic spine.[17] Asymmetrical anatomy may, however, cause changes in the coupled motion at a segment.[18]

Regional Interdependence[edit | edit source]

The regional interdependence theory proposes that: “seemingly unrelated impairments in remote anatomical regions of the body may contribute to and be associated with a patient’s primary report of symptoms.”[19] It has been proposed that there may also be central mechanisms involved in mediating regional interdependence.[20]

[21]

Examples of interdependency in the thoracic spine include the following:[1]

1. Cervical spine[edit | edit source]

Tsang and colleagues[22] found that motion of the thoracic spine, particularly the upper thoracic spine, contributes to neck mobility. The upper thoracic spine contributes:[22]

  • 25 percent to cervical flexion and extension
  • 10 percent to cervical rotation

Thoracic spine changes are, therefore, implicated in a loss of cervical range of motion, so this area should always be assessed in patients with neck dysfunction.[22]

Similarly, Engell and colleagues have found that when manual therapy techniques (e.g. high-velocity low-amplitude spinal manipulative therapy) are applied to the thoracic spine, forces can be transmitted to the neck.[23]

2. Shoulder[edit | edit source]

The scapula is a sesamoid bone, which rests upon the thorax. It is influenced by the position of the thoracic spine elements and the ribs. Postures such as thoracic kyphosis, thoracic scoliosis or flattened / inverted thoracic spine, can change the resting position of the scapula.[1]

3. Other Relationships[edit | edit source]

  • Sympathetic nerve blocks at the thoracic spine can improve chronic upper extremity neuropathic pain[28]
  • 70 percent of patients with lateral elbow pain have co-existing thoracic pain (compared to 16 percent of the control group)[29]

Postural and Positional Implications[edit | edit source]

Certain postural dysfunctions could result in compensatory thoracic dysfunction (i.e. ‘gives’):[1]

  • Inextensible hamstrings force the thoracic spine to 'give' into flexion during stride, lunging and long sitting
  • Inextensible hip flexors can cause lordosis and kyphosis
  • A leg length discrepancy and asymmetrical load can cause thoracic scoliosis
Figure 1. Forward head position.


Poor cervico-thoracic postures such as[1]:


Can cause[1]:

  • Muscle imbalances
  • Joint incongruity
  • Ligament laxity
  • Altered neurodynamics


Thoracic scoliosis[1]:

  • Even minor curves cause wedging of the vertebrae and discs[30]
  • 80 percent of athletes who experience asymmetrical loading on their trunk and shoulders (e.g. javelin throwers, tennis players) have thoracic scoliosis[31]
  • It could, therefore, be proposed that scoliosis provides a mechanical advantage in asymmetrical sports[1]

Summary[edit | edit source]

  • Potentially 40 percent of patients presenting for physiotherapy with back or neck pain will have an associated thoracic spine dysfunction which needs to be assessed and managed
  • Biomechanics and knowledge of the clinical anatomy of the thorax will help you to better understand the underlying pathogenesis of these conditions
  • Thoracic rotation is essential for optimal sports performance and functional activities
  • Postural dysfunctions such as tight hamstrings or hip flexors may force compensatory 'gives' in the thoracic spine - it is essential to look for the source of the problem

References[edit | edit source]

  1. ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 Bell-Jenje T. The Thorax Simplified - Anatomy, Biomechanics and Regional Interdependence Course. Plus , 2021.
  2. ↑ 2.0 2.1 Leboeuf-Yde C, Nielsen J, Kyvik KO, Fejer R, Hartvigsen J. Pain in the lumbar, thoracic or cervical regions: do age and gender matter? A population-based study of 34,902 Danish twins 20–71 years of age. BMC Musculoskelet Disord. 2009;10(39).
  3. ↑ Roquelaure Y, Bodin J, Ha C, Le Marec F, Fouquet N, Ramond-Roquin A et al. Incidence and risk factors for thoracic spine pain in the working population: the French Pays de la Loire study. Arthritis Care Res (Hoboken). 2014;66(11):1695-702.
  4. ↑ Kenhub - Learn Human Anatomy. Thoracic Spine - Definition & Components - Human Anatomy | Kenhub. Available from: https://www.youtube.com/watch?v=3mniZ_zQuRE [last accessed 28/8/2021]
  5. ↑ Heneghan NR, Hall A, Hollands M, Balanos GM. Stability and intra-tester reliability of an in vivo measurement of thoracic axial rotation using an innovative methodology. Manual Therapy. 2009; 14(4):452-5.
  6. ↑ Fujii R, Sakaura H, Mukai Y, Hosono N, Ishii T, Iwasaki M et al. Kinematics of the lumbar spine in trunk rotation: in vivo three-dimensional analysis using magnetic resonance imaging. Eur Spine J. 2007;16(11):1867-74.
  7. ↑ 7.0 7.1 Lee LJ. A closer look at the thorax [Internet. Physical Therapy Web [cited 30 August 2021]. Available from: https://physicaltherapyweb.com/closer-look-thorax-lj-lee/
  8. ↑ Heneghan NR, Lokhaug SM, Tyros I, Longvastøl S, Rushton A. Clinical reasoning framework for thoracic spine exercise prescription in sport: a systematic review and narrative synthesis. BMJ Open Sport Exerc Med. 2020;6(1):e000713.
  9. ↑ Heneghan NR. Webb K, Mahoney T, Rushton A.  Thoracic spine mobility, an essential link in upper limb kinetic chains in athletes: A systematic review. Transl Sports Med.  2019;2:301-15.
  10. ↑ Kaczmarek PK, Lubiatowski P, Cisowski P, Grygorowicz M, Łepski M, Długosz J et al. Shoulder problems in overhead sports. Part I - biomechanics of throwing. Pol Orthop Traumatol. 2014;79:50-8.
  11. ↑ 11.0 11.1 11.2 11.3 Lee LJ. Thoracic ring approach. Available from: https://ljlee.ca/teaching-models/the-thoracic-ring-approach/ (accessed 28 August 2021).
  12. ↑ McConnell J. Recalcitrant chronic low back and leg pain--a new theory and different approach to management. Man Ther. 2002;7(4):183-92.
  13. ↑ Mohanty PP, Pattnaik M. Mobilisation of the thoracic spine in the management of spondylolisthesis. J Bodyw Mov Ther. 2016;20(3):598-603.
  14. ↑ Cleland JA, Childs JD, McRae M, Palmer JA, Stowell T. Immediate effects of thoracic manipulation in patients with neck pain: a randomized clinical trial. Man Ther. 2005;10(2):127-35.
  15. ↑ Edmondston SJ, Singer KP. Thoracic spine: anatomical and biomechanical considerations for manual therapy. Man Ther. 1997;2(3):132-43.
  16. ↑ Kudzinskas A, Callahan AL. Anatomy, Thorax. InStatPearls [Internet] 2021 Jul 31. StatPearls Publishing.
  17. ↑ Masharawi Y, Rothschild B, Dar G, Peleg S, Robinson D, Been E et al. Facet orientation in the thoracolumbar spine: three-dimensional anatomic and biomechanical analysis. Spine (Phila Pa 1976). 2004;29(16):1755-63.
  18. ↑ Andriacchi T, Schultz A, Belytschko T, Galante J. A model for studies of mechanical interactions between the human spine and rib cage. J Biomech. 1974;7(6):497–507.
  19. ↑ Sueki DG, Cleland JA, Wainner RS. A regional interdependence model of musculoskeletal dysfunction: research, mechanisms, and clinical implications. J Man Manip Ther. 2013;21(2):90-102.
  20. ↑ Ghamkhar L, Arab AM, Nourbakhsh MR, Kahlaee AH, Zolfaghari R. Examination of regional interdependence theory in chronic neck pain: interpretations from correlation of strength measures in cervical and pain-free regions. Pain Med. 2020;21(2):e182-e190.
  21. ↑ FoundationPT. The truth about aches and pains - Regional Interdependence Overview. Available from: https://www.youtube.com/watch?v=v4YXQgamW2Q [last accessed 28/8/2021]
  22. ↑ 22.0 22.1 22.2 Tsang SM, Szeto GP, Lee RY. Normal kinematics of the neck: the interplay between the cervical and thoracic spines. Man Ther. 2013;18(5):431-7.
  23. ↑ Engell S, Triano JJ, Howarth SJ. Force transmission between thoracic and cervical segments of the spine during prone-lying high-velocity low-amplitude spinal manipulation: A proof of principle for the concept of regional interdependence. Clin Biomech (Bristol, Avon). 2019;69:58-63.
  24. ↑ Barrett E, O'Keeffe M, O'Sullivan K, Lewis J, McCreesh K. Is thoracic spine posture associated with shoulder pain, range of motion and function? A systematic review. Man Ther. 2016;26:38-46.
  25. ↑ Strunce JB, Walker MJ, Boyles RE, Young BA. The immediate effects of thoracic spine and rib manipulation on subjects with primary complaints of shoulder pain. J Man Manip Ther. 2009;17(4):230-6.
  26. ↑ Boyles RE, Ritland BM, Miracle BM, Barclay DM, Faul MS, Moore JH et al. The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement syndrome. Man Ther. 2009;14(4):375-80.
  27. ↑ Haider R, Bashir MS, Adeel M, Ijaz MJ, Ayub A. Comparison of conservative exercise therapy with and without Maitland Thoracic Manipulative therapy in patients with subacromial pain: Clinical trial. J Pak Med Assoc. 2018 Mar;68(3):381-7.
  28. ↑ Yoo HS, Nahm FS, Lee PB, Lee CJ. Early thoracic sympathetic block improves the treatment effect for upper extremity neuropathic pain. Anesth Analg. 2011;113(3):605-9.
  29. ↑ Berglund KM, Persson BH, Denison E. Prevalence of pain and dysfunction in the cervical and thoracic spine in persons with and without lateral elbow pain. Man Ther. 2008;13(4):295-9.
  30. ↑ Stokes IA, Aronsson DD. Disc and vertebral wedging in patients with progressive scoliosis. J Spinal Disord. 2001;14(4):317-22.
  31. ↑ Swärd L. The thoracolumbar spine in young elite athletes. Current concepts on the effects of physical training. Sports Med. 1992;13(5):357-64.
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