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The Thoracic Spine and Rib Cage:
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Evidence-Informed Physical
Therapy Patient Management
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
ABSTRACT
e thoracic spine and rib cage region are not frequently a
primary source of symptoms for patients presenting to outpatient
physical therapy. However, when present, thoracic spine pain
can be as equally painful and disabling compared to neck and
back pain. Furthermore, the thoracic spine region has been
linked to pain and dysfunction of interrelated musculoskeletal
disorders such as neck pain, shoulder pain, and elbow pain.
is monograph for the 5th edition of Current Concepts
has been updated with the latest evidence, all new case study
questions, and additional information on condition-specific
rehabilitation of various thoracic spine and rib disorders. is
monograph begins with a review of the functional anatomy,
biomechanics, and pathokinesiology of the thoracic spine
and rib cage. Differential diagnosis, including assessment for
potential serious pathology, is covered in detail. An examination
and management process for patients with thoracic spine and
rib cage disorders, grounded in an evidence-informed, patientcentered model, is presented. Commonly used examination
procedures, manual therapy interventions, and selected exercises
are depicted and described for the physical therapy clinician.
Finally, case scenarios are provided to test the reader’s clinical
reasoning ability.
Key Words: manual physical therapy, regional interdependence,
screening
LEARNING OBJECTIVES
Upon completion of this monograph, the course participant
will be able to:
1. Describe the clinical anatomy of the thoracic spine and
rib cage as it relates to development of an accurate clinical
examination, a clinical diagnosis, and a plan of care for
individuals with thoracic spine, rib cage, or related body
region pain.
2.
Apply the clinical biomechanics of the thoracic spine and rib
cage to the development of a clinical diagnosis and treatment
program.
Apply differential diagnosis including screening of patients
3.
with thoracic spine pain and identify those requiring referral
to another provider.
4.
Conduct a patient centered interview for individuals with
thoracic spine pain capturing biomedical and psychosocial
aspects.
Perform a physical examination of the thoracic spine and rib
5.
cage that will guide patient management strategies.
6.
Describe physical therapy interventions including education
and counseling, manual therapy, and exercise as guided by
the individual patient presentation.
Apply the concept of regional interdependence and how
7.
examination and management of the thoracic spine can
assist with treatment of other related areas.
Interpret appropriate outcome measures and scales associated
8.
with thoracic spine pathology.
PRE-LEARNING CASE SCENARIO
A 47-year-old female presents to outpatient physical
therapy with a chief complaint of middle to lower thoracic
spine pain. She works in clothing retail sales. Onset occurred
after receiving and sorting a big shipment of boxes of clothing
3 weeks ago. Her symptoms were initially severe, and she took
3 days off work. Since that time, the symptoms have improved
but there are residual complaints. Her pain is located centrally
in the middle to lower thoracic spine. ere is constant lowlevel pain (3/10) that is aggravated (6/10) by trunk rotation,
bending over, lifting, prolonged sitting/driving, and prolonged
standing. e symptoms are eased somewhat by a heating
pad and taking nonsteroidal anti-inflammatory medication
(Ibuprofen). ere is no specific 24-hour pattern to her pain
and she denies pain that wakes her at night. She denies radiating
symptoms, recent unexplained weight loss, abdominal pain/
gastrointestinal distress, fever/chills, or generalized fatigue/
malaise. She had thoracic spine radiographs that revealed
“degenerative disc disease from T8 to T12.” She is concerned
by these findings and has been avoiding activity because she
does not want to cause any further “deterioration to her spine.”
Her past medical history included breast cancer that was treated
with a mastectomy and radiation. ere was no lymph node
involvement. e surgery was 5 years ago, and she has been
cancer free on annual oncology follow-up.
Outcome measures:
Numeric Pain Rating Scale: 6/10 on average
•
• Patient specific functional scale: 5/10, average of 3 activities
including bending, lifting, and standing
• STarT Back Screening Tool: 6 out of 9, including 4 out of 5
on the psychosocial subscale
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Physical examination findings:
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• Observation: walks with reduced trunk rotation, appears
tense and guarded with all movements, mild increase in
kyphosis in the middle to lower thoracic region
• oracic range of motion: rotation is limited to approximately
50% of normal in both directions with reproduction of her
concordant symptoms at end range, flexion is full with pain
at end range, extension is limited to 50% of normal range
with stiffness reported at end range
•
Segmental mobility: posterior to anterior spring testing over
the spinous processes of T8-10 produces concordant pain
and reveals hypomobility
• Palpation: moderate tenderness of the middle to lower
thoracic paraspinal muscles
• Breathing: no pain with normal or deep breathing
1. Based on the history and examination what red flag condition
should be considered with the patient?
a. Metastatic bone disease.
b. Spinal infection.
c. Osteoporotic vertebral compression fracture.
d. Visceral referred pain.
e correct answer is a. Metastatic bone disease. She has
a history of primary breast cancer and this puts her at risk for
metastatic bone disease. However, there is no other red flags such
as night pain, weight loss, neurological symptoms, or malaise.
She had radiographs of the thoracic spine but radiographs are
not sensitive enough to completely rule out bony metastases.
e patient should be monitored for response to treatment and
if she fails to improve or develops concerning symptoms, then
a referral for magnetic resonance imaging may be indicated.
Spinal infection is not likely because she does not have any risk
factors such as recent intravenous therapy or recent surgery
and she denies symptoms of infection such as fever or constant
unrelenting pain. A vertebral compression fracture is possible
but unlikely because she is younger than the typical age group
(over 50) with this condition, and she does not report a history
of osteoporosis. Visceral referred symptoms could be considered
but she denies abdominal pain, gastrointestinal complaints, or
other related symptoms. Refer to the section of this monograph
on pathological conditions for additional information related
to this question.
What is the most plausible diagnosis for this patient?
2.
a. oracic degenerative disc disease.
b. Subacute thoracic extensors muscle strain.
c. oracic spine pain (mechanical, nonspecific).
d. oracic spine disc herniation.
for red flag conditions and other conditions that can be tied
to a specific pathology. e patient had radiographs revealing
degenerative disc disease but this is a very common finding in
people over the age of 30 who do not report pain. Extensor
muscles strain is not likely, because it is unusual for only the
muscles of the spine to be involved in isolation. But the spinal
extensor muscles may be involved as part of sensitization of the
entire region. oracic disc herniation is unlikely because of
the absence of radiating or neurological symptoms. Similar to
degenerative changes, findings of disc herniation on magnetic
resonance imaging are common in people without symptoms.
See the section on pathological conditions for additional
information related to this case.
3.
What is this individual’s risk profile for developing chronic
pain and disability?
a. Minimal risk.
b. Moderate risk.
c. High risk.
d. Unable to determine at this time.
e correct answer is c. High risk. Her STarT Back Tool
is 6 out of 9 including 4 of 5 on the psychosocial subscore.
She is reporting some fear avoidance of activity due to concerns
about her imaging findings and is displaying tension and
guarding with her movements. is does not mean that she
will definitely develop chronic pain or disability, but she is at
increased risk. Patients at high risk may benefit from educational
interventions to help address any psychosocial factors, in this
case her concerns over imaging findings and related avoidance
of activity. Additional interventions targeted to high-risk
individuals could include graded exposure. She could, under
the guidance of her therapist, gradually return to bending and
lifting movements to build confidence and decrease fear of, and
sensitivity to, these activities. e STarT Back Tool has not been
validated for individuals with thoracic spine pain but it has been
extensively researched for people with low back pain. e score
and subsequent risk category scores are not fully predictive of
the individuals’ prognosis, but they can serve to direct treatment
interventions and the intensity of those interventions. See
the section on Condition-Specific Rehabilitation for more
information related to this question.
What impairment would be most useful to address with her
4.
rehabilitation at this time?
a. Posture.
b. Strength.
c. Mobility.
d. Motor control.
e correct answer is c. oracic spine pain (mechanical,
nonspecific). Similar to the lumbar and cervical region, the
majority of thoracic spine pain is considered nonspecific except
e correct answer is c. Mobility. Early in the course of
care, interventions such as manual therapy and exercise are
typically targeted toward restoring mobility as a priority. is
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8
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individual’s concordant symptoms were reproduced with range
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of motion and segmental mobility assessment, suggestive of lack
of mobility. erefore, the physical therapist would target these
impairments to manage/reduce symptoms. Manual therapy
could include either thrust or nonthrust manipulation targeting
the T8-10 region (see section on Manual erapy). A thorough
consideration of red flags (eg, thoracic spine metastasis from
breast cancer, frailty, osteoporosis, etc) should be made prior
to applying manual therapy techniques to the thoracic spine.
erapy could involve thoracic mobility exercise in multiple
directions, or the clinician may attempt to determine if there is
a directional preference and elect to prescribe exercise matching
the directional preference. Additional impairments of strength,
posture, or motor control, if present and reasoned to be
relevant, could be addressed as symptoms reduce and mobility
has been restored. See Condition-Specific Rehabilitation for
more information related to this question.
INTRODUCTION
In comparison to disorders of the cervical and lumbar
spine, primary thoracic spine disorders have been studied at
a relatively lower frequency in the rehabilitation literature.
Fouquet et al
general population is 66%, with 15% of the population with
spinal pain reporting thoracic pain compared to 44% reporting
neck pain and 56% reporting low back pain (LBP). Fouquet
1
et al
between sexes with a prevalence of 9% for males and 15% for
females. is was substantially lower than the LBP prevalence
for the same population (26% male, 25% female). Roquelaure
2
examined risk factors associated with thoracic spine pain in
et al
a working population. Males were more likely to have thoracic
spine pain if they were age > 50, were tall, performed frequent
or sustained trunk bending (> 2 hours per day), were unable
to change position or task during work, or had an occupation
requiring driving > 4 hours per day. Higher perceived physical
exertion at work was associated with increased risk of thoracic
spine pain. Interestingly, body mass index was not associated
with higher risk of thoracic spine pain for either sex.
Several of these risk factors overlap substantially with those
for neck and lower back pain. Additionally, individuals with
thoracic spine pain often report concomitant neck or lower
back pain. Despite the strong overlap in these conditions,
primary thoracic and chest wall dysfunction can be equally
as painful and disabling compared to neck and lower back
3,4
pain.
pain, motion, and posture of the entire spine. In addition to
this biomechanical link, thoracic spine pain may be involved as
part of widespread symptoms covering multiple body regions
that are often experienced and reported by individuals with
chronic spinal pain. e peer reviewed literature contains
multiple reports involving treatment of the thoracic spine and
rib cage for individuals with related spinal and peripheral joint
1
estimated that the prevalence of spinal pain in the
reported differences in prevalence of thoracic spine pain
oracic spine and rib cage dysfunction can influence
5,6
region conditions.
ese studies have generally reported a
favorable outcome for multimodal intervention programs that
include manual therapy directed to the thoracic spine. Based
on these premises, the authors of this monograph suggest that
clinicians consider the thoracic spine as a potential cause of, or
contributing factor to, common musculoskeletal disorders. is
monograph will review the clinical anatomy, biomechanics,
history, examination, diagnosis, evaluation, prognosis, and
intervention strategies to assist with management of individuals
with both primary and secondary thoracic spine and rib cage
disorders.
CLINICAL ANATOMY
Surface Anatomy
e primary or key anatomical landmarks used in
examination of the thoracic spine and rib cage are the spinous
processes, the transverse processes, and the rib angles. e
scapula has also been used to orient surface anatomy of the
thoracic spine and rib structures. e root of the spine of the
scapula is located at the height of the tip of the T3 spinous
process when the arm is adducted.
scapula is typically positioned parallel to the thoracic midline.
e inferior angle of the scapula (IAS) has historically been said
to be located in line with the tip of the 7th thoracic spinous
process. But a systematic review investigating this premise
reported that the IAS is most often found at the level of T8 but
could vary anywhere from T4 to T11.
may be most accurate to identify a given thoracic spinous process
by counting down from C7, typically the most prominent
spinous process, although it may be T1 in some individuals.
Static positioning of the scapula in reference to thoracic and rib
landmarks may be subject to differences between individuals
due to normal anatomical variance or pathology.
In the manual therapy and medical literature, the rule of
3s is often referred to when describing the relative location of
spinous and transverse processes.
length of the spinous processes varies by region. According to
the rule of 3s, the spinous processes of T1 through T3 are at
the same level as the transverse processes of the same vertebra,
the spinous processes of T4 through T6 are one half vertebral
level below their respective transverse processes, the spinous
processes of T7 through T9 are 1 full vertebral level below their
respective transverse processes, and the spinous processes of T10
through T12 are at the same level as the transverse processes of
10,11
the same vertebra.
Geelhoed et al12 investigated the validity
of the rule of 3s in a study with 5 cadaver specimen, and reported
that the spinous processes of T7 through T12 were, in general,
at the same level as the transverse processes of the next caudal
vertebrae. Above T7, the results were similar but more variable.
ere are some limitations to this study, most notable that it
was conducted on cadavers in a prone position.
13
Geelhoed et al
have proposed an alternative to the rule of
3s called the Geelhoed’s rule that states the spinous processes of
7
e medial border of the
9
Based on this study, it
10
In the thoracic spine, the
8
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9
all thoracic vertebrae are located in a transverse plane with the
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transverse processes of the adjacent caudal vertebra. Oakley et
14
measured the relationship between vertebrae in 44 cadaveric
al
specimens, and concluded that the Geelhoed’s rule may be more
accurate in locating transverse processes than the rule of 3s. As
15
a proposed alternative to the rule of 3s, Page et al
studied the
accuracy and validity of locating thoracic transverse processes
in 6 cadaveric specimens using portable ultrasound and a new
proposed method using alternative landmarks, including the
intercostal spaces and transverse process reference lines. e
study determined that using the proposed protocol proved an
accurate and valid strategy to detect bony landmarks, but study
limitations such as using both fresh and iel-fixed cadavers
and a single assessor affected the strength of their conclusions.
In summary, in the thoracic spine, it is recommended that the
clinician consider that the transverse processes of a vertebra are
frequently found above their corresponding spinous process, or
potentially at the same level.
e posterior rib angles may be palpated in standing,
seated, or prone positions. e rib angles serve as the site for
the attachment of the iliocostalis muscle and are located on
the posterolateral aspect of the rib cage. In the osteopathic
literature, tenderness of these landmarks has been reported as a
10,11
marker of rib cage dysfunction.
However, this has not been
validated in clinical or laboratory research. Manual therapy
clinicians postulate that muscular tension secondary to rib joint
dysfunction is a possible mechanism that leads to this hallmark
tenderness. is determination must be carefully correlated
with a patient’s symptom profile due to the potential for rib
angle tenderness in individuals with or without thoracic or ribrelated pain.
Osseous and Ligamentous Anatomy
Characteristics of the thoracic vertebrae vary by region,
with the superior segments sharing commonalities with those
of the cervical spine, and the inferior segments becoming more
like those of the lumbar spine. Hence, the vertebral bodies
become larger and of greater bone density from top to bottom
16
to support increasing loads superimposed by body mass.
e
anterior to posterior and transverse dimensions of the vertebral
16
bodies are similar.
e height of the vertebral bodies is slightly
less anteriorly, and this contributes to the dorsal kyphosis of
11
the thoracic spine.
e thoracic posterior facet joints are
synovial joints that are planar in structure. ey are primarily
in the frontal plane, with the superior facet oriented 60° from
11
the horizontal plane and 20° from the frontal plane.
e
inferior facet matches the orientation of the superior facet,
facing anteriorly, inferiorly, and slightly medially. e superior
facet originates from the inferior aspect of the superior vertebra
of the thoracic spinal motion segment while the inferior facet
originates from the superior aspect of the inferior vertebra of
the spinal segment. e thoracic discs are relatively thin, with
a disc to vertebral body height ratio of 1 to 5, compared to 2
11
to 5 in the cervical spine, and 1 to 3 in the lumbar spine.
e
thoracic disc morphology, along with the attachment to the rib
cage, is thought to contribute to the relatively lower mobility of
the thoracic spine compared to the cervical and lumbar regions.
Twelve pairs of ribs enclose the thoracic cavity, forming a
protective cage for the cardiopulmonary organs. e ribs are long,
elastic, curved structures made of highly vascular spongy bone
11
encased in a thin layer of compact bone.
as true or false and as typical or atypical.
e ribs are classified
11
Ribs 1 through 7
are true ribs because they directly attach to the sternum. Ribs
8 through 12 are false ribs because they attach distally to the
costochondral cartilage of the superior rib or in the case of ribs
11 and 12, have no anterior attachment at all. e heads of ribs
3 through 9, the typical ribs, have 2 facets for attachment to the
corresponding demi-facets on the vertebral bodies. e superior
rib facet attaches to the superior vertebral body, and the inferior
facet attaches to the numerically corresponding vertebral body,
forming the costovertebral joint. Between the 2 facets on the
rib head is a crest that attaches to the intervertebral disc. e
atypical 1st, 10th, 11th, and 12th ribs attach to only 1 facet on
the corresponding vertebral body. e second rib attaches to T1
and T2 but is considered atypical because of its attachment to
the junction of the manubrium and sternum. Ribs 1 through
10 also attach to the corresponding thoracic transverse processes
forming the costotransverse joints. In the upper thoracic spine
down to T5 or T6, the rib portion of the joint is concave and
the transverse process portion is convex. In the lower thoracic
spine, the costotransverse joints are planar. is shape appears
to allow for more rotation or torsional movement above rib
7 and more planar gliding movement below that level. us,
during inspiration, the upper rib cage rises (flexes) in the sagittal
plane while the lower ribs widen (abduct) in the frontal plane.
Ribs 11 and 12 do not attach to the transverse processes and do
not have a costotransverse joint.
Several spinal ligaments provide additional stability to the
17
thoracic vertebrae and rib structures.
e ligamentum nuchae,
interspinous and supraspinous ligaments, ligamentum flava,
and the posterior longitudinal ligament limit spinal flexion.
e anterior longitudinal ligament, in addition to the anterior
annulus fibrosus, limit spinal extension. Lateral side bending
is limited by the intertransverse ligaments, contralateral
annulus fibrosus, and facet joint capsules. e costovertebral
joints are reinforced by the radiate and capsular ligaments.
e costotransverse and superior costotransverse ligaments
collectively provide stabilization at the costotransverse joint.
Key Muscles
e thoracic spine and rib cage serve as the attachment
site for numerous muscles. Discussion will focus on the muscles
relevant to the examination, intervention, and diagnosis of
thoracic spine and rib cage dysfunction. e trapezius muscle
originates from all the thoracic spinous processes, the external
occipital protuberance, the ligamentum nuchae, and the spinous
10
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process of C7. It serves an important role in assisting with the
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force coupling creating scapular upward rotation and posterior
tipping during elevation of the humerus. e iliocostalis
thoracis starts at the angle of ribs 7 through 12 and ascends
to the angles of ribs 1 through 6 and the transverse process
of C7. e iliocostalis lumborum originates on the posterior
aspect of the sacrum and thoracolumbar fascia and ascends to
the angles of ribs 6 through 12. e erector spinae muscle group
serves an important role in health and function of the spine. In
reference to the thoracic spine, the erector spinae muscles help
to maintain an upright, neutral thoracic curve. Spinal extensor
weakness and reduced muscle density has been associated with
thoracic hyperkyphosis, osteoporosis, decreased quality of life,
and increased risk of falling in older adults.
18,19
e serratus anterior muscle arises from the outer surface
and superior border of the upper 8th through 10th ribs and the
fascia of the associated external intercostal muscles. It courses
close to the chest wall to attach to the anterior surface of the
vertebral border of the scapula. Its action is to protract the
scapula and it also contributes to the force coupling for scapular
upward rotation and posterior tipping. When the scapula is
fixed, it is reported that the action of the serratus anterior will
result in a posteriorly directed force on the ribs.
11
e pectoralis major is a thick muscle with 3 proximal
attachments, from the clavicle, the sternum, and the costal
cartilages of ribs 1 through 6. e distal attachment is into the
lateral lip of the bicipital groove of the humerus. e general
action of the muscle is to adduct and internally rotate the
humerus. e clavicular portion of the pectoralis can also assist
the coracobrachialis and anterior deltoid with glenohumeral
flexion. When the distal attachment is fixed with the humerus
flexed, the action of the pectoralis muscle will result in an
anterior, superior, and lateral force on the anterior rib cage. e
pectoralis minor arises from the anterior and superior surfaces
of ribs 3 through 5 and attaches to the superomedial aspect of
the coracoid process. Adaptive shortening or hypertonicity of
this muscle can lead to protraction and anterior tipping of the
scapula, which may potentially affect normal scapular motion
20
during elevation of the arm.
e anterior scalene muscle arises from the anterior tubercle
of the transverse processes of C3 through C6 and attaches to the
scalene tubercle on the inner border of the first rib. e middle
scalene muscle arises from the transverse processes of C2 through
C7 and attaches on the first rib medial to the anterior scalene.
e anterior and middle scalene muscles are potentially relevant
contributing factors to dysfunction of the first rib because they
both can elevate the first rib when the cervical spine is fixed.
11
e posterior scalene muscle arises from the posterior tubercle
of the transverse processes of C4 through C6 and attaches to the
outer surface of the second rib. Given its origin and insertion,
the posterior scalene muscle can potentially elevate the second
rib when the cervical spine is fixed. e scalene musculature
may be implicated with pain disorders of the neck and upper
quarter, as well as being a potential peripheral compression site
in thoracic outlet syndrome (TOS).
e diaphragm is the primary muscle of inspiration and has
broad musculoskeletal attachments to the ribs and spine. e
muscles of the diaphragm are grouped into 3 portions: sternal,
costal, and lumbar. e sternal portion arises from the back of
the xiphoid process, the costal portion from the internal surfaces
of the costal cartilages and adjacent parts of the lower 6 ribs, and
11
the lumbar portion from the first 2 or 3 lumbar vertebrae.
Lack of relaxed diaphragmatic breathing is an impairment that
often accompanies both acute and chronic spinal disorders and
could contribute to thoracic spinal mobility restrictions.
Neurovascular Structures
e 12 thoracic spinal nerves divide into anterior and
posterior primary rami. Each thoracic spinal nerve exits below
11
its respective intervertebral disc.
e cutaneous branches
of the anterior and posterior thoracic rami spinal nerve form
each thoracic dermatome. e thoracic dermatomes run in
a circumferential pattern just inferior to the corresponding
thoracic vertebrae from posterior midline to anterior midline.
e posterior rami are divided into medial and lateral branches.
e medial branch of the upper 6 segments supplies the
semispinalis and multifidus muscles and the skin of the upper
back. e medial branch of the lower 6 thoracic segments
supplies the transversospinalis and longissimus muscles. Each
medial branch has ascending and descending branches to the
21
facet joints above and below.
e lateral branch of the posterior
rami supply the longissimus and iliocostalis muscles, and the
costotransverse joints. e lower 6 segments eventually emerge
21
from the iliocostalis lumborum muscles to become cutaneous.
e anterior rami travel anteriorly in the intercostal space and
are known as the intercostal nerves. e 12th anterior rami
forms the subcostal nerve as it travels below the 12th rib. Each
thoracic spinal nerve contributes preganglionic sympathetic
fibers to the sympathetic chain. e sympathetic chain is just
anterior to the rib head and is lateral to the costovertebral joint.
21
e muscular branches of the typical intercostal nerves
supply the innermost intercostal, internal intercostal, external
intercostal, subcostal, and serratus posterior muscles. e
cutaneous branches supply the skin on the lateral and anterior
aspect of the thorax and abdomen. e muscular branches
of the 7th through 11th intercostals and the subcostal nerve
innervate the abdominal muscles. e subcostal nerve supplies
sensation to the skin of the abdominal wall, over the iliac crest
22
and to the lateral hip.
which nociceptive input arising from the thoracolumbar
junction could lead to referred pain in the hip region.
is is a potential avenue through
23
e
superior part of the first intercostal nerve (T1) forms part of
the brachial plexus. e lateral cutaneous branch of the second
22
intercostal nerve is known as the intercostobrachial nerve.
e
intercostobrachial nerve supplies sensation to the floor of the
axilla and joins the medial brachial cutaneous nerve to supply
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11
the medial side of the arm as far distal as the elbow region. is
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connection allows for the potential for nociceptive input arising
from the upper thoracic spine to contribute to symptoms in the
22
upper extremity.
e sinuvertebral nerve, a recurrent branch of
the spinal nerve and the anterior rami, consists of both somatic
and autonomic fibers and supplies the dura, the outer fibers of
the intervertebral disc, medial aspect of the facet joint, and the
posterior longitudinal ligament.
21
e spinal canal within the thoracic spine is notably
narrower than in other regions. e region from T4 through T9
is known as the critical zone due to the small diameter of the spinal
canal and reduced blood supply in comparison to other regions
11
of the spine.
Symptomatic thoracic disc herniations are a rare
diagnosis that most commonly occurs below the T7 level. e
clinical importance of this is that large thoracic disc herniations
have the potential to cause central spinal cord compression. Less
serious pathology, such as mobility impairments in this region,
may be associated with upper or lower quarter neurogenic and
sympathetic signs or symptoms, such as bilateral extremity
paresthesias and sweating. is constellation of signs and
symptoms has been sometimes referred to as T4 syndrome. e
origin of the T4 syndrome or related signs and symptoms is
unknown and is likely a result of amplification of nociceptive
input into the peripheral and central nervous systems. Clinically,
interventions targeting mobility impairments in this area may
assist with a temporary reduction in the signs and symptoms
associated with T4 syndrome.
Thoracic Pain Referral Patterns
Examination of the thoracic spine and rib cage is indicated
for patients whose symptoms appear to originate from
this anatomical region or are referred to areas segmentally
innervated by these levels. Diagnostic hypotheses involving the
thoracic spine are based on the location, nature, and behavior
of symptoms, and symptoms provoked during the upper or
lower quarter screening examination. e pain referral pattern
of the thoracic spine and rib cage articulations, and also other
somatic structures that can refer pain to the thoracic spine,
has implications for conducting and interpreting the physical
examination. e pain referral patterns of the thoracic facet
joints have been investigated in 2 studies.
3
Dreyfuss et al
provided preliminary evidence in the
asymptomatic population that the thoracic facet joints can
create nociceptive input leading to both local and referred pain.
e facet joints from T3-4 through T10-11 were injected with
a noxious substance and the study participants reported where
they experienced symptoms after injection of each joint. e
authors reported that in all participants the most intense area
of evoked pain occurred 1 segment inferior and slightly lateral
to the joint injected. Furthermore, no joints referred pain more
superior than one half of the vertical height of that vertebral
segment; however, distal referral was up to 2.5 segments below
the injected level. In addition, 2 participants had anterior chest
wall and sternal pain when the T3-4 and the T4-5 segments
were injected.
To further investigate the pain referral of the thoracic facet
4
joints, Fukui et al
injected the C7-T1 to T2-3 and T11-12
segments in a group of 15 patients complaining of thoracic
spine pain. Pain referral from the C7-T1 to T2-3 segments
overlapped extensively, with pain reported over the paravertebral
region and inferiorly toward the superior angle of the scapula
and the interscapular region toward the inferior angle of the
scapula. e T11-12 segment produced pain localized to the
paravertebral region of the segment, and in 1 patient pain was
perceived over the ipsilateral iliac crest. Across all participants,
only unilateral pain was reproduced and no radiating pain,
including anterior or lateral chest wall pain, was reported.
In a prospective case series of 46 patients with chronic
thoracic spine pain, 48% responded to a medial branch block
24
performed on 2 separate occasions.
Based on the injection
response, there was a 48% prevalence rate of thoracic facet joint
mediated pain. is is in comparison to the reported 15% to
45% prevalence of facet joint pain in patients with chronic
lumbar pain and 54% to 60% in patients with chronic cervical
pain. is study took place in 1 private pain management
practice and there was no placebo intervention, so the true
prevalence rate of thoracic facet joint mediated pain in the
general patient population needs further clarification.
Due to their innervation, both the costovertebral and
costotransverse joints have the potential to generate nociceptive
25
signals. Young et al
performed a pain mapping study of the
costovertebral joints with 8 asymptomatic volunteers. Using
video fluoroscopic guidance, the T2 to T7 costovertebral joints
were injected. Participants reported symptoms ipsilateral to
and directly over the joint injected. Only with injection to the
T2 costotransverse joint did they report pain 2 vertebral levels
above the region injected. In a clinical case series, Benhamou
26
reported on 28 patients who had pseudovisceral pain
et al
that was relieved by injection into the costovertebral joint. In
27
a cadaver dissection study, Nathan
noted a 60% incidence of
osteophytes at the costovertebral joint that appeared to encroach
on the thoracic sympathetic chain. is could potentially
explain the findings of pseudovisceral pain being relieved by
injection of the costovertebral joint.
Similar to the cervical and lumbar regions, the thoracic
disc is capable of producing nociceptive input. oracic disc
pathology is often seen on imaging studies such as radiographs
28
or magnetic resonance imaging (MRI).
Symptomatic thoracic
disc herniation is estimated to occur in approximately 1 per 1
million persons each year. e presence of disc pathology on
imaging studies, however, does not automatically implicate
29
the disc. Wood et al
have demonstrated that the incidence of
asymptomatic thoracic disc protrusion is approximately 37%.
Furthermore, based on a 2-year follow-up study by Wood
29
there was little change in the size of the protrusions,
et al,
suggesting that these disc abnormalities are commonly present.
12
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erefore, the authors advise that clinicians should interpret the
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presence of thoracic disc protrusions seen on MRI with caution.
Although descriptive in nature, reports in the literature suggest
a link between thoracic disc herniations and thoracic and chest
wall pain. However, there are no studies reporting the symptom
referral pattern for the thoracic discs. A thoracic disc protrusion
could potentially create thoracic nerve root compression and a
radiculopathy. In this instance, the clinician may find decreased
sensation in the corresponding thoracic dermatome and the
patient may report lancinating pain in a similar region. Twelve
case reports in the literature have highlighted the potential for
thoracic disc herniation and outlined their pain referral patterns.
Pain referral patterns can range from abdominal, flank, chest,
and periscapular pain based upon herniation location. Primary
complaints of only radicular symptoms due to a symptomatic
thoracic disc herniation might be mistakenly diagnosed as
psychogenic pain, intercostal nerve entrapment, or visceral
disease, among others. Successful treatment for these patients
ranges from nonsurgical measures, such as physical therapy, to
operative techniques like decompression procedures or nerve
root injections.
Nociceptive input from the lower cervical spine has
the potential to lead to referred pain in the upper to middle
thoracic spine region. Based on pain mapping studies, the facet
joints and intervertebral discs of the C5-6 and C6-7 segments
are associated with referred pain in the upper thoracic spine
30,31
and interscapular region.
For patients with upper thoracic
and interscapular region pain, clinical examination is required
to differentiate the thoracic versus the cervical spine or other
structures as contributing to the patient’s symptoms.
CLINICAL BIOMECHANICS AND
PATHOMECHANICS
Thoracic and Rib Cage Motion
Motion in the thoracic region is affected by the unique
morphology of the thoracic spine, the rib cage, and rib
articulations. Due to this morphology, thoracic spine range of
motion (ROM) is less compared to what is seen in the cervical
and lumbar spine. e thoracic spine can be thought of as 3
units. e upper thoracic spine and cervicothoracic (CT)
junction function in a manner similar to the cervical spine. e
middle thoracic spine functions independently with significant
influence by the rib cage. Finally, function of the lower thoracic
spine and thoracolumbar junction more closely resemble that of
the lumbar spine. Although the addition of the rib cage limits
the range of thoracic spinal motion, the thoracic segments are
capable of moving independently of the rib cage.
the ribs increase stability of the spine by bearing weight under
33
applied loads to the thoracic spine.
Readers are encouraged to
view the literature regarding potential deviations to the following
thoracic and rib cage biomechanics in patient populations who
have undergone surgical procedures, such as a spinal fusion, or
those diagnosed with scoliosis.
32
Moreover,
Flexion and extension
Due to the morphology of the facet joints, the contribution
to overall motion in the sagittal plane gradually increases from
T1-2 to T11-12 as the facets become more oriented in the sagittal
34
Overall, the reported amount of thoracic flexion and
plane.
extension ROM varies widely across studies, likely due to the
35
differences in measurement methods.
Mannen et al35 studied
thoracic cadaver specimens with rib cages intact and reported a
mean value of 7.7° of flexion and 9.6° of extension. e average
age of the cadavers was 71 years. With forward flexion, the
superior vertebra translates forward in the transverse plane and
36
rotates forward in the sagittal plane.
e articular facets of
the superior vertebra glide upward and forward on the superior
facets of the inferior vertebra. In a clinical model proposed
36
by Lee,
flexion of the thoracic spine results in concomitant
forward rotation of the rib head at the costovertebral joint.
e hypothesis is that the anterior translation of the superior
vertebra of the motion segment pushes the superior demifacet
of the rib head. e concave tubercle of the rib glides superiorly
on the convex facet on the thoracic transverse process at the
costotransverse joint. Extension results in posterior translation
of the superior vertebra and backward rotation in the sagittal
36
e inferior facets of the superior thoracic vertebra
plane.
glide down and back on the superior facets of the inferior
vertebra at the facet joint. In the clinical model proposed by
36
thoracic extension produces a concomitant posterior
Lee,
rotation of the rib head at the costovertebral joint and inferior
glide at the costotransverse joint. It is interesting to note that
end range active bilateral shoulder flexion is coupled with end
range thoracic extension and that the lower thoracic spine
contributes to this thoracic extension ROM during shoulder
37
elevation.
e clinical significance of this is that limited
thoracic spine extension can contribute to shoulder elevation
mobility impairments often seen in older adults.
Side bending
Side bending of the thoracic vertebrae in the frontal plane is
accompanied by a small ipsilateral lateral translatory movement
36
of the superior vertebrae in the horizontal plane.
Side bending
in the thoracic spine gradually increases from T1-2 to T11-12.
35
Mannen et al
on average. In a similar study, Narimani and Arjmand
reported total thoracic side bending to be 23.3°
38
reported
a mean ± standard deviation of 24.5° ± 7.4° of total thoracic
side bending. In right side bending, the right inferior facet of
the superior vertebra glides inferolaterally and the left inferior
36
facet glides superomedially.
Lack of agreement exists as to
whether thoracic rotation couples contralaterally or ipsilaterally
during side bending. e thoracic spine coupling pattern was
the topic of a systematic review involving 8 different studies.
39
e reviewed studies included both in-vitro and in-vivo designs.
Across the 8 studies, there was no consistent coupling pattern
reported. e authors concluded that methodological study
design differences could account for the reported variability
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13
and that more research is needed. In an in vivo study by
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40
Willems et al,
using motion analysis, rotation was found to
couple to the ipsilateral side with primary side bending. ere
was some variability within and between individuals, and the
ipsilateral coupling pattern was not as consistent in the upper
thoracic spine. Moreover, a study by Narimani and Arjmand
38
demonstrated that the greatest extent of coupled motion
occurred in the lower thoracic spine during lateral side bending
and rotation in standing, but there was no consistent directional
coupled motion among individuals. A study analyzing the
T2 through T7 segments in asymptomatic individuals found
that the thoracic spine extended, rotated, and side bent to the
41
ipsilateral side during elevation of the arm.
36
model developed by Lee,
side bending of the thoracic spine
In the clinical
leads to approximation of the ribs on the ipsilateral side and
separation of the ribs on the contralateral side.
Rotation
oracic spine rotation is greatest in the upper segments
42
and significantly reduced in the lower segments.
35
reported a mean total amount of thoracic rotation of 26°. In
al
studies by Willems et al
40
and Alqhanti et al,43 the middle section
Mannen et
(T4-8) of the thoracic spine was determined to contribute most
to rotation in standing and sitting. oracic spine rotation is
accompanied by slight translation of the superior vertebra
3
to the contralateral side.
40
ipsilateral coupling of side flexion with primary rotation
al,
In the in vivo study by Willems et
predominated, but there was variability within and between
36
individuals. In the clinical model proposed by Lee,
right
and anterior rotation of the left rib.
Inspiration and expiration
Clinical models of rib cage motion during respiration
postulate that the ribs follow a pump-handle and bucket-handle
11
motion.
During inspiration, as the anterior-posterior diameter
of the thorax expands and the intercostal muscles contract, the
ribs move through the axes of their necks at the costovertebral
and costotransverse joints and the anterior ends of the ribs rise
with the sternum. is anterior superior motion is referred to
as the pump-handle motion. Concurrently during inspiration,
as the transverse diameter of the thorax expands and intercostal
muscles contract, the ribs move laterally and superiorly. is
movement is referred to as a bucket-handle motion because it
is similar to a bucket handle moving away from its attachments
when the handle is raised. During expiration, the rib moves
inferiorly in both the anterior and lateral aspects. Due to the
axis of motion through the costovertebral and costotransverse
joints, the pump-handle motion is thought to predominate in
the upper ribs, whereas the bucket-handle motion predominates
in the lower ribs. An in vivo study, however, determined that
rib cage motion was similar at all levels in terms of the relative
anterior and lateral expansion of each rib during inspiration.
44
e 11th and 12th ribs, due to the lack of anterior attachments
and costotransverse joints, are thought to move in a calipertype motion. In the caliper motion, the ribs move posterior
and lateral during inspiration and anterior and medial during
expiration. Of note is that during inspiration the thoracic
segments extend, and during expiration the segments return to
their neutral position.
45
Neural Dynamics
e concept of neural tissue dynamics has been discussed
46,47
in the clinical orthopaedic physical therapy literature.
Evaluation and treatment of neural tissue is supported by basic
46-49
science research and clinical case reports.
In the thoracic
spine, several areas deserve mentioning in relation to neural
dynamics. e sympathetic chain lies anteriorly along the rib
22
heads and the costovertebral joints.
eoretically, the thoracic
sympathetic chain is elongated during flexion, contralateral
46
rotation, and contralateral side bending of the thoracic spine.
Further stretching could be accomplished by performing
thoracic flexion and contralateral side bending in a slump
long-sitting position (cervical flexion with bilateral hip flexion
and knee extension). e thoracic posterior primary rami run
inferior and lateral along the posterior thorax. ese nerves
are stretched during cervical and thoracic flexion and could be
potentially injured as a result of a whiplash type injury from
a motor vehicle accident. Neurogenic symptoms of burning,
itching, and paresthesia in the region of the thoracic posterior
rami could implicate these nerves as involved in the patient’s
symptoms. Bilateral and unilateral assessment of these nerves
could be performed as described in the slump test above. e
intercostal nerves formed by the thoracic anterior rami, could
be involved after trauma to the ribs such as with rib fractures
or surgery such as a thoracotomy. As stated previously, the area
from T4 through T9 is known as the critical zone due to the
small diameter of the vertebral spinal canal. In addition, the T6
46
spinal cord segment is reported to be a tension point.
is is
an area where the motion of the spinal cord relative to the spinal
46
canal converges in different directions. Butler
postulates that
during flexion of the cervical and thoracic spine, similar to the
slump position, the cord, in relation to the spinal canal, is pulled
from above cranially toward the cervical spine and caudally from
below toward the lumbar spine. Mobility impairments of the
middle thoracic region could contribute to signs and symptoms
associated with adverse neural tissue dynamics. Symptoms and
ROM associated with a positive slump test can be altered after
spinal manipulative treatment of the middle thoracic region.
50
Harstein et al
investigated the immediate effects of thoracic
spine thrust and nonthrust manipulation techniques on the
upper limb provocation test and seated slump test in individuals
with identified neurodynamic mobility impairments. Both
the thrust and nonthrust interventions resulted in medium
effect sizes for the upper limb provocation test, whereas thrust
techniques had a medium effect size for the seated slump test
14
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compared to nonthrust mobilizations that had a small effect
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size. Limitations to this study include assessing immediate
treatment effects only and the multifactorial mechanisms likely
responsible for explaining the efficacy of spinal manipulation
therapy.
As mentioned previously, a clinical condition referred to
as the T4 syndrome, has been described as a constellation of
signs and symptoms associated with stiffness of the upper to
51
middle thoracic region.
Typical signs and symptoms include
headaches, neck pain, upper extremity pain, and bilateral
“stocking glove” paresthesia. It is thought that these signs and
symptoms could be resulting in part from the dysfunction of
the thoracic spine and its resulting influence on the sympathetic
nervous system. A published case report described a decrease in
symptoms in a patient with upper extremity complex regional
pain syndrome after a thrust manipulation directed to the upper
52
thoracic spine.
An experimental study found that grade 3
posterior to anterior nonthrust mobilization applied to the T4
segment produced sympathoexcitatory effects in both hands of
53
asymptomatic individuals.
Sympathetic nervous system activity
was measured via skin conductance, a method that the authors
considered valid and reliable, showing that manipulation of the
T4 thoracic region produced an increase in skin conductance in
the hands. However, this study does not provide direct evidence
into the mechanism of how manipulation of the thoracic region
can provide a reduction in symptoms in patients with T4
syndrome. Existing literature on T4 syndrome is largely of lowquality evidence, and therefore evidence regarding the diagnosis
54
and best treatment are limited.
Further research is required
behind how manipulation of the thoracic spine potentially
produces beneficial effects.
Pathomechanics
To the authors’ knowledge, there are no studies analyzing
the motion of the thoracic spine and rib cage in individuals
with primary or secondary thoracic spine disorders. As a
result, the pathomechanics of the thoracic spine are based
largely on applied anatomy and biomechanics, expert opinion,
and clinical models. A clinical model enables clinicians to
categorize movement impairments and can be useful to direct
interventions. Similar to other regions of the spine, mobility
of the thoracic spine naturally decreases with aging. Structural
thoracic spine abnormalities such as scoliosis and kyphotic
deformities will also tend to reduce thoracic mobility.
In most clinical texts, pathomechanical models of motion
restriction usually make reference to motion impairments
10,55,56
of specific joint articulations.
In the thoracic spinal
segments, motion impairments are usually made in reference
to the motion of the facet joints. But, in reality, restriction of
a thoracic functional spinal unit can involve the facet joints,
the intervertebral disc articulation, the costovertebral joints,
the costotransverse joints, and associated muscular, neural,
fascial, and ligamentous structures. It is important to note that
apparent thoracic spine mobility impairments are very common
in individuals who do not have symptoms. Additionally, the
connection between pain, disability, and thoracic spine
movement impairments has not been fully assessed in the
literature. It is often assumed that restricted spinal mobility is
linked to pain and that addressing this impairment will lead to
a reduction in symptoms. However, this concept is tenuous and
interventions directed toward increasing thoracic spine mobility
such as manual therapy or exercise may be associated with a
reduction in symptoms without a significant concomitant
change in spinal mobility.
57
Flexion movement impairments reflect the inability of the
thoracic spinal unit to rotate forward in the sagittal plane.
In the thoracic spine, flexion impairments appear to most
commonly occur in the upper to middle thoracic spine regions,
10,55
approximately T3-4 through T6-7.
is may be observed
by a relative straightening or a reduction of the normal
posterior thoracic kyphosis in that region. A flexion movement
impairment of the upper thoracic spine is thought to occur after
a whiplash-type injury as a result of a rear-impact collision. It is
thought that the upper thoracic segments become jammed into
extension when the upper trunk is thrust forward and upward
58,59
during the initial impact.
A unilateral flexion impairment
may exist, whereby a thoracic spinal motion segment has
decreased flexion and contralateral rotation and side bending.
A unilateral thoracic spine flexion impairment could be evident
during combined motion testing of flexion, contralateral
rotation, and contralateral side bending.
Extension impairments are the opposite of flexion
impairments and reflect the inability of the thoracic motion
segment to rotate backward in the sagittal plane. Extension
impairments are thought to more commonly occur in the upper
thoracic spine and at the CT junction (C7 through T2), where
58
an increased posterior thoracic kyphosis is often present.
e
lower thoracic spine is also thought to be more commonly
restricted in extension, as observed by an increased middle
to lower thoracic kyphosis. Age-related structural changes
of the thoracic spine including disc height degeneration and
anterior wedging of the vertebral body can also contribute to
60
extension impairments.
A unilateral extension impairment
can be observed by a lack of combined motion into extension,
ipsilateral rotation, and ipsilateral side bending.
As individuals age, spinal mobility generally decreases, and
this can be particularly significant in the thoracic spine. oracic
spine mobility deficits are common in older adults and have
been associated with decreased quality of life and increased risk
18
of falling. For example, Imagama et al
reported a significant
association between sagittal plane thoracic spine ROM and
health related quality of life measured by the SF-36 in elderly
Japanese men. A common scenario is the development of a
thoracic hyperkyphosis. e increased kyphosis can be linked
to vertebral compression fractures, spinal extensor muscle
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15
weakness, and degenerative changes of the thoracic spine.19
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Fortunately, spinal flexibility and extensor muscle strength can
be improved with exercise programs and this will be discussed
further in the intervention section.
possibility of serious pathology or disease. Potential conditions
that would require a medical referral can be divided into visceral
conditions that refer pain to the thoracic spine, and serious
conditions of the thoracic spine.
64
Rib joint pathomechanics
e upper rib joints could theoretically become dysfunctional at either the costovertebral or costotransverse articulations. Several authors describe a condition where the first rib is
found to be in a relatively superior position on physical exam-
10,61
ination.
is is thought to commonly occur after traumatic
injuries such as a whiplash or with repetitive overuse of the upper extremity. e exact mechanism is unknown, but it is most
plausible that this finding is created by soft tissue tension and
subluxation. Impaired mobility of the first rib during inspiration and expiration has been demonstrated through cineradi-
62
ography in patients diagnosed with TOS.
One potential site
of entrapment associated with TOS is between the first rib and
the clavicle. e theory is that elevation of the first rib leads to a
reduction in the space between the first rib and clavicle leading
to an entrapment of the neurovascular bundle.
Middle and lower rib movement impairments can occur
either in isolation or concurrently with thoracic spine impairments. Reduced motion at the costovertebral, costotransverse,
or costosternal joint can contribute to rib mobility impairments.
ese impairments may result from aging, repetitive or postural strain, or muscle guarding subsequent to a traumatic injury.
Situations where these articulations develop excessive movement or hypermobility can also potentially occur as a result of
traumatic sprain or repetitive strain injuries. In the osteopathic
manual medicine literature, several mechanical rib joint dys-
functions have been described including respiratory dysfunction
10
(bucket- or pump-handle) and traumatic subluxations.
However, the existence of these dysfunctions or a clinician’s ability to
diagnose them has not been subjected to peer reviewed research.
PATHOLOGIC CONDITIONS
A clinician must first rule out the presence of serious or
visceral cause of the symptoms that requires referral to another
health care provider. It is estimated that primary thoracic spine
pain only makes up approximately 15% of all spinal pain.
In a sample of workers, the incidence of thoracic spine pain
was higher in women (20%) compared to 10% in their male
1
counterparts.
Because the presence of primary thoracic pain
is relatively uncommon compared to other spinal conditions,
clinicians should be suspicious of nonmechanical causes in
patients presenting with a primary complaint of thoracic
63
spine and chest wall pain.
A medical screening form, which
the patient completes prior to the clinician conducting an
examination, is a useful first step in the medical screening
process. Positive responses to questions on the medical screening
form will then cue the therapist to probe further to ascertain the
63
Visceral Causes of Thoracic Spine Pain
Primary visceral causes of thoracic spine pain should be
considered when there are no clear mechanical features to a
64
patient’s pain.
Visceral conditions that can refer pain to the
thoracic spine include myocardial ischemia, dissecting thoracic
aortic aneurysm, peptic ulcer, acute cholecystitis, renal colic,
and acute pyelonephritis. e International Association for the
Study of Pain (IASP) developed a taskforce to explore secondary
65
visceral causes of spinal pain including the thoracic spine.
Potential secondary causes include inflammatory conditions of
the viscera (eg, chronic pericarditis, esophagitis, etc), vascular
conditions (eg, venous thrombosis, recurrent ischemic heart
disease, etc), and mechanical conditions (eg, traction of
65
ligaments/vessels, stenosis of esophagus, etc).
Referred pain is pain perceived in a region separate from
21
the location of the primary source of the pain.
e mechanism
of referred pain is not completely clear although the most
accepted theory is that referred pain is due to the convergence
of primary afferent neurons to a common second-order neuron
in the spinal cord. Pain elicited by a visceral structure can be
misperceived as arising from a somatic structure that has a
primary afferent neuron converging onto the same second-order
21
neuron.
e majority of the visceral organs are innervated by
the thoracic spinal nerves. erefore, several visceral conditions
or pathologies may refer pain to the thoracic spine and rib cage.
Conversely, nociceptive input arising from the thoracic
spine and rib cage structures could be potentially experienced
as visceral in origin. In the authors’ experience, some patients
who have been diagnostically worked up for multiple
visceral diagnoses, with inconclusive findings, have had a
musculoskeletal disorder involving the thoracic spine. Once
the thoracic spine region was treated, the patient’s symptoms
that were seemingly experienced as visceral in origin resolved.
A case example is a 24-year-old female dental student whose
chief complaint was right upper abdominal quadrant pain and
dyspepsia. She had undergone a computed tomography scan
and ultrasound imaging of the abdomen without significant
findings and was prescribed a proton pump inhibitor. is
medication, which is used to treat gastrointestinal reflux, did
not relieve her symptoms. She was referred to physical therapy
for assessment. Her right upper abdominal quadrant symptoms
were reproduced with palpation and spring testing of the
right lower thoracic spine (T9-10 region) and adjacent ribs.
Two sessions of manual therapy techniques (mobilization and
manipulation) to this region, followed with mobility exercises,
resolved her symptoms. Literature on thoracic spine referred
visceral symptoms is lacking and is an area that would benefit
from research. Sound clinical reasoning is required when
16
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