The thoracic spine is one of the most common musculoskeletal problems that present to physiotherapists. This includes disorders to the intervertebral joints, rib articulations or thoracic discs and may be associated with varied combinations of pain, altered movement and muscular spasm. The thoracic spine is one of the more difficult areas for assessment and treatment due to the interplay between it and the shoulder girdle/upper limb, cervical spine, lumbar spine, cardiovascular system, visceral system and nervous system.

The role of the thoracic spine

The thoracic spine has a complex and often overlooked role within the body. It is a key area of load transfer between the upper and lower body, it is also a key area for rotational movement within the body particularly around T2-10. It must also be assessed and treated as a functional unit including not only the spine but the thoracic cage. This unit provides a site for myofascial attachments (head, neck, scapula, clavicle, shoulder, lumbar spine and pelvis) as well as visceral connections. It has a role in respiration, is protection for vital organs, and has a relationship to emotions and sympathetic nervous system.

Common causes of thoracic pain

• Intervertebral joint sprain involving the disc or zygapophyseal (facet) joint

• Paraspinal muscle strain

• Costovertebral and costotransverse joint sprain

• Scheuermanns syndrome in adolescents

• Postural/overuse syndromes in students and office based workers

Rib or compression fractures, thoracic outlet syndrome and T4 syndrome are less common causes of thoracic pain. Other causes of pain which should not be missed and physios are trained to flag include cardiac or lung conditions (pneumothorax, pulmonary embolism), peptic ulcer, tumor (breast cancer or secondary bone mets) and mesothelioma after exposure to asbestos.

Optimal Thoracic spine movement

The primary movement of the thorax is rotation. The main rotation centres in the body are the atlantoaxial joint, mid thoracic spine, hips and subtalar joint. If rotation is suboptimal in these areas, you will end up with ‘victims’ by compensating in body parts in between them e.g. cervical, lumbar and knee pain. Normal physiological movement of the thoracic spine into flexion involves the ribs rotating anteriorly and vertebra flexing. As the thoracic spine extends, the ribs rotate posteriorly and vertebra extend. Lateral flexion is a combination of vertebra side bending, ipsilateral ribs approximate and the vertebra translates contralaterally slightly.

The Importance of Posture and Alignment

Another component of a thoracic spine examination is postural assessment. This includes the thorax position relative to the body, ideally with the manubriosternal junction over the pubic bone and the centre of the thorax aiming to be over the centre of the sacrum. It also includes an assessment of the regional position of the thorax in the sagittal (often kyphosis), coronal (scoliosis/listed) and transverse plane (scoliosis). Scapula position and the presence of thoracic torsions are also assessed. Poor alignment and poor patterns of repetitive movement are a big cause of thoracic spine pain and dysfunction.

Treatment options

• Soft tissue massage, muscular and trigger point releases

• Light thoracic mobilisations for pain relief

• Firm thoracic mobilisations for stiffness

• Manipulations

• Modalities such as heat, ice and TENs

Protection, compression, padding, strapping options in the acute stage

• Support braces or tape assisted posture retraining in chronic stage

• Muscular stretches and neural sliders

• ROM and breathing exercises

• Postural training for core and alignment

• Muscular strength and endurance exercises

• Dry needling

• Manual handling, ergonomics, technique training, education and advice

• Sport, work, hobby specific retaining

Early and acute treatment focuses on understanding the diagnosis, reduction in pain and poor movement patterns and restoration of range of motion. As with any other exercise prescription, programs start more neutral range, light intensity, activation based with high reps and frequency. This is progressed to full range, increased resistance and lower frequency. Complexities such as unstable base, speed, sports specific challenges, balls, bats, racquets can also be added depending on the clients needs and abilities.

Peter Hogg

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