TS Classification/Diagnoses Flashcards
Arm Pit Pain (Body Chart)
T2
Whole Head Pain (Body Chart)
T4 Lower Lumbar
Low Back Pain (Body Chart)
T9-L2 Facet
Right UQ Pain (Body Chart)
T9
Lower Abdominal Pain (Body Chart)
T10/12 (Or L4/5)
Groin Pain (Body Chart)
T12 (L1)
Non-Radicular Referral
CS Facets
Green: C2-3
Purple: C3-4
Blue C4-5
Red: C5-6
Yellow: C6-C7
Non-Radicular Referral
Disc
Non-Radicular Referral
Generalized Hypomobility
Flattened TS
T4 Syndrome
Non-Radicular Referral
Nerve Root
(T2 and T8)
Non-Radicular Referral
Left Body:
L Yellow: T4-5
L Orange: T6-7
L Green: T8-9
L Blue: T10-11
R Purple: T3-4
R Green: T5-6
R Orange: T7-8
Plum: T9-10
Right Body:
Orange: T2-3
Blue: T9-10
Non-Radicular Referral
T2
Non-Radicular Referral
T4
Lower Lumbar
Non-Radicular Referral
T9
Non-Radicular Referral
T9-L2 Facet Lesions
Non-Radicular Referral
T10/12
(or L4/5)
Non-Radicular Referral
T12
(or L1)
Body Chart
1st Rib
Upper Rib/TOS
CTJ Pain
(From top to bottom, left then right)
Left T3
Left T5
Left T7
Right T2
Right T4
Right T6
Common pain generators of TS
Facet, Nerve, Disc, Rib, Mm
S/Sx Referred Radicular pain
Neurologic Tissues:: Sharp, stabbing, severe, burning band along intercostal space
Tumor compressing structures:: signs of cord compression, hyperreflexia, spasticity/clonus, Babinski, altered gait, symptoms of cancer
(Mediastinal tumors; TS common site for metastases)
Viscerogenic Referral
GI, Heart, Lungs, Kidneys, Pancreas, Metabolic Disorders
Vasculogenic Referral
TOS
(venous congestion/arterial deprivation)
GI Disorders
- Ask if pain is relted to food/eating
- Colorectal cancer, peptic ulcer dissease, acute cholecystitis, biliary colic, sever esophagitis
Peptic Ulcer Disease
- 5-10 thoracic vertebra
- periodic symptoms
- relief with antacids
- pain/food/meal time relationship
- Symptoms consistent with anemia (fatigue, SOB on exertino, tachycardia, orthostatic hypotension) if occult bleeding present
Biliary Colic
(initial gallstone disease)
- pn upper right back
- midback between scapula
- right interscapular or subscapular areas
Acute Cholecystitis
- (obstruction due to gall stones)
- right subscapular area
- increase with movement or respiration
- low grade fever may be present
Severe Esophagitis
- Burning pain
- associated with foul taste
- morning pain, worse after meal
- epigastric tenderness
- or subscapular areas
Cardiac Conditions
- pn radiating over left pectoral region, shoulder, medial left arm, right UE, epigastrium, jaw (MI)
- pts with cardiac Hx and associated S/Sx (weak pulse, extremely high/low BP, unexplained perspiration/pallor, pulsating sensation in abdomen (AAA)
- Palp abdominal aorta
Pleuropulmonary Conditions
- breathlessness
- Sx in right upper back (basilar pneumonia)
- Sx in scapula (emphysema, pleurisy)
- Sx in ipsilateral scapula (spontaneous pneumothorax)
Kidney Disorders
- pn in posterior lateral thorasic cage and upper lumbar
- recent or coexisting UTI, enlarged prostate, kidney stone or past kidney stone (pyelonephritis)
- sudden, severe back/flank pain, chills, fever, N/V, renal colic, Sx of UTI (kidney stones)
Pancreatic Carcinoma
- middle thoracic/lumbar pain
- pain unrelated to digestive activities
- S/Sx: jaundice, anorexia, severe weight loss, GI difficulties unrelated to meals
Metabolic Disorders
- decreased calcification of bone
- Osteoporosis, Diabetes, RA, Herpes Zoster
Osteoporosis
- long term asthmatic have increased risk
- 50% of all vertebral Fx in TS
- Cushing’s Disease
- Paget’s Disease
Diabetes
- Diabetic Thoracic Olyradiculopathy
- Abdominal pain due to intercostals neuralgia
RA
- can induce discitis
- source: CVJ
Herpes Zoster
- >70 years old
- no change with motion
- intercostal pn
- dermatomal pattern
- (shingles)
Handprint pn:
Thumbprint pn:
Hand: TS facet/CS facet
Thumbprint: CTJ/IDD/LS Facet
What’s different about T4
- spinal canal smaller than other vertebrae
- smaller canal to cord ratio
Facet Joint Dysfunction
Location of Sx
- Local (rare) or referred, nonradicular pn
- unilateral pain (handprint pain)
- rarely midline
- Levels overlap
Flattened Upper TS
Location of Sx
- Referred, nonradicular
- general thoracic ache, several segments
- bilateral (symmetrical more common)
- associated with intractable head, neck, shoulder girdle, arm and rib joint pn
T4 Syndrome
Location of Sx
- referred nonradicular
- glove-like
- nocturnal symptoms in sidelying or supine
- pn in axilla
- paresthesia in T1, T2 dermatomes
- headache when sympathetic system increased
General Hypomobility
Location of Sx
- Referred, nonradicular
- general thoracic ache, several segments
- bilateral (symmetrical more common)
Disc
Location of Sx
- Referred, nonradicular
- IDD/ProT, ProL (posterolateral): band-form pain, unilateral, nonradicular
- Prot/ProL: (Central): severe central and radicular pn
- more common in lower levels (T6-10)
Nerve Root
Location of Sx
- Radicular: sharp, stabbing, severe, burning
- referred band along intercostal space
- T1 & T2: may have N/T, weakness in hand, pn in medial arm, forearm
- T2 & T3: rare
T3-T8: unilateral/posterior pn, or front of trunk
-T9-T11: pn radiating to buttock
Facet Joint Dysfunction
Agg Factors
Pain with 3D movements
Flattened upper TS
Agg Factors
- Pn with loaded extension postures
- may have difficulty with flexion postures (unable to reverse curve)
General Hypomobility
Agg Factors
- Pulling/pushing activities
- sustained position
- sustained flex/ext, twisting or deep breathing
- CVJ: localized pn by coughing, sneezing or deep inspiration
T4 Syndrome
Agg Factors
Pulling and reaching activities
Disc
Agg Factors
- pn worse with prolonged sitting and physical labor
- pn with rotation>flexion/extension
- not worse with 3D movements
- not worse at night
Facet Joint Dysfunction
History
-gradual vs sudden
Flattened Upper TS
History
- Gradual vs sudden
- long history of mid-back pain
General Hypomobility
History
- work Hx of prolonged positions (typing, computer, surgeon)
- Upper: thoracic region stiffness, hardened and forward curved. Upper rib joints typically fixed. Limited UE movment. Mm imbalances present
T4 Syndrome
History
- unknown etiology
- possibly due to sympathetic reaction to hypomobile segment
- more in women than men (3:1)
Disc
History
- gradual onset/degenerative changes in disc
- high velocity macrotrauma
- Axial load: disc lesion/compression fracture
- Rotatory: disc vs rib fracture
Facet Joint Dysfunction
Observation
- flatt vs increased kyphosis
- increased curve in CTJ
Flattened Upper TS
Observation
- reduced TS kyphosis
- resistant to treatment, hard to change contour of spine
General Hypomobility
Observation
Increased TS kyphosis
T4 Syndrome
Observation
-forward head, accentuated TS kyphosis, protracted shoulder girdle
Disc
Observation
increased TS kyphosis
Facet Joint Dysfunction
Neurodynamic Testing
&
Neuro Exam
Negative
Negative
Flattened Upper TS
Neurodynamic Testing
&
Neuro Exam
-Negative
negative
General Hypomobility
Neurodynamic Testing
&
Neuro Exam
+/- thoracic slump test
negative
T4 Syndrome
Neurodynamic Testing
&
Neuro Exam
+thoracic slump test and ULNT1
negative
Disc
Neurodynamic Testing
&
Neuro Exam
+ thoracic slump test
nerve root involvement rare (horizontal path of nerve), if nerve involved=large disc protrusion
Nerve Root
Neurodynamic Testing
&
Neuro Exam
+Thoracic slump test
Sensation findings
Beevor’s Sign
Beevor’s Sign
- characteristic sign of SCI betweent T10 and T12
- umbilicus is pulled upward with trunk flexion
- upper abdominals intact but lower not so contraction pulls umbilicus upward
- also seen in ALS
Facet Joint Dysfunction
ROM
pn/restriction in 3D movements
Flattened Upper TS
ROM
- Depends on pn generator (disc, facet, rib)
- Typically flexion restriction
- 3D restriction if facet
- 1D restriction if disc
General Hypomobility
ROM
- depends on pain generator (disc, facet, rib)
- Limited UE movements
T4 Syndrome
ROM
- Gross cervical and thoracic motions usually normal
- depends on pain generator (disc, facet, rib)
Disc
ROM
- TS Rotation most comparable sign followed by flexion and extension
- Flexion: flexion + Expiration: increases pn
- Extension: ext + inspiration increases pn
Facet Joint dysfunction
Special Tests
Loss of motion and pn with 3d movements
Flattened Upper TS
Special Tests
loss of motion with 2D/3d movement tests
General Hypomobility
Special Tests
loss of motion and pn with 2d/3d movements tests
T4 Syndrome
Special Tests
- hypermobility (most common at C6-7)
- stiffness in adjacent segments (T1-4)
Disc
Special Tests
ProT/ProL (central): positive breathing, can have positive cord signs
Flattened Upper TS
Palpation
C7-T1 segments stiff with variable mobility in flattened section of spine
General Hypomobility
Palpation
Stiff TS segments
Ribs stiff
T4 Syndrome
Palpation
- Local tenderness
- local thickening and stiffness of one segment
Muscle Length/Strength
positional length/strength of lower trap, serratus, middle trap
-flexibiity of pec minor/major, lats, rhomboids, upper traps, levator
Physical Outcome Measures
- Oswestry Low Back Disability Questionnaire
- Neck Disability Index
- McGill Pain Questionnaire
Upper Rib Dysfunction
Location of Sx
UE Sx of N/T, pn or vascular Sx
Upper Rib Dysfunction
1st & 2nd Rib
Includes: Costal joint derangement (CTJ vs CVJ), Synovitis (costochondral/costosternal), costal arch syndrome (slipped rib tip)
Muscular Condition
Location of Sx
Local pn/tenderness
Scoliosis
Location of Sx
asymptomatic unless injury
Upper Rib Dysf
Agg Factors
- pn with deep breathing/cough, arm elevation
- Synovitis: pn with deep breathing, trunk rotation, sneezing coughing
Scoliosis
Agg Factors
-depends on structure at fault within the context of all health conditions of the TS
Upper Rib Dysf
History
- Gradual or sudden onset
- 1st Rib: typically a mouth breather
Scoliosis
History
Static (structural): caused by hemivertebrae, osteoporosis, osteomalacia or compression fractures/genetic, congenital/idiopathic
Sciatic: caused by sciatic pain by a lumbar disc herniation
Idiopathic: present since childhood
Upper Rib Dysf
Observation
-elevated upper trap due to elevated 1st rib, vs upper trap tightness
Muscular condition
Observation
-spasm, Mm guarding, tightness, atrophy
Scoliosis
Observation
-adaptive shortening of intrinsic trunk Mm on concave side and lengthining on convex side
Upper Rib Dysf
Neurodynamic
Neuro Exam
+/- T Slump test/ULNT1
negative
Muscular Condition
Neurodynamic
Neuro Exam
Negative
negative
Scoliosis
Neurodynamic
Neuro Exam
+/- T Slump test/ULNT1
Negative
Upper Rib Syndrome
ROM
TS SB most comparable
+Breathing:
TS flexion, increase pn with inspiration
SB toward pn, increase pn with inspiration
Muscular Condition
ROM
Pn with passive stretch
Scoliosis
ROM
depends on structures involved
Upper Rib Dysf
Special Tests
Upper Rib: positive TOS special tests
pn with positional testing and spring testing
Muscular Condition
Special tests
pn with resisted motion
Upper Rib Dysf
Palpation
1st rib: stiff, elevated (or 2nd rib)
Tietze’s Syndrome: localized swelling of costochondral cartilage
-stiffness with rib mobility testing. Pn/stiff with palpation (unilateral PA pressure) of CTJ joint
Scoliosis
Palpation
- depends on direction of curve
- vert bodies rotate toward convex side with SP toward concave side
- ris on convex side more post rotated (creates rib hump)
- ribs on concave side rotated ant
Pain generators for general hypomobility
Upper TS:
Mid TS:
Lower TS:
Upper TS: rib>zaj>disc
Mid TS: disc>zaj>rib
Lower TS: disc>rib>zaj
Schmorl’s Nodes
- herniation of disc substance through endplate of adjacent vertebra
- Acute: axial load (motorcyclists, falling off ladder, jumping from height; common T8-T12)
- Chronic: associated with jumping sports (gymnasts, wrestling); can give rise to early disc degeneration
Scheuermann’s disease
- typically in pubescent athletes (12-18 yo)
- flexion overload of ant vert body
- >30* flexion
- defect to the ring apophysis of vert body and anterior wedging
- end plate can crack leading to Schmorl’s node
- thoracic kyphosis with pn in extension/rotation
Scheuermann Disease Intervention
- bracing
- postural training
- strengthening trunk extensors, shoulder ER, neck extensors
- surgery fro curves >75*
Spondylodiscitis
- Inflammation of disc
- 4-5 yo (due to sepsis)/14-19 yo and >50yo
- central thoracic pain with capsular pattern
- pn radiation into LE and or laterally
- positive percussion and or heel drop
- positive MRI or CT
- Management: bedrest/antibiotic
TOS
- Compression syndrome involving subclavian artery/vein and/or brachial plexus from neck to axilla
- vascular (rare) vs neurogenic
Scheuermann’s Disease
Profile
-12-18 yo
CVJ/CTJ Derangement
Profile
>55 yo
CVJ vs CTJ
(Costal Joint derangement)
- >55yo
- initial Dx: renal colic, PE, spinal tumor, GI, pleurisy bc of Sx location (chest, abdomen, flank, paravertebral thoracic)
- improvement after local injection
- ankylosing spondylitis: CVJ synovitis
Tietze’s Syndrome
Profile
20-45 yo
Tietze’s Syndrome
- Costochondritis
- inflam of costochondral cartilage (2nd/3rd costochondral junctions)
- gradual/sudden
- increased pn with deep inspiration, cough, sneeze
- local swelling of costosternal cartilage
- linked to excessive UE movement pulling on rigid upper ribs
- intervention: injection, transverse friction to costochondral junction, rib/upper TS mobs
Costal Arch Syndrome
- “slipped rib tip”
- subluxation of interchondral joints between lower costal cartilatges may trap intercostal nerves (causing referred abdominal pain)
- intervention: injection, postural management
Dysfunction at manubriosternal Junction
profile
15-20 yo
Dysfunction at manubriosternal junction
due to AS, Rieters (bladder dysf), psoriasis
TS Vertebral Fractures
- hyperflexion or axial loading
- common: ant wedge Fx or burst Fx
- most: 9th and 11th vert bodies
- Tx: bed rest, return to activity
Compression Fx
- High velocity macrotrauma
- due to osteoporosis
- extension limitation
End Plate Fx
Non-capsular pattern
younger population
Sx resolve spontaneously
Costal Joint Derangement
Location of Sx
-localized pn 3-5cm from midline where rib articulates with TP and vertebral body
Costochondral/Costosternal Dysfunction
Location of Sx
local unilateral/anterior pn
Costal Arch Syndrome
Location of Sx
vague epigastric pn
increased pn after eating
sitting
cannot lean against lower rib cage
