Thoracic Spine

-Few people have a normal thoracic spine,

; diseases affecting cervical and lumbar spine also occur in the thoracic region.
- Degenerative changes are common, with peak incidence at C7–T1 and T4–T5; however, symptoms
are rare due to anatomical factors.
- Degenerative joint disease is common; disk lesions are rare, occurring in about 2% of disk problems.
- Muscle lesions in the thorax and abdomen are more common compared to cervical and lumbar
regions, leading to posttraumatic scarring and persistent symptoms.
- Rib cage involvement is often neglected; costal sprain is common and expressed as thoracic or upper
lumbar pain.
- Sustained contraction of intercostal muscles can result from sneezing or coughing, leading to
inspiratory-type lesions.
- Expiratory-type lesions occur in lower ribs due to the attachment of the quadratus lumborum.
- Thoracic spine is a common source of postural pain, especially in adolescence.
- Poor posture may contribute to the development of Scheuermann’s disease in the young and
osteoporosis in the aged.

Functional Anatomy
- Thoracic vertebrae are characterized by articular facets on the vertebral bodies for rib articulation and
long, thin spinous processes angling downward.
- T1 to T3:
- Spinous processes project directly backward.
- Tip of the spinous process aligns with the transverse process.
- T4 to T6:
- Spinous processes project half a vertebra below their attachment.
- T7 to T9:
- Spinous processes are a full vertebra lower than their attachment.
- T10 to T12:
- Spinous processes return to being palpable at the same level as the vertebral body.
- Spinous processes are long and overlap, especially in the middle to lower region.

- The typical thoracic vertebra has a body with roughly equal transverse and anteroposterior diameter.
- Apophyseal joints are vertical, oriented at about 60° from the horizontal plane, with superior facets
facing upward and back, and inferior facets facing downward and forward.
- T1: Transitional, longest transverse process in thoracic spine, junction for cervical-thoracic curve
change, affects thoracic outlet.
- T12: Transition to lumbar, bridge between lumbar-thoracic spine, often dysfunctional.
- T3: Transition from cervical lordosis to thoracic kyphosis, axis for shoulder girdle.
- T6: Axis for entire thoracic spine.
- Thoracic Kyphosis: Smooth posterior convexity; flat spots need careful evaluation.
- Thoracic Disks: Narrower, flatter; increase in height and width from superior to inferior.
- Spinal Canal: Narrow, small epidural space; narrowest between T4 and T5.
- Clinically: Thoracic spine starts at T3, upper two joints best examined with cervical segments.
- Ribs: Vital in evaluation; move with pump-handle, bucket-handle, and caliper-like motions.
- Upper Ribs: Mainly combined pump-handle and bucket-handle motions.
- Middle Ribs: Primarily bucket-handle motion.
- Lower Ribs: Move like calipers.
- Ribs 2-4: Greater proportion of pump-handle movement, influenced by scalene muscles during
inhalation.
- Rib 1: Moves with about half pump-handle and half bucket-handle motions.
- Ribs 8-10: Greater proportion of bucket-handle motion, influencing transverse diameter of the chest.
- Floating Ribs: Have a greater proportion of caliper-type motions.

Ribs 2-9: have 3 costovertebral joints, The head of each rib articulates with two adjacent vertebrae and
one transverse process
Ribs 1& 10-12: have 2costovertebral joints , The head of each rib articulates with one vertebral body
and its transverse process.
Ribs 1-7 : connects to the sternum through synovial joints.
- Intervertebral foramina in the thoracic spine are not posterior to the disks, unlike the cervical and
lumbar spine. Nerve root involvement requires a large prolapse of disk tissue, making it uncommon.

The convexity of the thoracic spine leads to high anterior disk load, causing compression fractures and
degenerative changes. Thoracic disk disease symptoms are less common than in the cervical and
lumbar spine due to the level position of intervertebral foramina and restricted spinal movements.

Biomechanical regions

• Vertebromanubrial region (C7–T2)

• Vertebrosternal region (T3–T7)
Vertebrochondral region (T8–T10)
• Thoracolumbar region (T11–T12)

INNERVATION: The intercostal nerves (the anterior branches of the thoracic spinal nerves) supply
the chest wall, the intercostal muscles, the costotransverse joints, the parietal pleura, and the skin

-Mechanical causes of thoracic and rib cage dysfunction include: disk lesions, facet lesions,
costovertebral and costochondral lesions, and spondylosis

DISK PROLAPSE
- Thoracic disk problems are rare, representing 1 to 6 patients per 1,000. morecommon in men in fifth
decade.
- T11 and T12 are most commonly affected vertebrae.
- Clinical history often involves axial trunk compression..
- Localized pain corresponds to the involved segment, aggravated by coughing or increased
intrathoracic pressure.
- Cord involvement may lead to radicular signs, sensory loss, upper motor neuron lesions, and bladder
symptoms.
- Medial prolapse(posterior) may produce cord symptoms, posterolateral disk prolapse is likely to
involve nerve roots.

DISK PROLAPSE ON POSTERIOR LIGAMENT AND DURA(POSTERIOR)

- Prolapsed disk pressure on posterior ligament and dura causes spondylogenic referred pain.
- Pain felt in upper back (thoracic origin) or low back (lumbar origin), with potential wider area.
- Involvement of dura mater : unilateral extrasegmental dural reference of pain.
- Thoracic dura interference: posterior pain spreading to the neck or midlumbar region, affecting
multiple dermatomal levels.
-Coughing or deep breathing increases the pain
- Pain described as dull, deep, and poorly localized.

DISK PROLAPSE AGAINST NERVE ROOT(POSTEROLATERAL)

- Disc pressure on nerve root's dural sleeve leads to radicular pain along the nerve's dermatome.
- Pain can occur in any part of the affected nerve root's dermatome.
- T1 and T2 symptoms may extend to the arm; lower levels cause trunk-related symptoms.
- Cervical disc lesion commonly causes upper thoracic pain.
- Further nerve parenchymal pressure results in altered conduction, leading to paresthesia, anesthesia,
sluggish reflexes, and motor weakness.
The most common site of prolapse is between T11 and T12. Symptoms include local back pain and
radicular pain. Pain refers to the lumbar region, especially the iliac crest.
MINOR INTERVERTEBRAL DERANGEMENT, MAIGNE THEORY
- Maigne introduces the concept of Minor Intervertebral Derangement (MID).
- MID involves isolated mild pain in one intervertebral segment, typically reversible with mobilization
or manipulation.
- MID includes one of the two apophyseal joints in the mobile segment, triggering nociceptive activity
in the posterior primary dermatome and myotome. Tender skin and painful, cordlike muscles are
common features.
-according to maigne the intervertebral disk affects the functional ability of mobile segments. Minor
lesions in the disk can trigger apophyseal joint dysfunction, leading to muscle spasms, pain, and loss of
function. This leads to avoidance of painful pressure or movement, which becomes fixed and self-
perpetuating over time.

THORACIC PAIN OF LOWER CERVICAL ORIGIN

- Injury to the lower cervical region is associated with upper thoracic pain.
- About 70% of common thoracic pain is of lower cervical origin.
- Clinical signs include localized tenderness (cervical point or interscapular point(ISP)), inferior
cervical MID, and tender facet on the same side as back pain.
- The anterior cervical "push-button" sign links cervical spine involvement to thoracic pain.
- Therapeutic trials of cervical mobilization are important, leading to disappearance of cervical MID
and ISP.- Lower cervical spine pain can mimic coronary ischemic pain, causing diagnostic confusion.

PAIN OF THORACIC ORIGIN

- Thoracic pain of thoracic origin is rarer.
- Postural thoracic pain resembles cervical origin but not always localized to T5-T6.
- Clinical examination reveals MID of thoracic segment with:
1. Tenderness of corresponding supraspinous ligament.
2. Tenderness of neighboring skin tested by skin-rolling maneuver.
3. Pain after lateral pressure on one side of the spinous process.
4. Elective pain elicited by "resisted" pressure of the spinal processes.
- Treatment includes mobilization, skin-rolling massage for persistent tenderness, muscle reeducation,
postural exercises, and correction of static deficiencies.

THORACIC HYPOMOBILITY
- Capsular fibrosis is a common cause of apophyseal joint disease.
- Hypomobility is the primary dysfunction, while hypermobility is less common but significant.
- Stiff joints within a segment can lead to reduced disk nutrition and instability in neighboring
segments..
- Treatment focuses on maintaining correct posture and incorporating lifelong extension exercises.
- Regular extension exercises have shown to reduce compression fractures in spinal osteoporosis.
- Neurologically involved individuals, such as those with cerebral palsy or traumatic head injury, often
experience thoracic hypomobility.
- Common issues include forward head, increased thoracic kyphosis, and altered breathing
patterns(usually avoiding diaphragmatic breathing (diaphragm is restricted))
- Treatment involves reducing tone and abnormal movement patterns through therapeutic exercise,
positioning, and developmental activities.
- Emphasis is on trunk and proximal movements, with activities stressing extension and trunk rotation
being effective.
- Joint articulations, thoracic stretching, and soft tissue manipulations are effective.

UPPER THORACIC SPINE SYNDROMES

- Upper thoracic spine is the stiffest part, causing well-localized pain with potential distal symptoms
via the autonomic nervous system.
- T4 syndrome features arm pain, paresthesias, posterior head and neck pain, hypomobility at T3-T4,
T4-T5, T5-T6, (T4 invariably involved) and tenderness/stiffness.
- Unknown mechanism, but predisposing factors include unaccustomed activities, trauma, and a
relaxed posture with forward head and accentuated thoracic kyphosis.
-patients with the symptom complex have a positive upper limb tension test and some have a positive
slump test.
- Symptom relief often achieved through articulations or manipulation after three or four treatments.
- Treatmentand evaluation options include Klapp's quadripedal exercises, postural correction exercises,
-- upper limb tension tests, slump test, and mobilization of the costotransverse joint.

MIDTHORACIC /COSTOVERTEBRAL DISORDERS

- T5 to T7: Common for apophyseal joint pain.
- T8 to T10: Common for rib articulation issues and visceral-like referred pain.
- Localized degenerative disk lesions uncommon; higher incidence in jobs with repeated thoracic
rotation(golfers)
- Nerve root involvement may cause chest pain worsened by movement and lying down.
- Treatment: Traction, back support, and gentle mobilization for nerve root involvement.
- Costovertebral joint: Affected in inflammatory or degenerative diseases.
- Dysfunction causes localized pain 3-4 cm from midline, with potential referred pain.
- Degenerative changes may be asymptomatic initially, becoming symptomatic after trauma.
the joints with a single facet (one, eleven, and twelve) have a much higher incidence of degenerative
changes than those which have two hemifacets.
- Treatment: Mobilization techniques usually successful, local anesthetic injections may help.

LOWER THORACIC SPINE & THORACOLUMBAR JUNCTION DYSFUNCTION

- Lower thoracic and thoracolumbar junction pain common; often mistaken for lumbar issues.
- Pain referred to lumbar, iliac crest, buttock, inguinal, and abdominal areas.
- Dermatomal symptoms in posterior or anterior branches of dorsal rami.
- In cases, an iliac crest ("crestal") point found at the gluteal level, usually 8 or 10 cm from the median
line, more lateral or more medial, indicating thoracolumbar origin.Examination of the thoracolum
bar region will also reveal the signs of an MID between T10 and L2. The gluteal pinch-roll maneuver is
likely to be painful .on the involved side -. The two most characteristic signs are pain to lateral pressure
over the spinous process and posterior articular sensitivity on the same side as the crestal point
- Acute or chronic presentation; common in those older than 40.
- Patients do not assume an antalgic posture as in the lumbar spine; marked local contracture, stiffness,
vertebral tenderness.
- Severe pain on lateral flexion of the trunk and rotation to one side during active motions.
- Management: mobilization techniques.
- Chronic involvement more common; therapeutic exercise may be of little value.
- Lower thoracic syndromes involve the diaphragm, potentially impacting lumbar conditions.
- Diaphragmatic involvement may affect the low-pressure lymphatic and venous system.

THORACIC DERANGEMENT SYNDROME OF MCKENZIE

- Common cause of neck and thoracic pain.
- Results from joint structure displacement.
- Mechanical deformation of pain-sensitive tissues.
- Disk Involvement:
- McKenzie distinguishes posterior and anterior derangements.
- Thoracic spine mostly involves posterior derangement.
- Patterns in Thoracic Spine:
- Derangement 1: Central or symmetrical pain; rapidly reversible.
- Derangement 2: (Rare) acute kyphosis, due to trauma or serious disease
- Derangement 3: Unilateral or asymmetrical pain; rapidly reversible.
- Diagnosis and Examination:
- Assess posture and movement effects on symptoms.
- Pain during movement or end range, with obstruction changes.
- Treatment Approach - Derangement:
- Teach postures and movements reducing mechanical deformation.
- Involves static thoracic extension and rotation.
- Nonspecific Thoracic Pain:
- Classified into postural and dysfunction syndromes.
- Postural Syndrome:
- Overstretching of normal tissue, insidious onset.
- Time-dependent symptoms, normal range of motion.
Tx - Focus on maintaining optimal alignment.
- Dysfunction Syndrome:
- Pain due to stretching of shortened tissues.
- May have acute or insidious onset, intermittent pain.
Tx - Exercises aim to elongate shortened tissues.
- Treatment Principles:
- Comprehensive program: posture, body mechanics, individualized exercises.
- Tailor program based on classification or syndrome.

THORACIC HYPERMOBILITY SYNDROMES

- Hypermobility in thoracic spine: less common but significant.
- Causes: postural imbalances, muscle imbalances, trauma.
- Excessive motion due to lack of thoracic and hip rotation, combined with shoulder girdle protraction.
- Signs and symptoms: back painfatigue in static positions, , relief with movement.
Hypermobility :Excess range of motion , Instability:complain of giving away ,slipping out.
- Assessment: evaluate alignment, use tests like vertical compression test to identify instability and
deviations.
- Wadsworth test for segmental vertebral instability may indicate hypermobility in lower
thoracolumbar spine.
- Wadsworth Test
- **Position: Prone position with legs over the table edge, feet on the floor.
- **Procedure: Therapist applies vertebral posterior–anterior glide.
- **Positive Test: Pain during glide with feet supported and paraspinal muscles relaxed; no pain
when legs are actively extended (bilateral hip extension) with contracted paraspinal muscles.
- Objective examination: signs like sharply angulated segments, uncoordinated muscle contraction,
hypertrophied bands suggest hypermobility.
- Angulated segment during active forward bending may suggest hypermobility.
- Presence of "shake," "catch," or "hitch" indicates instability.
- Hypermobile apophyseal joint causes freer upward sliding of the vertebra during forward bending
produce side bending to opposite side.
- Movements during tests (forward bending, sidebending, and rotation) may feel excessively free or
show a forward step or slip during forward bending.
- Conservative treatment: decrease stresses on unstable segments, emphasize stabilization techniques,
abdominal and back exercises.- Include correction of posture, support for involved segment, and
diaphragmatic breathing exercises.

RIB CONDITIONS
COSTAL SPRAIN
- Most rib lesions linked to intercostal muscle spasms.
- Caused by sudden movements like sneezing or coughing.
- Classified as respiratory rib dysfunctions, limiting normal rib motion.
- Costal sprains cause thoracic or upper lumbar pain.
- No tenderness in the spine, but pain occurs with pressure on a specific rib.
- False ribs typically involved.
- Patients complain of continuous soreness at the costovertebral angle, worsened by certain movements.
It may vary from a simple feeling of discomfort to pronounced chronic lumbar pain when the false ribs
are involved.
- Rib maneuver by Maigne is a key test for costal sprain evaluation.
- Evaluation of corresponding apophyseal joint necessary.
- Assessment of sternoclavicular and costo-chondral joints for ribs one to seven..
- Deep transverse frictions can be effective for treatment.
- If not treated, chronic costal sprains may lead to thoracic and lumbar pain.
- Chronic costal sprains can result in diagnostic errors.
- Mobilization involves articulating the rib in the nonpainful direction.

HYPO AND HYPERMOBILITY DYSFUNCTIONS

- Intercostal muscle irritation may result from a central source, Intervertebral joint lesions can cause
nerve irritation and muscle contraction.
- Dysfunction termed as a structural rib deformity.
- Results in restricted rib mobility.
 - Evident positional changes on palpation.
- May include alterations in eversion (lower rib margin prominence), inversion, lateral flexion,
anteroposterior compression, lateral compression, and subluxation.

FIRST RIB SYNDROME

- Compression syndrome characterized by Unilateral pain or tenderness over the supraspinous fossa.
- Referred pain, aching, or paresthesia in C8 or T1 dermatomal distribution of the arm, forearm, or
hand.
- Costotransverse joint may sublux superiorly due to scalene pull.
- Often associated with dysfunction of C7–T1 or T1–T2.
- Palpation reproduces symptoms with posteroanterior pressure on costotransverse joint and first rib.
- hypertrophy or adaptive shortening of scalenus anticus or medius muscles, associated with elevation,
hypomobility, or subluxation of the first rib.
- Additional signs: forward head, protracted shoulders, and restricted acromioclavicular and
sternoclavicular joints.
- Initial treatment using the palpation technique that elicits symptoms.
- Beneficial interventions: Manipulations of restricted joints, soft tissue manipulation for tight muscles,
postural reeducation.
- Attention to associated cervical joint dysfunction to prevent recurrence from scalene muscle
tightness.

HYPOMOBILITY
- Forward head and increased thoracic kyphosis.
- Posterior pain at costovertebral or costotransverse joint, occasionally radiating laterally into chest
wall.
- Discomfort during diaphragmatic breathing and movements requiring rib cage excursion.
1. Altered breathing pattern, avoiding diaphragmatic breathing.
2. Inhalation restriction: no upward rib movement; exhalation restriction: no descent of rib during
expiration.
3. Palpation findings: Tenderness at costovertebral joint, altered rib position.
4. Motion restriction
- Treatment involves:
- Mobilization of restricted segments.
- Soft tissue mobilizations and stretching of involved intercostal muscles.
- Self-mobilization and stretching for increased rib cage excursion.
- Postural reeducation.

HYPERMOBILITY
- Causes localized pain in costal margin or costochondral area.
- Dull ache with occasional sharp episodes.
- Aggravated by rotational activities.such as twisting while bending forward.Clicking sounds may be
present
1. Protective posture and shallow breathing.
2. Tenderness at costochondral junction.
3. Excessive joint-play motion.
4. Clicking sounds may be present.
- Gentle stretching to intercostal area.
- Correct hypomobilities.
- Advise on body mechanics for strain reduction.

KYPHOSIS
- Localized, sharp, posterior angulation called gibbous or hump back.
- Dowager’s hump, often associated with postmenopausal osteoporosis.
- Decreased pelvic inclination(20 with a mobile spine (flat back).
- Decreased pelvic inclination(20 with thoracolumbar or thoracic kyphosis (round back(Type I
or Type II.).
- Excessive thoracic kyphosis, along with protracted shoulder position, affects normal shoulder girdle
joint function.
- shortening of internal rotators and serratus anterior, lengthening of rhomboids and lower trapezius.
- Adaptive anterior shortening of the glenohumeral capsule can occur.
 - Round back Type I(without rounded shoulders) or Type II(with rounded shoulders).
- Type I results from postural habits, while Type II may result from structural abnormalities like
Scheuermann's disease or vertebra plana.
- Scheuermann's disease often leads to anterior wedging of vertebrae, affecting about 10% of the
population, commonly between T10 and L2.
- Dramatic changes in thoracic kyphosis often parallel the development of scoliosis.
- Multiple causes, including diseases like osteoporosis or Scheuermann's.
- In osteoporosis or Scheuermann's, then Exercise intervention may not reverse the disorder but
could potentially retard or prevent further exaggeration of kyphosis.
- Few conditions result in decreased kyphosis.
- Decrease or reversal of the kyphosis in the interscapular thoracic spine involves the T2 to T6
vertebrae and may be associated with congenital fixation.

SENILE KYPHOSIS
- Senile kyphosis associated with aging.
- It causes round shoulders and a forward head posture.
- Primarily affects older individuals and involves severe degeneration of midthoracic intervertebral
disks.
- Radiologic changes include loss of disk space in the anterior part of the disks.
- Upper thoracic kyphosis, known as dowager's hump, is common in postmenopausal women, men
with heavy shoulders, and those with poor postural sense.
- Dowager's hump leads to a loss of movement in the upper thoracic region and hypermobility in the
lower cervical spine… causes increased cervical lordosis, forward head, and may have flat
interscapular region.
- Symptoms may include localized upper thoracic, shoulder, cervical, and arm pain.
- Senile kyphosis and upper thoracic kyphosis are usually asymptomatic, but some patients may
experience severe, aching pain.
- Pain relief strategies include the use of a brace, analgesics, exercise, postural control, stretching to the
intercostal area, and mobilization techniques.

OSTEOPOROSIS
- Osteoporosis, associated with senile or upper thoracic kyphosis, weakens vertebral bodies and
increases fracture risk., cause ant wedging.
- Regular extension exercises significantly reduce compression fractures by strengthening back
extensors and improving bone density.
- These exercises also help maintain upright posture, potentially lowering fracture risk.
- Caution is advised in exercise prescription for spinal osteoporosis, favoring isometric abdominal
strengthening exercises over flexion forces.
- Lifelong extension exercises, starting around age 40,involve prone extension with gradual repetitions.
- Severe osteoporosis may benefit from sitting extension exercises to minimize pain.

POSTURAL DISORDERS
- Muscle pain related to postural changes is common, often in women with sedentary occupations
lacking physical fitness.
- Complaints include stiffness and tenderness in shoulder girdle and thorax muscles, with pain in
cervical and lumbar regions.
- Aggravating factors include prolonged sitting, typing, continuous use, fatigue, stress, and weather
changes.
- Common victims include writers, musicians, dentists, and computer programmers.
- Treatment involves reassurance, prophylactic advice, correction of postures, muscle-bracing exercises,
relief positions, and special chairs.
- Changing posture is a form of exercise involving proprioceptive neural circuits.
- Exercise programs for postural correction, based on principles by Kendall and Sahrmann, are
beneficial.
- Soft tissue treatment options include stretching techniques to restore muscle length.
- Assistive devices like specialized taping procedures, posture-correction braces, or support bras with
criss-cross back straps can be used.
- Posture should be addressed both statically and dynamically, and movement therapies like the
Alexander technique and Feldenkrais method may benefit those with thoracic dysfunction or
osteoporosis.
OTHER CLINICAL SYNDROMES
- Thoracic pain, beyond vertebral dysfunction, requires distinguishing between rib and thoracic pain.
- First rib dysfunction can cause upper limb pain, neck pain, and headaches.
- Frozen shoulder may relate to dysfunction of the first and second rib, especially the second rib.
- Upper rib dysfunctions may result in shoulder pain, numbness, and tingling in the arm and hand.
- Costosternal tenderness and restricted motion could indicate a T3 rib torsion lesion.
- Manual therapy benefits patients with chronic obstructive lung disease and those who underwent
thoracotomy or coronary artery bypass sternotomy.
- Compression deformities in the thoracic spine, common in osteoporosis-prone or posttraumatic cases,
respond well to structural evaluation and gentle techniques like muscle energy, strain counterstrain, and
stretching.

CLINICAL CONSIDERATIONS:
1.C4 to C7 (Lower Cervical) Pain referred to upper thoracic region; evaluate both areas together.
2. T1 to T4 (Upper Thoracic) Stiff region with well-localized pain.
3. T5 to T7 (Midthoracic) Common for apophyseal joint pain; T8 to T10 prone to rib cage articulation
problems and visceral-like referred pain.
4.T11 to L1 (Thoracolumbar) Common thoracolumbar pain; may refer to lumbar region, with T11–
T12 frequent for thoracic disk lesions.

- History signs of thoracic spine dysfunction pain:

1. Visceral disorders are unaffected by thoracic movements.
2. Pain increases on trunk rotation toward the painful side but eases with rotation away.
3. Pain worsens on trunk side flexion toward the painful side; neuroma limits flexion away.
4. Aggravation by coughing, sneezing, or deep inspiration suggests costovertebral joint involvement.
5. Relief achieved with firm back pressure.

PHYSICAL EXAMINATION

OBSERVATION
-Observe the patient’s posture, body type, gait, and ability to move freely

FUNCTIONAL ACTIVITIES
-The functional activities that are likely to aggravate thoracic problems are rotational movements, a
combination of flexion and rotation, or sustained unsupported sitting.

GAIT
The typical gait patterns that might be expected in patients with thoracic or lumbar spine are the short-
leg gait, Trendelenburg’s gait, and the gluteus maximus gait.

INSPECTION

1. BONY STRUCTURE AND ALIGNMENT

- Proximal or Shoulder Crossed Syndrome: Protracted shoulders, forward head.

-Pelvic or Distal Crossed Syndrome or Kyphosis–Lordosis Posture:Increased kyphosis,
exaggerated lordosis.
- Flat Back Posture: Reduced lumbar curvature, limited mobility.
- Sway Back Posture:Increased lumbar lordosis, anterior pelvic tilt, protruding buttocks, and a
backward-leaning upper body.
- Handedness Posture: Asymmetry in upper limb and shoulder alignment.
- Layer Syndrome:Complex patterns of muscle tightness and weakness.

4 Alignments:
Posterior alignment
Anterior alignment
Sagittal alignment
Transverse rotary alignment
Posterior alignment:
-The inferior angle of the scapula aligns with the T7 spinous process.
-The spine of the scapula is level with the T3 spinous process.
- The medial borders of the scapulae are parallel and about 5 cm lateral to the spinous processes
-A common sign of scoliosis is unequal shoulder levels and apparent winging of a scapula.
.-Lateral shift: This is present if the shoulders and trunk have moved laterally in relation to the pelvis,
if lat. Shift is symptomatic it may be due to lumbar derangement
-Scoliosis
- Deformity with one or more lateral curves in lumbar or thoracic spine.
- Types: Structural (does not straighten during bending) or nonstructural.
- Structural scoliosis results in a lumbar bulge or rib hump with forward bending.
- Functional Scoliosis:
- Caused by muscle imbalance, poor posture, or leg-length discrepancy.
- Generally straightens with forward bending and sidebending into the convexity, except in the
presence of muscle spasm or guarding.
- Acute Scoliosis:
- Result of facet joint impingement causing entrapment of soft tissue within the facet joint.
- Patient may shift away from impingement to alleviate pain.
- Common type: lateral shift or protective scoliosis.
Pigeon Chest (Pectus Carinatum):Protrusion of the sternum and ribs, creating a forward-pointing
chest.
Funnel Chest (Pectus Excavatum):Sunken appearance of the chest due to inward depression of the
sternum.
Barrel Chest: Enlarged and rounded chest shape, often associated with chronic lung diseases.

Infrasternal angle: normal 90°.

Sagittal Alignment (the patient is viewed from the side)

-In cervical spine the head normally lies 4-8 cm from the apex of the thoracic kyphosis to the deepest
point in the cervical lordosis.

Transverse Rotary Alignment (the patient is viewed from the front and from behind)
- The stance width should be normal and the feet slightly (5 to 10°) pointed outward.
-In scoliosis the ribs are pushed posteriorly and the thoracic cage is narrowed on the convex side of the
curve; the ribs on the concave side move anteriorly

2.SOFT TISSUE INSPECTION

-Shortness of the rectus abdominis results in anterior rib cage depression, shortness of the internal
oblique results in an increase in the infrasternal angle and shortness of the external oblique results in , a
decreased angle.
-Short obliques can cause either long lumbar lordosis with paraspinal atrophy and narrow infrasternal
angle or thoracic kyphosis with depressed chest and narrow infrasternal angle.
JOINT TESTS
-Joint tests include:
Joint integrity tests
Active and passive physiologic movements of the thoracic spine and other relevant joints.
Accessory or joint-play movements

JOINT INTEGRITY TESTS

-specific tests include vertical compression and traction to stress the anatomical structures resisting
vertical forces. These tests help assess the stability and integrity of the thoracic spine and identify
potential sources of pain or dysfunction.
-Specific passive translation test: A variety of passive translation tests of a segmental spinal unit may
be performed like Lateral stability (rotation) test for the midthoracic spine (T3–T7)

ACTIVE PHYSIOLOGIC MOVEMENTS

-when evaluating active movement, the examiner should assess the range, rhythm, and quality of
movement, while noting any localized restrictions, protective deformities, muscle guarding, or painful
arc of motion.

PASSIVE PHYSIOLOGIC MOVEMENTS

-Passive physiologic intervertebral movements (PPIVMs), which examine the movement at each
segmental level, are done with palpation. Palpate between the spinous processes and compare the
movement obtained at each level. The chief movements of the T4 to T12 region are forward and
backward bending. Sidebending and rotation are limited by the ribs. Rotation occurs mostly at the
lower thoracic and upper lumbar spine

MUSCLE TESTS
- In the thoracic spine, the hyperactive,dominant global muscles include the external and internal
obliques, rectus abdominis, latissimus dorsi, thoracic erector spinae, and some scapular muscles
(rhomboids, levator scapulae, and trapezius - lower part).
- Certain scapular muscles, including subscapularis, serratus anterior, and pectoralis major (abdominal
part), are prone to weakness.
- Injury to the thorax can lead to atrophy and weakness in the deep localized stabilizer muscles.

-Muscle tests include:

Resisted isometrics
Muscle strength
Muscle control
Muscle length.

PALPATION
when palpating the thoracic spine, the examiner assesses bony alignment, muscle spasms or guarding,
muscle and skin consistency, temperature alterations, swelling, and localized tenderness. The tapping
test and palpation of relevant points help identify tender areas and potential sources of pain or
dysfunction.

NEUROLOGIC TESTS
Neurologic examination involves examining the integrity and mobility of the nervous system and
specific diagnostic tests.

-About 50% of spinal cord tumors originate in the thoracic area of the cord.

THORACIC SPINE TECHNIQUES

-Can be used for hypomobility,hypermobility, instability, and soft tissue dysfunction.
Soft tissue manipulations
Joint mobilizations

Made by:
M.Abdullah
Ureedullah