Assessment and Treatment of the Thoracic Spine

Original Editor - Jess Bell based on the course by Tanya Bell-Jenje
Top Contributors - Jess Bell, Kirenga Bamurange Liliane and Merinda Rodseth

Subjective Assessment[edit | edit source]

Further information about the assessment of the thoracic spine is available here, but specific questions to consider in the subjective assessment include:[1]

  • 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 if so, 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?
    • Is there stiffness for a prolonged period in the morning?
    • Is there also a history of enthesopathies?
      • NB: enthesopathies are pathologies that affect the entheses (i.e. the bony insertion sites of tendons and ligaments)[2]
    • This history could indicate that the patient has a seronegative spondyloarthropathy[1][3]
  • What are the patient's functional impairments?
    • Consider sport and activities of daily living
  • What is the patient’s medical history?
    • It is essential to have a detailed understanding of this history as there are a number of conditions that can masquerade as musculoskeletal thoracic pain
  • Are there any psychosocial factors contributing to the pain?
  • Are there any red flags?[4]

Subjective information can give quite specific clues about the potential cause of pain (i.e. inflammatory, mechanical or non-mechanical):[1]

  • Nerve root or facet pain may be described as lancinating / nauseating. It may radiate and follow the angulation of the 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
  • Constant, burning pain can be a sign of inflammation
    • This could be from an auto-immune disorder, a severely effected joint, or referred from another structure (e.g. a duodenal ulcer might cause a constant burning pain in the thoracic region)
  • When patients have immobility, they tend to report stiffness, restricted movement, or a sense of feeling ‘stuck’

Objective Assessment[edit | edit source]

The objective examination is guided by findings in the subjective interview. Remember:[1]

  • 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

Objective Testing[edit | edit source]

Figure 1. Common postural dysfunctions.

The following tests should be included in an objective examination of the thoracic spine:[1]

  • Static and dynamic postural assessment:
    • Watch how the patient moves / drifts / hinges
    • Consider different types of postural dysfunctions[5] (see Figure 1)
    • Is the postural change a primary or secondary problem (e.g. lumbopelvic dysfunction)
  • Breathing mechanics
  • Figure 2. Dermatomes.
    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
  • Neurological
  • Palpation, including the clavicle and first rib

Active Thoracic Movement Tests[edit | edit source]

During the active movement tests:[1]

  • Assess the patient in sitting in order to isolate the thoracic spine (this position blocks the lumbar spine)
  • Assess for asymmetry of movement and any segmental restriction
    • Remember that motor control is also important in the thoracic region, not just stiffness

Thoracic Flexion and Extension[edit | edit source]

  • Flexion: feel for anterior tilt of the ribs
  • Extension: feel for posterior tilt of the ribs
  • NB extension is the most limited movement in the thoracic spine[10]

Thoracic Rotation[edit | edit source]

Rotation is one of the most useful tests for the thoracic spine. During rotation movements, it is possible to identify:[1]

  • Stiffness
  • Sequencing issues

Thoracic Side Bend / Lateral Shift[edit | edit source]

Assess the patient from behind - it is only necessary to assess the patient from the front if you wish to specifically examine the ribs from this position. During thoracic side bend there is:[1]

  • Ipsilateral approximation of the ribs
  • Contralateral separation of the ribs
  • Contralateral rib translation

Treatment[edit | edit source]

Sleep[edit | edit source]

Sleep is the most powerful antioxidant.[1] It is recognised that there is a bi-directional relationship between pain and sleep.[11]

Thoracic Manipulation[edit | edit source]

It is still not known if / why thoracic manipulation works, but it has been found that thoracic manipulation can decrease pain, improve mobility and enhance a patient’s feeling of health.[12]

  • There is, however, no evidence that one manipulation is better than another
  • There is no evidence that thoracic manipulation has a long-term effect, so if it is used, it should be used in combination with specific rehabilitation exercises
  • Joint position, direction, velocity and force are all variables that should be considered[1]

Postural Correction and Motor Control[edit | edit source]

Correcting a patient’s posture can also have a positive impact on a patient’s pain.[1]

  • Consider the centre of gravity
  • Look for areas of muscle spasm or hyperactivity (e.g. of iliocostalis)

Iliocostalis Release[edit | edit source]

Iliocostalis is the most lateral of the erector spinae.[13] Patients with significant thoracic kyphosis and lumbar lordosis may have increased activity of iliocostalis. This muscle can be released under the 10th and 11th ribs.[1]

Posterior-Anterior Glides[edit | edit source]

Patients with inverted thoracic spines, rotated spines and / or increased kyphosis will likely find posterior-anterior (PA) glides of the spinous processes uncomfortable as they are highly nociceptive.[1]

Instead, it can be beneficial to perform a PA glide on the rib angle (which results in a mobilisation of 13 articulations for each thoracic ring). For individuals with inverted spines, this will create an anterior-posterior (AP) movement on the spinous process.[1] For patients with increased kyphosis, a PA glide on the rib angle while performing an AP glide on the anterior shoulder / coracoid can be effective. A rotatory technique for patients with kyphosis can be effective.[1]

Exercise Therapy[edit | edit source]

A survey of thoracic spine management trends in the United Kingdom found that exercise is used widely as a treatment modality despite limited supporting evidence.[14] Speed, starting positions, dosage and load progression have not been investigated, but exercises which aim to stretch, mobilise and stabilise the thoracic spine can be beneficial in clinical practice.[1]

Types of Exercises[edit | edit source]

Stretches for the thoracic spine are shown in Figure 3. Figure 4 shows stretches that can specifically address an inverted thoracic spine.

Figures 5 and 6 show exercises to mobilise the thoracic spine, while Figure 7 focuses specifically on exercises that rotate the thoracic spine.

Exercises to stabilise the thoracic spine are shown in figures 8, 9 and 10. Initially it is beneficial to use closed kinetic chain exercises (Figures 8 and 9) before aiming to increase strength through range (Figure 10).

A Lot is Unknown[edit | edit source]

  • Most ‘research’ is anecdotal, or found on social media / YouTube
  • Information from other regions of the spine has been ‘transferred’ to the thoracic spine
    • The unique features of the thoracic spine are often not recognised
  • There are many deep thoracic muscles whose contribution to motor control in the thorax is unknown, such as semispinalis thoracic and rotatores
  • It is also not known what role the thoracic spine has in proprioception

Summary[edit | edit source]

Assessment:[1]

  • It is beneficial to use anatomical knowledge and biomechanical insights to look at poor motion habits
  • Do not focus on tiny faults

Management:[1]

  • It can be helpful to use specific manual techniques to mobilise restricted areas, but this will not result in macro changes
  • Postural adjustments can, however, be used to change systems and make macro changes
  • Thoracic rotation is essential for movement, sports and performance
    • Utilise exercises that promote rotation, stability (motor control) and strength
  • Exercise therapy should be used in conjunction with manual therapy to achieve an optimal outcome
  • Management should not just focus on thoracic stiffness - it is perhaps more important to address thoracic motor control and segmental stability

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 1.13 1.14 1.15 1.16 1.17 1.18 Bell-Jenje T. Assessment and Treatment of the Thoracic Spine Course. Physioplus, 2021.
  2. Alvarez A, Tiu TK. Enthesopathies. [Updated 2021 Jul 18]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK559030/
  3. Martey C. Co-morbidities within Spondyloarthritis Course. Physioplus, 2020.
  4. Finucane LM, Downie A, Mercer C, Greenhalgh SM, Boissonnault WG, Pool-Goudzwaard AL et al. International framework for red flags for potential serious spinal pathologies. J Orthop Sports Phys Ther. 2020;50(7):350-72.
  5. Czaprowski D, Stoliński Ł, Tyrakowski M, Kozinoga M, Kotwicki T. Non-structural misalignments of body posture in the sagittal plane. Scoliosis Spinal Disord. 2018;13:6. 
  6. Jones MR, Prabhakar A, Viswanath O, Urits I, Green JB, Kendrick JB et al. Thoracic outlet syndrome: a comprehensive review of pathophysiology, diagnosis, and treatment. Pain Ther. 2019;8(1):5-18.
  7. Li N, Dierks G, Vervaeke HE, Jumonville A, Kaye AD, Myrcik D et al. Thoracic outlet syndrome: a narrative review. J Clin Med. 2021;10(5):962.
  8. John Gibbons. Upper Limb Tension Test (ULTT) for the Median Nerve (C5-T1 Brachial plexus). Available from: https://www.youtube.com/watch?v=fhsrNKWVh0s [last accessed 4/9/2021]
  9. John Gibbons. Upper Limb Tension Test - Radial Nerve (C5-T1 Brachial Plexus). Available from: https://www.youtube.com/watch?v=VngRTMhAlGE [last accessed 4/9/2021]
  10. Wilke HJ, Herkommer A, Werner K, Liebsch C. In vitro analysis of the segmental flexibility of the thoracic spine. PLoS One. 2017;12(5):e0177823.
  11. Haack M, Simpson N, Sethna N, Kaur S, Mullington J. Sleep deficiency and chronic pain: potential underlying mechanisms and clinical implications. Neuropsychopharmacology. 2020;45(1):205-16.
  12. Takatalo J, Leinonen T, Rytkönen M, Häkkinen A, Ylinen J. The effect of thoracic spine manipulation on thoracic spine pain and mobility – Preliminary results of RCT. Manual Therapy. 2016;25:e161.
  13. Henson B, Kadiyala B, Edens MA. Anatomy, Back, Muscles. [Updated 2021 Aug 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK537074/
  14. Heneghan NR, Gormley S, Hallam C, Rushton A. Management of thoracic spine pain and dysfunction: A survey of clinical practice in the UK. Musculoskelet Sci Pract. 2019;39:58-66.