Assessment and Treatment of the Thoracic Spine

Original Editor - Jess Bell based on the course by Tanja Bell-Jenje
Top Contributors - Jess Bell, Kim Jackson, Kirenga Bamurange Liliane, Tarina van der Stockt, Lucinda hampton, Olajumoke Ogunleye, Aminat Abolade and Merinda Rodseth

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Subjective Assessment

Detailed information on the assessment of the thoracic spine is available here, but specific questions to consider in the subjective assessment include:

• How did the problem begin? How long has it been a problem?
• How has the pain progressed over time?
• Is there a history of overload or trauma?
• Does the patient have pain with breathing? And during which part of the breath does this occur?
• What effect does coughing and / or sneezing have?
• Can the patient lie on the affected side at night?
• How is the pain behaving and what is the level of irritability?
  • Consider in particular more stiffness
  • If there is stiffness for a prolonged period in the morning, and a history of enthesopathies, the patient may have a spondyloarthropathy
• What are the specific functional impairments? (e.g. during sport, activities of daily living)
• What is the patient’s medical history?
  • Essential to know due to spinal masqueraders in the thoracic spine
• Are there any psychosocial factors contributing to the pain?
  • The sympathetic nervous system is prominent in the thoracic region
• Are there any red flags?

Pain can be caused by inflammation, or it may originate in the cartilage, ligaments, bone (fracture) or the nerve root:

• Nerve root or facet pain may be described as lancinating / nauseating and it may radiate and follow angulation of rib
• Costochondritis tends to be described as a deep, boring, aching pain in the chest wall that may radiate (often posteriorly or to the neck)
• Rib fracture or intercostal strain is typically described as a sudden, sharp / piercing pain, which is then aggravated by laughing, sneezing, coughing, deep breaths or any type of straining manoeuvre
• When patients have immobility, they tend to report stiffness, restricted movement, or a sense of feeling ‘stuck’

Objective Assessment

The objective examination is guided by findings in the subjective interview. Remember:

• It is essential to understand which structures are loaded during each test
• Keep tests to a minimum
  • “Less is more” to avoid flaring up the patient
  • Consider combinations of tests
• The best ‘special test’ is the one the patient demonstrates to you
• Consider the diaphragm

During the assessment, the therapist should develop a sound hypothesis. “If you can’t find it, you can’t assess it and you can’t treat it”.

Objective Testing

Figure 1. Common postural dysfunctions.

The following tests should be included in an objective examination of the thoracic spine:

• Static and dynamic postural assessment:
  • Watch how the patient moves / drifts / hinges
  • Consider different types of postural dysfunctions(see Figure 1)
  • Is the postural change a primary problem or related to something else in the chain (e.g. lumbopelvic dysfunction)
• Breathing mechanics
• ROM tests from neutral
  • Look for intersegmental restrictions
  • Assess from behind
• Inter-ring and articular palpation during motion
• Motor control and strength tests
  • Sitting
  • Puppy lie
  • 4 point
• Neurodynamic tests
  • Upper limb tension test for thoracic outlet syndrome (see videos below)
  • NB this test may not always be positive in TOS patients, but it needs to be assessed in detail
• Neurological
  • Thoracic dermatome testing
• Palpation, including the clavicle and first rib