Lecture 4b: Thoracic Spine And Rib Exam And Evaluation Flashcards
What is the most important region for load transfer b./t upper body and lower body
Thoracic spine
What are the 3 major areas of MSK dysfunction in the thoracic spine
• 1st Costo-vertebral (CV) joints
• 2nd Thoraco-lumbar (TL) junction
• 3rd Cervico-thoracic (CT) junction
T/F: MSK origins of pain/symptoms are less common in t-spine
T
Where can T spine pan refer distally
• Groin, pubis
• Lower abdominal wall
How is the onset of symptoms for mm or ligament issue and bone issue
- muscle or ligament may be immediate or delayed several hours or days
- bone pain is usually immediate
How is visceral pain usually
Vague and dull , hard for patient to pinpoint
Where does gallbladder pain refer to
Upper T thoracic/ scapular pain
What is usually the patient hx for aortic aneurysm
40-70 y/o w/ no clear MO, no hx of trauma , non mechanical symptoms
Pulsating abdomen when physical exam
What is a non msk thing that could cause pain in mid back
Cardiac
What non msk thing can mimic rib dysfucntion
Pleurisy
Where is Angina pain going to be for non msk thoracic pain
L , R or B jaw , neck, scapular pain , medial board of UE , mid thoracic pain
How may a patient present w myocardial infaraction
-chest pain
-pallor
- sweating
- dyspnea
-nausea
- palpation
- SYMTOMS > 30 mins
What are the 3 lung medical causes of thoracic pain
- apical (pancoasts tumor)
- pulmonary embolus (emergent)
- pnemorthorax (emergent)
Where in the spine does the apical (pancoast’s) tumor compress
C8-T1
Where is the pain and what is difficult with a pulmonary embolus
Chest, shoulder , or upper abdomen pain
Hard to breath
What is present w a pneumothorax
Chest pain that increases or decreased w breathing and have decreased breath sounds
Where is there pain with a pleura and what does it feel like
Pain w breahing and thoracic movements (mimics joint lesion),
Feels like knife like pain
What is a chlecystitis
C4 dermatome d/t irrigation of diaphragm
Is a dissecting aortic aneurysm urgent or emergent and what is it
Emergent
Sudden onset of chest pain that can radiate to the back
Not relieved by position change
What are the most common primary tumors that casues thoracic pain
Breast , lungs or colon
What are 2 inflammatory disease that can causes thoracic pain (non MSK)
- ankylosing spondy
RA
What is the key finding for ankylosing spondylitits
- young males
- limited chest expansion **
- night pain
- buttocks pain
What are the 4 neurogenic MSK causes of thoracic pain
- SC
- sensory nerve root infection
- nerve root palsy
- spinal stenosis
What is the critical zone for spinal stenosis
T4-T9
What are the 4 articular MSK causes of thoracic pain
- costo transverse sand costo vertebral Jong
- costo chondral and stereo chondral
- sterno manubrial
- z joint
What can Costo-transverse and costo-vertebral joints thoracic pain be from
- traumatic sprain from excessive spinal rotation
- subluxation after MVA , forceful rotation or direct truma
Disc pain is more common where in the thoracic region
Lower t spine
Does disc problems in the T spine require sx
Nah
What is Tietze syndrome
Local inflammation of costo sternal cartilage (typically 2nd rib)
Self limiting condition that may last from weeks to years
For thoracic spine dysfucntion , __ pain is common
Referred
It is importnat to DDx back pain in the t spine .. what are they (4)
• Visceral origins
• Serious origins
• T-spine dysfunction
• Rib dysfunction
What may visceral pain be accompanied by
Nausea and sweating ( pain tends to be vague and dull)
What should u ALWAYS do in a systems review
Take vitals
What should u clear in the systems review secondary to spinal cord susceptibility
UMN S/S (B UE symtoms , intermittent reposrts of LOB, decreased coordination in LEs)
How does MSK pain tend to present
Sharp and more localized and changes w specific positions and movements
What would make us thing it is serious pathology
No changes in pain based on position + night pain + unexplained weight loss
what kiind of dysfucntion is common in t spine
postural
what kind of HX of pain will ppl w postural dysfunctions have
pain following sustained positions or postures
is ti easy or hard to reproduce pain w exam for a postural dysfucntion
hard
will the neuro exam for a postural dysfunction exam be + or -
-
where in the t spine is thoracic disc patholody more comon
lower t spine
what is important to distinguish between with a thoracic disc patholofy
myelopathy and radiculopthy
thoracic disc path typicaltl results of what 2 things
- Narrow spinal canal and lateral foramina
- Degenerative △’s
The clinical presentations for thoracic disc path is widely variable and vague but what are 3 things that are common
- Pain w/ active and passive motion in at least 1 direction
- (+) dural signs w/ or w/o radiculopathy= (+) slump
- (+) coughing
If there a thoracic disc path at T9-T11 where will pain radiate
Into buttocks and mimic lumbosacral radiculopathy
Bilateral symptoms/ weakness may suggest myelopathy
If there a thoracic disc path at T3-T8 where will pain radiate
Pain and/or neuro SYMTOMS at lateral or anterior portions of trunk
If there a thoracic disc path at T2- T3 where will pain radiate
RAREST TYPE
Pain and/or neuro symptoms toward clavicle , scapular spine or medial arm
How is the dx of thoracic facet joint dysfunction made
Based on motion restrictions (8 potential joint or soft tissue restrictions
8 joints
2 articular facet + 2 costo-vertebral + 2 costo-transverse + 2 intervertebral
What is KEY in determining location of thoracic facet joint dysfucntion
palpation
if it is off to one side then we are thinking it is more a rib dysfucntion
What can causes thoracic facet joint dysfucntion
Change in training load or ergonomic set up
What is the Rx for thoracic facet joint dysfucntion
HVLAT
Active exercseis
Pt education
For a rib dysfucntion the ___ ___ joint may be invovled in inflammatory or degenerative joint disease
Costo vertebral
What is the clinical presentation for rib dysfucntion
- Pain w/ deep breathing, trunk rotation, coughing, sneezing
- Localized pain 3-4 cm from midline
What is the RX for rib dysfucntion
Manual therapy
Local injections
T/f: abdominal mm strains and contusions re common in the t spine
True
What is clinical presentation of abdominal mm strains and contusions
- Localized pain and tenderness
- Pain ↑’s w/ isometric contraction and/or passive stretching
- Pain worse w/ movement, deep inspiration, coughing
What is the RX for Abdominal Muscle Strains and Contusions
: RICE, anti-inflammatory meds, activity modifications, gradual strength training and passive stretching as tolerated
What are 2 things u should consider with thoracic vertebral fx
Trauma vs osteoporosis q
What is the MOI for thoracic vertebral fx
Hyperflexion or axial loading
How are the articuluar signs for thoracic vertbral fx
Positive in all directions
What test is usually postive with thoracic vertebral fx
Compression
Osteoporotic fx typically occur between what vertebral bodies
9th adn 11th
What should u consider w rib fx
Trauma vs repetitive stress
What can rib fx lacerate thru
Pleura
Lung
Abdominal organs
What can rib fx casues if in the upper ribs
Brachial plexus or vascular injury
How is the onset of pain for rib fx
Immediate
How is the articular signs and palpation for rib fx
(+)
What is the MOI for sternal fx
Seatbelt (very rare tho tbh)
During a sternal fx what can be life threatening
Posterior dislocation of SC joint
What is scheuermann Disease (AKA scheuermann kyphosis , juvenile kyphosis)
Defect in apophyseal ring of vertebral body causing anterior wedgin
What is a Schmorl node in scheuermann disease
Where end playe cracks causing disc herniation
What is the clinical presention with scheuermann disease
- Thoracic kyphosis
- Pain w/ thoracic extension and rotation
What is the etiology for T4 syndrome
Unknown
Can occur from T2-T7 but will always include T4
Is T4 syndrome more common in females or males
F
What test are (+) with T4 syndrome
Slump test and ULTTs
What is teh clinical presentation with T 4 syndrome
- hx of HAs , neck pain , UE pain
- night pain in sidelying or supine
- TTP on bony landmarks
-depression or prominence of 1 spinal segment - thickening or hypomobility of 1 segment while rest of spinal motin in normal
What is the pain pattern for T4 syndrome
Non predicable
The thoracic outlet is an anatomic space boarded by what 3 things
- 1st thoracic rib
-clavicle - superior border of scapula
What is the interscalence trinagle of the thoracic outlet bordered by anteriorly , posteriorly and inferiorly
Anteriorly: anterior scalence mm
posteriorly: middle scalence mm
Inferiorly- 1st rib
What syndrome is characterized by SYMTOMS attributable to compression of nerual and /or vascular structures that pass thru the thoracic outlet
TOS
What are the potential causes/compression sites for TOS
- presence of cervical rib
- scalence triangle **
- hyper abduction syndrome
- costoclavicualr syndrome
- pec major **
- 1st thoracic rib
T/f: tos can be limb threatening
Yes
How is teh dx for thoracic outlet syndrome
Subjective hx and physcial exam
- Neurogenic - compression of BP at scalence triangle (most common)
- Venous- compression of subclavian vein by structures making up the costoclavicaulr junction
- Arterial- compression due to abnormal bony or ligamentous structures at thoracic outlet region
What may the medical referral from 1st rib dysfucntion say
Cervical disc herniation
If it is parasthesias w non dermatome a pattern is it radic?
No bc it is no dermatomal
What mm is hypertonic in 1st rib dysfucntion
Posterior scalence muscle
Common SYMTOMS of 1st rub dysfunction come from what
Medial plexus (C8-T1)
What is the Rx for 1st rib dysfucntion
Gapping HVLAT
AROM exercises
Strengthening exercises
2nd rib dysfucntion medical referral may say what
Shoulder impingement
What is the 1st clue of 2nd rib dysfucntion
Posterior should pain w/o a shoulder history
How is the contractile testing and palpation of tendon insertions for 2nd rib dysfucntion
(-)
What is loss in 2nd rib dysfucntion
Shoulder girdle elevation
What are the 3 types of TOS
- Neurogenic - compression of BP at scalence triangle
- Venous- compression of subclavian vein by structures making up the costoclavicaulr junction
- Arterial- compression due to abnormal bony or ligamentous structures at thoracic outlet region
What is ‘flail chest/segment for rib fx
Paradoxical movement of chest wall during respiration ; indication chest wall instability and multiple fx
