Thoracic Examination

Functional Anatomy

The function of the thoracic spine and ribcage is the protection of the heart, lungs and viscera, ventilation of the lungs and a stable base for the attachment of muscles of the upper limbs, head and neck, vertebral column and the pelvis.[2] [3]Stability is provided at the expense of mobility. Reduced thoracic mobility may be due to; rib cage, spinous processes, zygapophyseal joint capsules, ligamentum flavum, dimensions of the vertebral bodies.[2]

The thoracic spine lies between the superior cervical spine and the inferior lumbar spine. It consists of 12 vertebrae that are distinct in shape and function from vertebrae found in other regions of the vertebral column. The bodies of the thoracic vertebrae are medium sized and heart shaped.[4] They are all weight-bearing and generally increase in size from superiorly to inferiorly with an increase in the amount of weight that needs to be supported. They possess articular facets on their sides for articulation with the heads of the ribs.[4][3]

For more detailed explanations of the anatomy of the thoracic vertebrae see here.

The rib cage consists of 12 pairs of ribs:

  • 1 st – 7 th ribs: (true) attach directly to sternum
  • 8 th – 10 th ribs: articulate with sternum via the costal cartilages above them
  • 11 th and 12 th ribs: floating ribs as they do not attach to sternum[2]

Subjective Exam

Primary thoracic spine pain disorders comprise approximately 15% of all back/spine complaints.[5] 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.

Symptoms (recorded on a body chart)

(i)Area

Distribution

  • May follow course of rib or run horizontally across chest.
  • Thoracic spine, scapula or sternum
  • Upper limbs (upper cervical spine)
  • Lower limbs (lower cervical spine)
  • Clear all other relevant areas and mark with ticks[6]

(ii)Type

Quality

Intensity

  • VAS
  • Pain diary may be useful for chronic pain patients

Depth

Abnormal sensation

  • Paraesthesia
  • Numbness

Constant/Intermittent

  • If, constant, check whether there is variation in the intensity of

symptoms

  • Constant unremitting pain may be indicative of neoplastic disease

(iii)Behaviour[6]

Aggravating factors

  • Deep breathing, rotation of the thorax

Easing factors

  • Thoracic extension

Severity and irritability

  • Used to identify those who will not be able to tolerate a full objective

examination

  • Severity - If patient is able to sustain a position that reproduces the

symptoms then condition is considered non-severe. If patient cannot sustain the position, the condition is

considered severe and no overpressures should be attempted

  • Irritability- If symptoms ease immediately after provocation then the

condition is considered to be non-irritable and all movements can be

tested. If symptoms take a few minutes to ease, the symptoms are

irritable and only a few movements should be attempted to avoid

exacerbating the patients’ symptoms

  • 24hr symptoms- Night, morning and evening symptoms (morning stiffness for a few minutes suggests spondylosis, stiffness and pain for a few hours suggests inflammatory processes such as A.S.) Position of sleep, no. of pillows, do symptoms affect sleep? Soft or firm mattress?

Improving, staying the same, getting worse[6]

Special questions (to identify precautions or absolute contraindications to examination

or treatment)

  • General health
  • Weight loss
  • RA
  • Drug therapy
  • X-rays and medical imaging
  • Neurological symptoms

HPC

  • Known or unknown cause
  • Sudden/slow onset
  • How long ago did symptoms start
  • Route to physiotherapy

PMH

  • Relevant medical history
  • Previous episodes
  • Previous Rx

Social history

  • Employment, dependants, leisure activities etc.

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:

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.[7][3]
Wainner and Fritz developed questions to help determine if the patient has a cervical radiculopathy;[8]

  • “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 the other due to the shared afferent innervation of the ANS sympathetics, which originate from T1-L2 afferents from the spinal cord.[9]
  • 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.[10]
  • 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.[11]
  • 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.[12] 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 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 (from in front, behind and from the side)

Posture (Sitting and and Standing)[3][13]

  • 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 sagittal planes.
  • The overall impression of inter-rater reliability for postural observation of kyphosis and label either excessive, normal or decrease range from moderate to substantial according to a study performed by Cleland et al.[14]
  • Paying attention to some of the following; symmetry, Cx/Tx/Lx curvatures, deviations of the spine, shoulder levels, shoulder girdle, scapula position, GH joint position, level of the pelvis, limb position
  • Muscle bulk and tone (compare sides, hand dominance)
  • Soft tissues (Skin colour and quality, Swelling, scars)
  • Gait (Trendelenburg gait, short leg gait)
  • Attitudes and feelings[6]

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. [13]

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.[15]

Assessment of skin temperature, soft tissues, muscle tone, tenderness, increased or decreased prominence of bones, position of vertebrae and ribs

  • Supine- sternum, ribs, clavicle, sternocostal and costochondral 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[6][13]

Movement Testing

Thoracic spine AROM, PROM, and Overpressure for:

  • Flexion
  • Extension
  • Side-bending
  • Rotation
  • Combined Movements (rotation with extension)
  • Assess for baseline symptoms including intensity and location prior to testing. Note changes in intensity and location of symptoms and where in the range they occur during test.
  • Ensure the motion is purely thoracic by ensuring the patient is not compensating with lumbar and pelvis movement.
  • Repeated motion may be performed to assess for centralization of symptoms or a directional preference.
  • Repeated motion testing has been predominately studied for lumbar and cervical spine at this time.
  • The normal end feel for all the motions listed is firm.
  • Flexion, extension and side-bending may be measured with a double inclinometer method, but no normative values have been found, and reliability of these measurements has not been researched.
  • Rotation and combined movements measured purely on observation.[16][13]


Passive Intervertebral Motion

[17]
[18]
[19]
[20]

To access accessory intervertebral motion apply pressure in a posterior to anterior direction to the thoracic spine either centrally directly on the spinous process (central) or unilaterally located just lateral to the spinous process.

Rib motion may be accessed in two locations, posterior to anterior pressure applied to the rib angles and anterior to posterior pressure applied at the costosternal joints.

The examiner assesses for pain provocation and mobility of each joint and determines whether it is hypomobile, hypermobile or normal. Also note pain provocation.[16]

Reliability of thoracic spine passive accessory:

Thoracic Spine Central PA assessment

  • Intra-rater and inter-rater reliability in the thoracic spine when determining mobility dysfunction was fair when using strict agreement of spinal levels. When the expanded agreement to include one segment above or below intra-rater and inter-rater reliability increased to good to moderate.[21]
  • Cleland found thoracic spine mobility testing ranged from fair agreement to substantial agreement between each separate segment of the thoracic spine.[14]
  • In the study by Potter, testing for thoracic joint dysfunction using postural observation, active and passive range of motion, palpation, and PAs was rated as poor to moderate for intra-rater reliability.[22][16]

Rib Cage

  • The intra-rater reliability was found to be fair with strict agreement and increased to good with expanded agreement.[21]

Reliability of Pain Provocation:

Central Thoracic PAs

  • Intra-rater pain provocation with strict agreement ranged from fair to good and inter-rater reliability was fair. When the agreement was expanded intra-rater reliability was increased to very good and inter-rater reliability increased to good.[21]
  • Pain provocation had a similar variance across the thoracic spine with a range from no agreement to substantial agreement.[14][16]

Rib Cage

  • Strict agreement the intra-rater reliability ranged from no agreement to moderate and no agreement for the inter-rater reliability. When the agreement was expanded both intra-rater and inter-rater reliability increased to complete agreement and good respectively.[21]

Muscle Testing

Testing both muscle length and strength is important to identify functional limitations and compensations of each muscle. The measurement serves as a baseline to aid in tracking progress and allows the therapist to properly target impairment with interventions.

Muscle Length Testing[13][14]

  • Latissimus Dorsi - moderate to substantial inter-rater reliability
  • Pectoralis Major- fair to substantial inter-rater reliability
  • Pectoralis Minor- moderate to substantial inter-rater reliability

Muscle Strength[13][14]

  • Middle Trapezius- no inter-rater reliability
  • Lower Trapezius- no inter-rater reliability
  • Seratus Anterior- fair to substantial inter-rater reliability
  • Rhomboids- moderate inter-rater reliability[6]

Neurologic Assessment

Questions to help determine the direction of the neurological screen.

  • Do you get symptoms into the legs or low back with neck movements?

If yes, perform a detailed neurological examination

  • Have you experienced any bilateral upper extremity symptoms or occasional loss of balance or lack of coordination in the lower extremities?

If yes, perform a detailed neurological examination

  • Upper Motor Neuron Reflexes (Hoffman, Babinski, Clonus)
  • Sensory Testing: T1 dermatome (medial forearm)
  • T1 Nerve Root Level: first dorsal interossei
  • Upper Quarter Neurologic Screen for upper thoracic
  • Lower Quarter Neurologic Screen for lower thoracic

Neural tissue provocation tests

  • Passive neck flexion
  • Neural tissue provocation tests for the upper limb
  • Straight leg raise
  • Passive knee bend
  • Slump test[13]


Special Tests

[23]
  • Cervical Rotation Lateral Flexion (CRLF) Test- If first rib elevation or hypomobility is suspected.
  • Slump Test- To determine neural tension.
  • Adsons test -  provocative test for Thoracic Outlet Syndrome accompanied by compression of the Subclavian artery by a cervical rib or tightened anterior and middle scalene muscles
  • Kehr’s sign- With the patient in supine and legs elevated, a report of pain in the supraclavicular area can be secondary to irritants or blood in the peritoneal cavity rather than musculoskeletal involvement. It is a classic symptom for a ruptured spleen and can result from other splenic injuries, renal calculi, diaphragmatic lesions, peridiaphragmatic lesions, or an ectopic pregnancy.
  • Cervicothoracic tests -  to provoke the patient’s symptoms of neck pain. These clinical tests are part of the examination proceeded in order to establish the differential diagnosis
  • Murphy’s Percussion- Place hand over costovertebral angle of the back and thump hand with the other fist. If there is a reproduction of back or flank pain this is a positive test and indicative of kidney involvement.
  • Palpate Abdomen:

     -Right Upper Quadrant: Liver, gallbladder, duodenum, head of pancreas, right kidney and the hepatic flexure of the colon.

     -Left Upper Quadrant: Stomach, spleen, left lobe of liver, body of pancreas, left kidney and adrenal gland, splenic   flexure of colon, and parts of the transverse descending colon.

     -Right Lower Quadrant: Cecum, appendix, ascending colon, right ovary and fallopian tube and right ureter.

     -Left Lower Quadrant: Left ovary and fallopian tube, left ureter, descending colon and sigmoid colon.

  • Palpation of the Aortic Pulse in the Abdomen- Use this test on patients at risk for an abdominal aortic aneurysm. Place the patient in a supine hooklying position with the abdominal muscles on slack. Palpate to the left of the patient’s navel feeling for a pulse, once felt continue laterally until the pulse can no longer be detected. If the distance the pulse is detected is > 2.5 cm refer the patient for additional diagnostic studies.
  • Rebound Tenderness- Place hand on abdomen in an area away from suspected inflammation, slowly and deeply palpate. Quickly remove hand. If the patient feels pain on release this is called rebound tenderness and can be indicative of an inflamed peritoneum.
  • Thoracic Excursion- Thoracic excursion can be measured on a patient you suspect decreased chest expansion, including ankylosing spondylitis. Using a cloth measuring tape and standardized measuring locations (5th thoracic spinous process/3rd intercostal space and 10th thoracic spinous process/xyphoid process) have the patient exhale completely and take the measurement, then have them inhale to their full capacity and record the measurement. [6]

Presentations

https://http://vimeo.com/40420688APchestwall pain ppt.PNG
Anterior and Posterior Chest Wall Pain Differential Diagnosis for the Physical Therapist

This presentation, created by Stephanie Pascoe, Evidence in Motion OMPT Fellowship, 2012.

View the presentation

References

  1. Thoracic Vertebrae
  2. 2.0 2.1 2.2 Oliver, J., Middleditch, A., (1991), Functional Anatomy of the Spine, Butterworth-Heinemann, Oxford
  3. 3.0 3.1 3.2 3.3 Levangie P, Norkin C, (2001), Joint Structure and Function; A Comprehensive Analysis, 3 rd Edition, F.A. Davis Company, Philadelphia
  4. 4.0 4.1 Thoracic Vertebrae. (2018, January 15). Physiopedia, . Retrieved 13:45, January 28, 2018 from https://www.physio-pedia.com/index.php?title=Thoracic_Vertebrae&oldid=182308.
  5. Linton SJ, Hellsing AL, Hallden K. A population-based study of spinal pain among 35-45-year-old individuals. Prevalence, sick leave, and health care use. Spine (Phila Pa 1976) 1998 Jul 1;23(13):1457-1463.
  6. 6.0 6.1 6.2 6.3 6.4 6.5 6.6 Magee, D, (2002) Orthopedic Physical Assessment, 4 th Edition, Saunders, London
  7. Wainner RS, Fritz JM, Irrgang JJ, Boninger ML, Delitto A, Allison S. Reliability and diagnostic accuracy of the clinical examination and patient self-report measures for cervical radiculopathy. Spine (Phila Pa 1976) 2003 Jan 1;28(1):52-62.
  8. Wainner RS, Fritz JM, Irrgang JJ, Boninger ML, Delitto A, Allison S. Reliability and diagnostic accuracy of the clinical examination and patient self-report measures for cervical radiculopathy. Spine (Phila Pa 1976) 2003 Jan 1;28(1):52-62.
  9. Benhamou CL, Roux C, Tourliere D, Gervais T, Viala JF, Amor B. Pseudovisceral pain referred from costovertebral arthropathies. Twenty-eight cases. Spine (Phila Pa 1976) 1993 May;18(6):790-795.
  10. Hamberg J, Lindahl O. Angina pectoris symptoms caused by thoracic spine disorders. Clinical examination and treatment. Acta Med Scand Suppl 1981;644:84-86.
  11. Blake C, Garrett M. Impact of litigation on quality of life outcomes in patients with chronic low back pain. Ir J Med Sci 1997 Jul-Sep;166(3):124-126.
  12. Kendall NAS, Linton SJ, Main CJ. Guide to assessing psychosocial yellow flags in acute low back pain: risk factors for long-term disability and work loss. New Zealand: Accident Rehabilitation; Compensation Insurance Corporation of New Zealand, and the National Health Committee, Ministry of Health 1997.
  13. 13.0 13.1 13.2 13.3 13.4 13.5 13.6 Petty, N, Moore, A, (2002), Neuromuscular Examination and Assessment A Handbook For Therapists, 2 nd Edition, Churchill Livingstone, Edinburgh
  14. 14.0 14.1 14.2 14.3 14.4 Cleland JA, Childs JD, Fritz JM, Whitman JM. Interrater Reliability of the History and Physical Examination in Patients With Mechanical Neck Pain. Arch Phys Med Rehabil 2006 10;87(10):1388-1395.
  15. Flynn TW, Cleland JA, Whitman JM, Users’ Guide to the Musculoskeletal Examination. Cervicothoracic spine examination. Evidence in Motion, 2008. p72-102.
  16. 16.0 16.1 16.2 16.3 Maitland, G, (1991), Vertebral Manipulation, 3 rd Edition, Butterworth Heinemann, London
  17. Physiotutors. Intervertebral Motion Assessment of Upper Thoracic Spine Flexion | PIVMs. Available from: https://www.youtube.com/watch?v=qcmUL4poIVk
  18. Physiotutors. Intervertebral Motion Assessment of Upper Thoracic Spine Extension | PIVMs. Available from: https://www.youtube.com/watch?v=KYNB6qQjRKs
  19. Physiotutors. Intervertebral Motion Assessment of Mid-/Lower Thoracic Spine Flexion | PIVMs. Available from: https://www.youtube.com/watch?v=_S5jXsUwJ7Q
  20. Physiotutors. Intervertebral Motion Assessment of Mid-/Lower Thoracic Spine Extension | PIVMs. Available from: https://www.youtube.com/watch?v=YhzT6QVdb5Y
  21. 21.0 21.1 21.2 21.3 Heiderscheit B, Boissonnault W. Reliability of Joint Mobility and Pain Assessment of the Thoracic Spine and Rib Cage in Asymptomatic Individuals. Journal of Manual and Manipulative Therapy 2008 12;16(4):210-216.
  22. Potter L, McCarthy C, Oldham J. Intraexaminer Reliability of Identifying a Dysfunctional Segment in the Thoracic and Lumbar Spine. J Manipulative Physiol Ther 2006 4;29(3):203-207.
  23. Physical Therapy Nation. Lindgren's Test for First Rib Dysfunction. Available from: http://www.youtube.com/watch?v=U7ZRo09Vn04 [last accessed 14/12/13]