Thoracic Spine & Rib Cage

Question 1

What are the thoracic spine red flags?

Answer 1

• Unexplained weight loss
• History of cancer
• Night pain/sweats
• Constant, unremitting pain
• Age > 50
• Violent trauma
• Fever
• Saddle paraesthesia
• Altered bowel/bladder function
• IV drug use
• Progressive neurology
• Systemic stenosis

Question 2

What are the spinal cord red flags?

Answer 2

• Sensory changes in hand (esp bilateral)
• Wasting of intrinsic muscles of hand
• Unsteady gait
• Hyper-reflexia (Hoffman’s sign)
• Weakness/sensory changes at multiple levels
• Bladder/bowel changes

Question 3

What is Hoffman’s sign?

Answer 3

• Hand in neutral position
• Flick distal phalanx of middle finger
• Look for flexion of distal phalanx of thumb

Question 4

What are the characteristics of vertebral compression fracture?

Answer 4

• Associated with weakening of vertebral trabecular bone (e.g. OP)
• Severe thoracic spine pain (acute onset)
• Progressive thoracic kyphosis
• Respiratory compromise
• Pressure sores
• Often caused by low force (bending, lifting light object)

Question 5

What is the difference between OP & osteopenia?

Answer 5

• Osteoporosis: T score <2.5

- Osteopenia: T score -2.5 to -1, may progress to OP

Question 6

What are the types of VCFs?

Answer 6

• Wedge
• Biconcave
• Burst

Question 7

How are VCFs managed?

Answer 7

• Address causative factors (medical, endocrinology)
• Symptom management (pain relief)
• Prevent/manage complications (respiratory, posture/bracing)
• Corrective (surgery if very severe)

Question 8

When does a rib stress fracture commonly occur?

Answer 8

• Golf, kayaking, swimming, baseball, squash
• Rowing (8-16% elite)
• Causes large time loss from raining & competition

Question 9

What are the characteristics of rib stress fractures?

Answer 9

• Generalised rib pain in lateral chest wall
• Anterolateral/lateral location
• Increased pain with activity & deep breathing, shoulder f/abd/e, trunk f & EOR e, scapular protraction/retraction

Question 10

What are the differential diagnoses for rib stress fractures?

Answer 10

• Serratus anterior strain
• Intercostal strain
• Ewing’s sarcoma (younger, non-elite, no recent increase in training load)

Question 11

What is the treatment for rib stress fracture?

Answer 11

• 3-8 weeks rest/modified training (e.g. smaller oars)
• Avoid NSAIDs
• Graduated return while monitoring symptoms

Question 12

What are the characteristics of facet joint pain?

Answer 12

• Deep, dull ache

- Inferior & lateral to injection location

Question 13

How is facet joint pain commonly treated?

Answer 13

• Diagnostic injection of local anaesthetic

- >80% pain reduction in 42% of patients with chronic thoracic pain

Question 14

What articulations occur between the thoracic vertebrae & the ribs?

Answer 14

• Costovertebral (costocoporeal) joints: Head of ribs with vertebral bodies
• Costotransverse: Neck of ribs with transverse processes

Question 15

Which costotransverse joints are commonly painful?

Answer 15

• Left T3, T5, T7

- Right T2, T4, T6

Question 16

What is thoracic outlet syndrome?

Answer 16

• Compression of brachial plexus, arteries, veins in the thoracic outlet
• Pain, paraesthesia, weakness & discomfort in upper limb
• Doesn’t follow exact dermatomal/myotomal distribution
• Aggravated by elevation of arms or movements of neck

Question 17

What are the common sites of compression in TOS?

Answer 17

• 1st rib & between anterior & middle scalene
• Beneath clavicle
• Sub-coracoid tunnel (beneath pec minor)

Question 18

What are the subtypes of TOS?

Answer 18

• Neurological (nTOS, approx 95%)

- Vascular (vTOS, approx 5%)

Question 19

What is the epidemiology of TOS?

Answer 19

• Common in 30-60 years
• Women > men
• Often follows neck/shoulder injury
• Common occupations: Secretary, manual labour, truck driver
• Common sports: Swimming, diving, water polo, rowing, baseball (pitching)

Question 20

What is the treatment for TOS?

Answer 20

Surgery (removal of 1st rib)

Physio:

• Loss of motor control, breathing dysfunction, central sensitisation
• Neck/shoulder ROM & strength, thoracic spine mobility, scapular control training)

Question 21

What is scoliosis?

Answer 21

• Abnormal curvature/rotation of the spine
• Starts at puberty
• Unknown causes but strong genetic link
• 1-3% of children aged 10-16
• Majority requires no intervention

Question 22

What does the screening for scoliosis involve?

Answer 22

• Adams forward bend test
• Definitive: Cobb angle >10 deg (from XR)
• Description: Right convex

Question 23

What is the natural history of scoliosis if untreated?

Answer 23

• Curve progression
• Back pain
• Cardiopulmonary problems
• Psychosocial concerns

Question 24

What is Scheuermann’s disease?

Answer 24

• Increased kyphosis due to wedge shaped vertebrae

- >5 deg wedging in >3 adjacent vertebrae

Question 25

What is the cause of Scheuremann’s disease?

Answer 25

• Vertebral end plate defective growth or deterioration

- Genetic link

Question 26

What is the natural history of Scheuremann’s disease?

Answer 26

• Back pain
• Disability due to back pain
• Sciatic pain
• Difficulty going up stairs

Question 27

What is the treatment for Scheuremann’s disease?

Answer 27

• Avoid sports with heavy loading
• Bracing
• Posture
• Strengthening
• Stretching (pecs & hamstrings)

Question 28

What are the physio treatment modalities for thoracic spine & rib pain?

Answer 28

• Education (contributing factors)
• Passive treatments (massage, mobs, manipulation, taping, EPA)
• Active treatments (home exercise)
• Lifestyle (PA, stress management)

Question 29

What can treatment of thoracic spine pain also help?

Answer 29

• Neck pain

- Shoulder ROM