Orthopaedic

Assessments

THORACIC
(DORSAL)
SPINE
Agenda
Introduction
Applied anatomy
Patient history
Observation
Examination
Active ROM
Passive ROM
Isometric resisted ROM
Special tests
 Thoracic Spine - Introduction

-Most rigid part of the spine due to the

ribs

-Must include examination of the ribs

as well as the areas above and below
 Thoracic Spine - Introduction

-The thoracic spine serves to protect

organs (ie. heart, lungs)

-Primary curve – kyphosis

-Lumbar and cervical spine are

secondary curves (lordoses)
 Thoracic Spine – Applied Anatomy

-The spinal canal is small and circular

-Smallest at T1-3, largest at T12
-Facets are located on the TVPs and the
bodies (costotransverse and costovertebral
joints)
-Superiorly to inferiorly, the TVPs reduce in
size from large, wing-like structures to
become more short and blunt
Thoracic Spine – Applied Anatomy
The SPs: Thoracic Spine – Applied Anatomy

-T1-3: are in the transverse plane as the

same body and TVP
-T4-6: project downward slightly and are on
a plane halfway b/w their own TVP and TVP
of vertebrae below
-T7-9: project downward and are on a
plane of the TVP below
-T10: similar to T9
-T11: similar to T6
-T12: similar to T3
 Thoracic Spine – Applied Anatomy

-T7 has the greatest spinous process

angulation

-Sometimes classified as a transitional

vertebra b/c it is the point at which the
lower limb axial rotation alternates with the
upper limb axial rotation
ie. Gait: axial rotation of the spine going
from one side to the other during gait
Thoracic Spine – Applied Anatomy
 Thoracic Spine – Applied Anatomy

COSTOVERTEBRAL JOINTS
-b/w the ribs and vertebral bodies
-24 joints
-ribs 1, 10, 11 & 12 articulate with a single
vertebra
-ribs 2-9 articulate with two adjacent
vertebrae and the intervening IVD
 Thoracic Spine – Applied Anatomy

COSTOTRANSVERSE JOINTS
-b/w the ribs and the TVPs of the vertebra of
the same level for ribs 1-10
-ribs 11 & 12 do not articulate with the -TVPs
so there is no costotransverse joint
associated for ribs 11 & 12
Thoracic Spine – Applied Anatomy
 Thoracic Spine – Applied Anatomy

COSTOCHONDRAL JOINTS
-b/w the ribs and costal cartilages

STERNOCOSTAL JOINTS
-b/w the costal cartilage and the
sternum
 Thoracic Spine – Applied Anatomy

Transitional vertebrae
-T1(facets are similar to that of the
cervical spine)
-T11-12 (facets are similar to that
of the lumbar spine)
 Thoracic Spine – Applied Anatomy

Facet Joints of the T-Spine

Resting Pos'n midway b/w
flexion and
extension
Close Packed Pos'n extension
Capsular Pattern side flexion
and rotation
equally limited,
then extension
 Thoracic Spine – Applied Anatomy

The Ribs
-Articulate with the demifacets on
vertebrae T2-9
-T1 & T10 possess a whole facet for ribs 1 &
10, respectively
-Rib 1 articulates with T1 only
-Rib 2 articulates with T1-2, Rib 3 articulates
with T2-3, etc
 Thoracic Spine – Applied Anatomy

Ribs 1-7 = TRUE RIBS (articulate with the

sternum directly)

Ribs 8-10 = FALSE RIBS (articulate directly

with the costocartilage of the rib above)

Ribs 11 & 12 = FLOATING RIBS (do not

articulate to either the sternum or the costal
cartilage at their distal ends)
 Thoracic Spine – Applied Anatomy

At the top of the rib cage, the ribs are

relatively horizontal

As the rib cage descends, the ribs run

more obliquely downward

By rib 12, they are more vertical than

horizontal
Thoracic Spine – Applied Anatomy
Thoracic Spine – Applied Anatomy
 Thoracic Spine – Applied Anatomy

INSPIRATION: ribs are pulled upward

and forward
Increases the AP diameter of the ribs

Ribs 1-6 – PUMP HANDLE

-rotate about their long axes
-during inspiration, they rotate upwards
Thoracic Spine – Applied Anatomy
 Thoracic Spine – Applied Anatomy

Ribs 7-10 – BUCKET HANDLE

-Increase in a lateral (transverse)
dimension
-With inspiration, they move upward,
backward and medially
Ribs 8-12 – CALIPER ACTION
-Move laterally, to increase lateral
diameter
Thoracic Spine – Applied Anatomy
 Thoracic Spine – History

Review relevant section in Magee

Scheuermann's Disease
-Aka: Juvenile Kyphosis
-Vertebral bone tissue dies causing
kyphotic deformity
-Cause: unknown
-Boys more affected than girls
Thoracic Spine – History
Thoracic Spine – History
Spinal posture Thoracic Spine – Observation

-Kyphosis
-Scoliosis
 Thoracic Spine – Observation

KYPHOSIS
-Most prevalent in the thoracic spine
-May be visually fooled by the
musculature or position of the
scapulae into thinking there is
excessive kyphotic curvature
 Thoracic Spine – Observation

KYPHOSIS
ROUND BACK:
BACK
-Thoracolumbar or thoracic kyphosis
and decreased pelvic inclination (20°)
-Secondary to prolonged postural
stresses or growth disturbances (ie.
Scheuermann's disease) that have
altered the centre of gravity
Thoracic Spine – Observation
 Thoracic Spine – Observation

KYPHOSIS
HUMP BACK:
BACK
-Localized, sharp, posterior angulation
= GIBBUS
-Usually structural
-Anterior wedging to one or two
vertebral bodies
-Pelvic inclination usually normal (30°)
Thoracic Spine – Observation
 Thoracic Spine – Observation

KYPHOSIS
FLAT BACK:
BACK
-Pelvic inclination decreased (20°)
-Similar to round back except the T/S
remains mobile
-Although a kyphosis is or should be
present, it does not have the
appearance of an excessive kyphotic
curve
 Thoracic Spine – Observation

KYPHOSIS
DOWAGER'S HUMP:
HUMP
-Secondary to postmenopausal
osteoporosis
-Osteoporosis causes anterior wedge
fractures to several vertebrae, usually in
the upper to middle thoracic spine
Thoracic Spine – Observation
Thoracic Spine – Observation
 Thoracic Spine – Observation

SCOLIOSIS
-One or more lateral curvatures to the
thoracic and/or lumbar spine(s)
-Structural vs. Non-Structural
 Thoracic Spine – Observation

Structural Scoliosis
-Structural change to the bone(s) of
the spine with associated loss of
normal flexibility
-Vertebral bodies rotate towards the
convexity of the curve
Genetics, idiopathic, congenital problem
(wedge vertebra, hemivertebra, failure of
vertebral segmentation)
 Thoracic Spine – Observation

Non-Structural Scoliosis
-No structural changes and is more
amenable to correction
-Poor posture, nerve root irritation,
inflammation in the spine, LLI, hip
contractual
 Thoracic Spine – Observation

Scoliotic Curves
-Designated according to the level of
the apex of the curve and in relation to
the convex side
-Cervical scoliosis (aka. Torticollis), the
apex is b/w C1-C6
-Cervicothoracic scoliosis, the apex is
at C7 or T1
 Thoracic Spine – Observation

Scoliotic Curves
-Thoracic scoliosis, the apex is b/w T2-
T11
-Thoracolumbar scoliosis, the apex is
at T12 or L1
-Lumbar scoliosis, the apex is b/w L2-
L4
-Lumbosacral scoliosis, the apex is at
L5 or S1
 Thoracic Spine – Observation

Scoliotic Curves
Example:
A right thoracic curve has a convexity
toward the right (concavity is towards
the left), and is in the thoracic spine.
 Thoracic Spine – Observation

Scoliotic Curves
-because the vertebral bodies rotate
towards the convexity, in the thoracic
spine, this rotation will cause the ribs on
the convex side to push posteriorly
-Rib “humping”
-Thoracic cage narrows on the convex
side
 Thoracic Spine – Observation

Scoliotic Curves
-Rotation of the vertebral bodies to the
convexity causes the SPs to deviate
towards the concavity
-Ribs on the concave side move
anteriorly causing Rib “hollowing” and
the thoracic cage widens
Thoracic Spine – Observation
 Thoracic Spine – Observation

-Observe how the patient sits

-Sits tall or sags
-Breathing pattern
-Children tend to breathe
abdominally
-Women tend to do upper thoracic
breathing
-Men tend to be upper and lower
thoracic breathers
 Thoracic Spine – Observation

Chest Deformities
Pectus Carinatum (pigeon chest)
-Sternum projects forward and
downward
-Increases the AP dimension of the
chest
-Impairs breathing by restricting
ventilation volume
Thoracic Spine – Observation
 Thoracic Spine – Observation

Chest Deformities
Pectus Excavatum (funnel chest)
-Sternum is pushed posteriorly by an
overgrowth of the ribs
-AP dimension of the chest is
decreased and the heart may be
displaced
-May result in kyphosis
Thoracic Spine – Observation
 Thoracic Spine – Observation

Chest Deformities
Barrel Chest
-Sternum projects forward and upward
so that the AP diameter is increased
-Seen in pathological conditions such
as emphysema
Thoracic Spine – Observation
 Thoracic Spine – Examination

-Examination may include cervical spine, lumbar

spine, pelvis, upper limbs and lower limbs
-Active movements are usually performed with
the client standing.
-Watch for trick movements in the hips. If seeing
a lot of cheating ...
... Performing the Active ROM in the sitting
position would help decrease or eliminate hip
involvement
 Thoracic Spine – Examination

Active ROM
Forward flexion 20° – 45°
Extension 25° – 45°
Lateral flexion 20° – 40°
Rotation 35° – 50°
Costovertebral expansion 3 – 7.5 cm
Rib motion (pump handle, bucket handle, caliper)
Combined, repetitive, & sustained movements
and postures (if necessary)
 Thoracic Spine – Examination

Forward flexion 20° – 45°

-Can use a tape measure to attain an indication
of overall movement
-First measure the length of the spine from the
SPs of C7 to T12 (normal standing posture)
-Ask client to bend forward and measure again
A 2.7cm (1.1”) difference is considered normal
 Thoracic Spine – Examination

Forward flexion 20° – 45°

-May also measure from the SPs of C7 to S1
-Ask client to bend forward and measure again

A 10cm (4”) difference is considered normal

Note: this measurement includes measuring

movement in the L/S as well as in the T/S
 Thoracic Spine – Examination

A third method: May also measure from the

fingertips to the floor

PROBLEMS: must be absolutely certain that you

are isolating movement in the T/S (vs. the L/S
and hips). With this method, movement could
be occurring completely in the hips
 Thoracic Spine – Examination

Active ROM (cont'd)

-During forward flexion, observe for the spine
from the “skyline” view
-A non-structural scoliosis will disappear
-A structural scoliosis will remain
-Look for rib humping on the side of convexity
and rib hollowing on the side of concavity
-The thoracic spine should flex smoothly and
evenly. Look for any apparent tightness or sharp
angulation
 Thoracic Spine – Examination

Extension 25° – 45°

-May use a tape measure using the SPs of C7
and T12

A 2.5cm (1.1”) difference (standing) is

considered normal

-Thoracic curve should curve backward or

straighten in a smooth, even manner
-A client with excessive kyphosis will continue to
demonstrate a kyphosis during extension
 Thoracic Spine – Examination

-If uncertain as to whether or not the kyphosis

exists during extension, have the client perform
extension from the prone position

Rotation 35° – 50°

-Have client place hands on opposite shoulders
-To eliminate hip involvement, may perform
sitting
 Thoracic Spine – Examination

Costovertebral expansion (method 1)

-Therapist places tape measure around the chest
at the level of the fourth intercostal space
-Client is asked to exhale as much as possible,
and therapist measures
-Client is then asked to inhale as much as
possible and hold the breath while the therapist
measures

Normal difference: 3-7.5cm (1-3”)

 Thoracic Spine – Examination

Costovertebral expansion (method 2)

-Same as method 1, except measurements are
taken at
(1) under the axilla (apical expansion)
(2) nipple line (midthoracic expansion)
(3) T10 rib level (lower thoracic expansion)
 Thoracic Spine – Examination

Rib Motion
-Client supine with therapist's hands placed in a
relaxed fashion over the upper chest, middle
chest and lower chest
-If a rib stops moving relative to the other ribs on
inhalation = DEPRESSED RIB
-If a rib stops moving relative to the other ribs on
exhalation = ELEVATED RIB
 Thoracic Spine – Examination

Rib Motion ...

-Restriction of one rib will restrict the adjacent
ribs
-If a depressed rib is the problem, it is usually
the highest restricted rib that is the problem
-If an elevated rib is the problem, it is usually
the lower restricted rib that is the problem
 Thoracic Spine – Examination

Passive ROM
Forward flexion tissue stretch
Extension tissue stretch
Lateral flexion tissue stretch
Rotation tissue stretch

Passive movements of the T/S are performed by

assessing each pair of vertebrae
 Thoracic Spine – Examination

Passive ROM
-Client seated
-Therapist places one hand on the head of client
and the other palpates over and b/w the SPs of
the lower cervical and upper thoracic spine (C5-
T3)
-Feel for movement while guiding the head into
flexion/extension/lateral flexion/rotation
 Thoracic Spine – Examination

Passive ROM ...

-For levels b/w T3 and T11, have client clasp
hands behind head and the elbows together in
front
-Therapist: place one hand and arm around the
client's elbows while palpating over and b/w the
SPs
-Feel for movement while guiding the torso into
flexion/extension/lateral flexion/rotation
 Thoracic Spine – Examination

Isometric Resisted ROM

-Client seated
-Test with spine in a neutral position
-With a pillow between you and the client, wrap
your arms around the client and place one leg
behind the client's buttocks
-Test for: flexion/extension/lateral flexion/
rotation
 Thoracic Spine – Examination

SPECIAL TESTS
Slump Test
First Rib Mobility Test
 Thoracic Spine – Examination
Special Tests – Neurological Dysfunction
SLUMP TEST
(aka. Sitting Dural Stretch)
-Series of steps performed sequentially
-Only progress to the next step if no positive was elicited
-Perform test:
Start with non-affected side, then repeat on affected
side, then repeat with both sides simultaneously.

POSITIVE FINDING:
Reproduction of the symptoms
INDICATION OF:
Dural, cord and/or nerve root impingement
 Thoracic Spine – Examination

-Client seated at the edge of table with their

hands behind their back

-Ask client to “slump” the back into flexion

-Therapist supports client's chin in the neutral

position (no head or neck flexion)

-Therapist applies gently overpressure across

shoulders

-Ask client to bring their “chin to chest”

 Thoracic Spine – Examination

-Therapist again applies overpressure by

placing hand over the head

-With the other hand, therapist dorsiflexes

client's foot maximally

-Client is asked to actively straighten the knee

as much as possible

-If unable to extend knee, release overpressure

to neck
Thoracic Spine – Examination
 SPECIAL TESTS - Thoracic
First Rib Mobility Test
(Method 1)
-Client supine: Palpate 1st rib,
bilaterally
-Note movements with deep
breaths in
-Palpate one side and passively
side flex head to opposite side
-Note range and movement
-Asymmetry may be due to rib
hypomobility or same side scalene
tightness
 SPECIAL TESTS - Thoracic
First Rib Mobility Test (Method 2)
-Palpate rib with thumb
-Reinforce thumb with other thumb. Place
caudal force noting movement, end feel, pain
-Test opposite side