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NOTES
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Academy of Orthopaedic Physical erapy, APTA.
For personal use only. No other uses without permission.
© 2021 Academy of Orthopaedic Physical erapy, APTA, Inc. All rights reserved.
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Academy of Orthopaedic Physical erapy, APTA.
© 2021 Academy of Orthopaedic Physical erapy, APTA, Inc. All rights reserved.
For personal use only. No other uses without permission.
The Thoracic Spine and Rib Cage:
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Evidence-Informed Physical
Therapy Patient Management
Independent Study
Course 31.2.4
Scott Burns, PT, DPT, OCS, FAAOMPT
Temple University
Philadelphia, Pennsylvania
Michael O’Hara, PT, DPT, OCS
Temple University
Philadelphia, Pennsylvania
William Egan,
PT, DPT, OCS, FAAOMPT
Temple University
Philadelphia, Pennsylvania
The Thoracic Spine and Rib Cage:
https://t.me/med1917
Evidence-Informed Physical
Therapy Patient Management
Guy G. Simoneau, PT, PhD, FAPTA—Editor
Gordon Riddle, PT, DPT, ATC, OCS, SCS, CSCS—Associate Editor
Cover Illustration by Joseph Kinstler
Dear Colleagues,
I am pleased to welcome you to e oracic Spine and Rib Cage: Evidence-Informed Physical erapy Patient Management
monograph written by Scott Burns, PT, DPT, OCS, FAAOMPT, Michael O’Hara, PT, DPT, OCS, and Bill Egan, PT, DPT, OCS,
FAAOMPT. is work is part of the Academy of Orthopaedic Physical erapy Independent Study Course series 31.2, Current Concepts
of Orthopaedic Physical erapy, 5th Edition.
Dr. Scott Burns is an Associate Professor, Director of the DPT program, and Interim Chair for the Department of Health and Rehabilitation Sciences within the College of Public Health at Temple University. Dr. Burns received his Master of Science in Physical erapy and
his transitional DPT degree from the University of Colorado in 2005 and 2006, respectively. In 2009, he became a board-certified Orthopaedic Clinical Specialist (OCS) and a Fellow of the American Academy of Orthopaedic Manual Physical erapists (FAAOMPT).
In 2016, he began his PhD at the University of Newcastle (Australia) investigating the role of the hip in individuals with low back pain
(anticipated completion in 2021). In 2010, he was recognized for teaching excellence with the Outstanding Teacher Award for the College of Public Health. Dr. Burns has 13 peer-reviewed manuscripts, 6 book chapters, and 26 peer-reviewed platforms/posters at national
conferences. At Temple University, Dr. Burns teaches primarily in the musculoskeletal tract and orthopaedic residency.
Dr. Michael O’Hara is an Assistant Professor of Instruction in the Department of Health and Rehabilitation Sciences at Temple University. Michael earned his DPT from Temple University in 2014, and subsequently completed an orthopaedic residency at the University
of Chicago Medical Center in 2015. Michael is a board-certified Orthopaedic Clinical Specialist (OCS), and serves as a current member
of the Specialist Academy for Content Experts (SACE). Michael’s current teaching responsibilities within the DPT program include the
musculoskeletal management course series, foundational courses in human anatomy, biomechanics, and therapeutic intervention, and
vestibular rehabilitation. He was recently the recipient of the 2020 Excellence in Teaching Award by the College of Public Health. Michael
also serves as an instructor in the Temple Orthopaedic Physical erapy Residency program. Michael has presented numerous posters,
platforms, and lab-based courses for conferences on a local, regional, and national level, and routinely offers continuing education courses
on a variety of musculoskeletal topics. Michael maintains clinical practice with Good Shepherd-Penn Partners in Philadelphia, PA.
Dr. William (Bill) Egan is a physical therapist with over 20 years of clinical experience. He graduated from the US-Army Baylor Program
in Physical erapy in 1999. Bill is a board-certified Orthopaedic Clinical Specialist (OCS) and a Fellow of the American Academy of
Orthopedic Manual Physical erapists (FAAOMPT). He has served as a core faculty member in the department of physical therapy
at Temple University for the past 13 years. He is an Associate Professor with the primary role of instruction within the DPT program,
providing instruction in the musculoskeletal management course sequence, the advanced musculoskeletal elective, diagnostic imaging,
evidence-based practice, and clinical pain sciences. In 2010, he was recognized for teaching excellence with the Outstanding Teacher
Award for the College of Public Health. Bill is the director of the Temple Orthopedic Physical erapy Residency program. He has delivered conference presentations and written book chapters and research articles. Bill provides post-professional continuing education to
physical therapists on the topics of orthopedic manual physical therapy and the management of patients with musculoskeletal disorders.
In this monograph, the authors provide a comprehensive review of the evaluation and treatment options for the thoracic spine. e
monograph concludes with clinical scenarios to provide additional clinical context to the information provided.
My sincere thanks to the authors for their contribution to the Current Concepts series.
Sincerely,
Guy Simoneau, PT, PhD, FAPTA
Editor
2920 East Avenue South, Suite 200 | La Crosse, WI 54601 | Office 608-788-3982 | Toll Free 800-444-3982 | Fax 608-788-3965
TABLE OF CONTENTS
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ACRONYM LIST ................................................................................................................................................................................................................5
ABSTRACT ..........................................................................................................................................................................................................................7
LEARNING OBJECTIVES
..............................................................................................................................................................................................7
PRE-LEARNING CASE SCENARIO ...........................................................................................................................................................................7
INTRODUCTION
............................................................................................................................................................................................................9
CLINICAL ANATOMY ....................................................................................................................................................................................................9
Surface Anatomy ........................................................................................................................................................................... 9
Osseous and Ligamentous Anatomy ............................................................................................................................................ 10
Key Muscles ................................................................................................................................................................................ 10
Neurovascular Structures .............................................................................................................................................................11
oracic Pain Referral Patterns ....................................................................................................................................................12
CLINICAL BIOMECHANICS AND PATHOMECHANICS
............................................................................................................................ 13
oracic and Rib Cage Motion ................................................................................................................................................... 13
Flexion and extension .......................................................................................................................................................... 13
Side bending ........................................................................................................................................................................ 13
Rotation...............................................................................................................................................................................14
Inspiration and expiration .................................................................................................................................................... 14
Neural Dynamics ........................................................................................................................................................................ 14
Pathomechanics ..........................................................................................................................................................................15
Rib joint pathomechanics .................................................................................................................................................... 16
PATHOLOGIC CONDITIONS
Visceral Causes of oracic Spine Pain ........................................................................................................................................16
Serious Causes of oracic Spine Pain .........................................................................................................................................17
oracic Vertebral Fractures ........................................................................................................................................................ 18
CLINICAL EXAMINATION AND DECISION-MAKING PROCEDURES ................................................................................................. 18
Diagnostic Imaging .................................................................................................................................................................... 18
Patient History and Interview ..................................................................................................................................................... 19
Patient profile and history of the current injury ................................................................................................................... 19
Area of symptoms and symptom behavior ............................................................................................................................ 19
Red flag screening questions ................................................................................................................................................. 19
Psychosocial factors .............................................................................................................................................................. 19
Patient expectations and goals .............................................................................................................................................. 20
Physical Examination .................................................................................................................................................................. 20
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..................................................................................................................................................................................16
3
Screening examination ......................................................................................................................................................... 20
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Functional examination ....................................................................................................................................................... 20
Observation ......................................................................................................................................................................... 20
Active range of motion ......................................................................................................................................................... 21
Measuring thoracic range of motion .................................................................................................................................... 21
Assessing for centralization ................................................................................................................................................... 22
Cervical spine screening ....................................................................................................................................................... 22
Screening of other adjacent body regions ............................................................................................................................. 22
Segmental examination of the thoracic spine ........................................................................................................................ 22
Segmental examination of the chest wall .............................................................................................................................. 23
Multifactorial Clinical Diagnosis ................................................................................................................................................. 23
CONDITION-SPECIFIC EVIDENCE-BASED REHABILITATION CONCEPTS
....................................................................................25
Primary oracic Spine Disorders and Rib Cage Pain with Low to Medium Risk of Prolonged Pain and Disability .................... 25
Primary oracic Spine Disorders and Rib Cage Pain with High Risk of Prolonged Pain and Disability ..................................... 25
Rehabilitation for Older Adults with oracic Spine Disorders ................................................................................................... 25
Chest Wall Pain ...........................................................................................................................................................................26
Upper Rib Syndromes ................................................................................................................................................................. 27
Manual erapy Procedures for the oracic Spine and Rib Cage ...............................................................................................27
oracic spine ...................................................................................................................................................................... 29
Rib cage ............................................................................................................................................................................... 32
Selected erapeutic Exercises ..................................................................................................................................................... 34
Increasing middle thoracic flexion ........................................................................................................................................ 34
Increasing thoracic spine extension ...................................................................................................................................... 35
Sidelying trunk rotation ....................................................................................................................................................... 35
Lower trapezius muscle reeducation ..................................................................................................................................... 35
Serratus anterior muscle reeducation .................................................................................................................................... 36
Regional Interdependence ........................................................................................................................................................... 36
Cervical spine ...................................................................................................................................................................... 36
Shoulder .............................................................................................................................................................................. 37
Key Takeaway Points ................................................................................................................................................................... 37
OUTCOME MEASURES AND RETURN TO FUNCTION .............................................................................................................................. 37
Key Takeaway Points ................................................................................................................................................................... 38
CASE SCENARIOS ........................................................................................................................................................................................................ 38
Case Scenario 1 ........................................................................................................................................................................... 38
Case Scenario 2 ........................................................................................................................................................................... 39
Case Scenario 3 ........................................................................................................................................................................... 40
Case Scenario 4 ........................................................................................................................................................................... 41
REFERENCES..................................................................................................................................................................................................................43
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For personal use only. No other uses without permission.
ACRONYM LIST
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CRLF: cervical rotation lateral flexion
CT: cervicothoracic
EMG: electromyography
IAS: inferior angle of the scapula
IASP: International Association for the Study of Pain
LBP: low back pain
LR: likelihood ratio
MDT: McKenzie Mechanical Diagnosis and erapy
MRI: magnetic resonance imaging
NPRS: Numeric Pain Rating Scale
NSAIDs: nonsteroidal anti-inflammatory drugs
PSFS: patient specific functional scale
RCTs: randomized clinical trials
ROM: range of motion
SBT: STarT Back Screening Tool
SMP: symptom modification procedure
TLS: Time Loaded Standing
TOS: thoracic outlet syndrome
ULNDT: upper limb neurodynamic test
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For personal use only. No other uses without permission.
© 2021 Academy of Orthopaedic Physical erapy, APTA, Inc. All rights reserved.
Opinions expressed by the authors are their own and do not necessarily reflect the view of the
Academy of Orthopaedic Physical erapy. e authors declare no conflict of interest.
e publishers have made every effort to trace the copyright holders for borrowed material.
If we have inadvertently overlooked any, we would be willing to correct the situation at the first opportunity.
© 2021, Academy of Orthopaedic Physical erapy. For personal use only. No other uses without permission.
Course content is not intended for use by participants outside the scope of their license or regulations.
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