Thoracic assesment
- Fysiobasen
- Oct 5
- 10 min read
The thoracic spine plays a complex and often underestimated role in the human body. It serves as a central hub for load transfer between the upper and lower body and is crucial for rotational movements.
To ensure a comprehensive evaluation and effective treatment, the thoracic region should be viewed as a functional unit — encompassing not only the vertebral column itself but also the ribs and their articulations.
Structural and Functional Relationships
The thoracic region provides:
Attachment sites for muscles and connective tissues: Linking the head, neck, scapula, clavicle, lumbar spine, and pelvis.
Connections to internal organs: Through rib structures that interface with thoracic and abdominal organs.
Role in Body Systems
Respiration: The thoracic spine is integral to breathing mechanics, contributing to rib movement and muscular coordination.
Protection of vital organs: The rib cage shields the heart, lungs, and major blood vessels.
Emotional and neural regulation: The thoracic spine interacts with the autonomic nervous system, influencing stress responses (“fight or flight”).
Initial Diagnose
Ved observasjon og vurdering av pasienten er det viktig å være oppmerksom på vanlige årsaker til smerte i thorakalcolumna. Dette hjelper med å screene for mulige tilstander og begynne eliminasjonsprosessen for å stille en diagnose.
Initial Diagnosis
During observation and assessment, clinicians must identify common causes of thoracic pain to guide differential diagnosis and treatment direction.
Common causes:
Sprain or strain involving intervertebral joints, costovertebral joints, or musculature.
Reduced thoracic mobility due to rib, joint capsule, ligament, or vertebral involvement (e.g., Scheuermann’s disease in adolescents).
Postural or overuse syndromes (common in sedentary workers and students).
Less common causes:
Rib or compression fractures.
Thoracic outlet syndrome.
T4 syndrome.
Red flags:
Cardiac or pulmonary conditions (pneumothorax, pulmonary embolism).
Peptic ulcer, malignancy, or mesothelioma following asbestos exposure【2】.
Functional Anatomy
The thoracic spine and rib cage form a biomechanical system essential for:
Protecting the heart, lungs, and visceral organs.
Enabling ventilation.
Providing stability for muscular attachment to the upper limbs, head, neck, and pelvis【3】【4】【5】— at the cost of mobility.
Thoracic Spine:
Located between the cervical and lumbar regions.
Composed of 12 vertebrae, heart-shaped vertebral bodies increasing in size caudally【6】.
Articulations for rib heads along the vertebral sides【5】【6】.
Rib Cage:
12 pairs of ribs:
1–7: True ribs (attach directly to the sternum).
8–10: False ribs (connect via costal cartilage above).
11–12: Floating ribs (no sternal attachment)【4】.
Subjective Examination
Symptoms (documented on a body chart):
Parameter | Description |
Region | Symptoms may follow rib paths or radiate horizontally across the chest; note thoracic spine, scapula, sternum, and extremities【7】. |
Type | Describe pain quality, intensity (VAS), and depth (superficial or deep). |
Abnormal sensations | Paresthesia, numbness, constant or intermittent pain. Persistent pain may indicate neoplastic disease. |
Behavior of Symptoms
Parameter | Description |
Aggravating factors | Deep breathing, trunk rotation. |
Easing factors | Thoracic extension. |
Severity | Inability to sustain symptom-provoking positions indicates severity; avoid overpressure. |
Irritability | Quick relief = non-irritable; delayed relief = irritable (limit movement testing). |
24-hour pattern | Morning stiffness (short = degenerative; prolonged = inflammatory). Night pain or positional effects should be recorded. |
Progression | Improving, stable, or worsening symptoms【7】. |
Special Questions
Used to identify contraindications or conditions requiring referral:
Weight loss: Unexplained?
Rheumatoid arthritis: Present?
Medication use: Corticosteroids, anticoagulants, etc.?
Imaging history: Previous X-rays or MRIs?
Neurological symptoms: Numbness, tingling, weakness?
History of Present Condition (HPC)
Known vs. unknown onset.
Sudden or gradual onset.
Duration and referral source (self or physician).
Past Medical History (PMH)
Relevant illnesses, prior episodes, or treatments and their outcomes.
Social History
Work-related posture or repetitive load.
Family or caregiving responsibilities.
Physical activity and recreation level.
Regional Considerations
Because the thoracic spine often refers symptoms from the cervical region, screening for neck involvement is essential【8】【5】.
Ask:
“Do neck movements influence your pain?”
“Where is the discomfort most prominent?”
Red Flags
Visceral conditions can mimic thoracic pain due to shared autonomic afferents from T1–L2【9】.
T4–T7 involvement:
May produce pseudoanginal pain.
Triggered by coughing, sneezing, deep breathing, or palpation【10】.
Yellow Flags
Fear-Avoidance Beliefs Questionnaire (FABQ): Used to identify maladaptive beliefs or behaviors delaying recovery.
Legal/Compensation Context: Patients involved in legal disputes may show higher disability despite physical improvement【11】.
Thoracic Spine Objective Examination
A thorough objective assessment of the thoracic region provides valuable insight into structural, postural, and functional abnormalities that may contribute to pain or dysfunction. The thoracic spine connects closely with cervical and lumbar regions, rib articulations, and respiratory mechanics, making its examination an essential part of clinical reasoning and treatment planning.
Screening for Serious Pathology
Imaging Considerations
Patients with acute thoracic pain and risk factors for osteoporotic compression fractures should undergo standard thoracic X-ray imaging.
X-ray: Highly sensitive for acute compression fractures.
If pain remains severe despite normal findings, proceed with CT or MRI for detailed evaluation.
Suspected Malignancy:Patients presenting with red flags for cancer must be referred for diagnostic imaging to exclude malignancy.
Suspected Ankylosing Spondylitis:
Refer for X-ray of the sacroiliac joints.
Conduct HLA-B27 laboratory testing for confirmation.
Observation
Observation should be performed from anterior, posterior, and lateral views, in both standing and sitting positions【5】【12】.
Key areas to assess:
Aspect | Description |
Spinal Curvatures | Evaluate thoracic curvature in frontal and sagittal planes. Kyphosis is graded as excessive, normal, or reduced based on inter-rater reliability (Cleland et al.)【13】. |
Symmetry | Inspect cervical (Cx), thoracic (Tx), and lumbar (Lx) curves for alignment. Compare shoulder height, scapular symmetry, GH joint alignment, pelvic balance, and limb positioning. |
Muscle and Soft Tissue | Assess tone, mass, and texture. Note differences due to hand dominance, skin color, swelling, or scars. |
Gait | Observe for Trendelenburg or antalgic gait patterns. |
Posture and Emotion | Note patient’s posture, comfort level, and emotional presentation during examination【7】. |
Movement Patterns
Patients are asked to perform functional movements to reproduce or modify symptoms — creating measurable “asterisk signs” for re-evaluation.
Common functional movements:
Looking upward.
Sit-to-stand transitions.
Raising one or both arms overhead.
Any movement that aggravates or relieves symptoms.
During movement observation:
Identify asymmetry or compensatory movement.
Record improvement or worsening of symptoms for future comparison【12】.
Palpation
General Procedure:Begin with superficial tissues before progressing deeper into thoracic structures.
Assess:
Skin temperature, moisture, and texture.
Presence of lymph nodes or soft tissue swelling.
Symmetry of bony landmarks and rib attachments【14】.
Specific Structures to Palpate:
Position | Structures |
Supine | Sternum, ribs, clavicle, sternocostal and costochondral joints. |
Prone | Spinous processes, costotransverse and costovertebral joints. Note that these joints may refer pain locally or one level above/below. |
Seated | First rib (anterior and posterior aspects)【7】【12】. |
Movement Testing
Thoracic Spine AROM, PROM, and Overpressure
Movement | Method and Observations |
Primary Movements | Flexion, extension, lateral flexion, rotation. |
Combined Movements | Rotation with extension. |
Symptom Recording | Note baseline pain (intensity and location) and any changes during movement. |
Compensation | Ensure pure thoracic movement without lumbar or pelvic involvement. |
Repeated Movements | Evaluate for centralization or directional preference. |
End Feel | Normal thoracic end feel is firm. |
Measurement | Flexion, extension, and lateral flexion via dual inclinometer; rotation visually assessed due to lack of normative data【15】【12】. |
Passive Intervertebral Motion (PIVM)
Technique:Apply posterior–anterior (PA) pressure centrally over spinous processes or unilaterally beside them.Rib movement can be tested using PA pressure on rib angles and AP pressure on costosternal joints.
Assessment:
Classify joints as hypomobile, hypermobile, or normal.
Document pain provocation sites【15】.
Reliability of Thoracic PIVM Testing
Test Type | Reliability |
Central PA Motion Testing | Intra-rater reliability: moderate to good with extended agreement (±1 segment). Inter-rater: fair to good【16】. |
Cleland et al. | Found moderate to substantial agreement for thoracic mobility testing【13】. |
Potter et al. | Combined posture, AROM/PROM, and PA testing had poor to moderate intra-rater reliability for diagnosing thoracic joint dysfunction【17】【15】. |
Rib Cage Mobility | Intra-rater: moderate (strict) to good (extended); inter-rater: improved with broader segmental agreement【16】. |
Pain Provocation Reliability
Structure | Findings |
Central Thoracic PA | Intra-rater: moderate–good (strict) → excellent (extended). Inter-rater: moderate → good【16】. |
Rib Cage | Strict: intra-rater none–moderate; inter-rater none. Extended: intra-rater excellent; inter-rater good【16】. |
Pain provocation responses varied across thoracic segments — from no agreement to substantial agreement across studies【13】【15】.
Muscle Testing
Assessment of muscle strength and length is essential to identify functional limitations, postural imbalances, and compensatory patterns. This evaluation provides a foundation for measuring progress and tailoring physiotherapeutic interventions to individual needs.
Muscle Length Testing【12】【13】
Muscle | Inter-Rater Reliability |
Latissimus Dorsi | Moderate to substantial |
Pectoralis Major | Moderate to substantial |
Pectoralis Minor | Moderate to substantial |
Muscle Strength Testing【12】【13】
Purpose:Muscle strength testing evaluates the functional capacity of thoracic, scapular, and postural stabilizers, identifying weakness that may contribute to pain, poor posture, or altered biomechanics.
Common Muscles Assessed:
Muscle Group | Primary Function | Clinical Relevance |
Rhomboids (Major & Minor) | Scapular retraction and downward rotation | Weakness leads to scapular winging and poor postural control |
Middle Trapezius | Scapular retraction and stabilization | Often weak in patients with rounded shoulders or thoracic kyphosis |
Lower Trapezius | Scapular depression and upward rotation | Critical for overhead activities and shoulder mechanics |
Latissimus Dorsi | Shoulder extension, adduction, internal rotation | Tightness can limit thoracic extension and shoulder elevation |
Pectoralis Major | Shoulder flexion, adduction, internal rotation | Shortening contributes to protracted shoulders |
Pectoralis Minor | Scapular protraction and anterior tilt | Common source of thoracic outlet and postural dysfunction |
Erector Spinae (Thoracic Portion) | Spinal extension and postural stability | Weakness contributes to kyphotic posture and fatigue |
Testing Position and Grading (Manual Muscle Testing – MMT):
Grade | Description |
5 (Normal) | Full ROM against gravity with maximum resistance |
4 (Good) | Full ROM against gravity with moderate resistance |
3 (Fair) | Full ROM against gravity with no added resistance |
2 (Poor) | Full ROM in gravity-eliminated position |
1 (Trace) | Visible or palpable contraction, no movement |
0 (Zero) | No contraction detected |
Clinical Insight:
Muscle imbalance between thoracic extensors and anterior chest muscles (pectorals) is a frequent contributor to forward head posture and increased kyphosis.
Consistent testing across sessions improves inter-rater reliability and treatment accuracy.
Neurological Assessment
Neurological Screening Questions
Clinicians should first determine whether a detailed neurological examination is required by asking:
Do you experience symptoms in your legs or lower back when moving your neck?→ If yes, perform a full neurological assessment.
Have you had bilateral upper limb symptoms, loss of balance, or coordination problems in your legs?→ If yes, perform a full neurological assessment.
Upper Motor Neuron Reflexes
Reflex | Purpose / Clinical Indication |
Hoffman’s Reflex | Indicates possible corticospinal tract involvement |
Babinski Reflex | Pathological reflex suggesting upper motor neuron lesion |
Clonus | Sustained rhythmic contractions indicating central nervous system dysfunction |
Sensory Testing
Dermatome | Area of Sensation |
T1 | Medial forearm |
Associated Myotome:
T1 nerve root: First dorsal interossei muscle
Neurological Screening Zones
Screening Type | Purpose |
Upper Quadrant Screening | Evaluates cervical and upper thoracic neurological function |
Lower Quadrant Screening | Assesses lumbar and lower thoracic nerve involvement |
Neural Tissue Provocation Tests【12】
Test | Purpose |
Passive Neck Flexion | Identifies neural tension or dysfunction in cervical/thoracic regions |
Upper Limb Neural Tests | Detects peripheral neural tissue dysfunction in the arms |
Straight Leg Raise (SLR) | Assesses neural tissue mobility in lower extremities |
Passive Knee Extension | Evaluates lumbar and thoracic neural tissue sensitivity |
Slump Test | Tests the entire neural axis from head to feet |
Special Tests for Thoracic and Related Conditions
Cervical Rotation Lateral Flexion (CRLF) Test
This test evaluates first rib elevation or hypomobility. The patient’s head is rotated away from the tested side and then gently laterally flexed. Limited motion or pain indicates dysfunction of the first rib, which can contribute to thoracic outlet symptoms.
Adson’s Test
Used to detect Thoracic Outlet Syndrome (TOS) caused by compression of the subclavian artery or brachial plexus.The patient extends and rotates the head toward the tested side while taking a deep breath. Diminished or absent radial pulse suggests vascular compression between the scalene muscles or under the clavicle.
Kehr’s Sign
Pain felt in the left supraclavicular region while the patient lies supine with elevated legs indicates possible referred pain from the diaphragm or intra-abdominal bleeding — often associated with splenic rupture or peritoneal irritation.
Murphy’s Percussion Test
The clinician places one hand over the patient’s costovertebral angle (around the lower ribs and spine) and gently strikes it with the other hand. Reproduction of deep flank or back pain may suggest kidney pathology or inflammation.
Abdominal Palpation
Palpation of the abdomen helps rule out visceral causes of thoracic pain.
Right Upper Quadrant: Liver and gallbladder (pain may radiate to the right shoulder).
Left Upper Quadrant: Stomach and spleen. Tenderness here may indicate splenic involvement.
Right Lower Quadrant: Appendix and cecum.
Left Lower Quadrant: Sigmoid colon or reproductive organs.
Abdominal Aortic Palpation
Performed with the patient supine, palpating slightly left of the umbilicus. A palpable, widened pulse (>2.5 cm) may indicate an abdominal aortic aneurysm.
Rebound Tenderness
Gentle pressure is applied and then released quickly. If pain increases upon release, peritoneal inflammation is suspected.
Thoracic Expansion Test
This test measures the mobility of the rib cage during respiration and helps identify conditions like ankylosing spondylitis.The clinician places a measuring tape around the chest at the level of the 5th thoracic vertebra (3rd intercostal space) and again at the 10th thoracic vertebra (xiphoid level).The difference between full inhalation and exhalation should be at least 5 cm in healthy adults. Reduced expansion indicates restriction in costovertebral or costosternal joints.
Clinical Outcome Measures
Although few thoracic-specific tools exist, several standardized measures are useful:
Neck Disability Index (NDI): For upper thoracic pain affecting neck function.
Oswestry Disability Index (ODI): For mid-to-lower thoracic or lumbar pain.
Occiput-to-Wall Distance: Measures postural kyphosis and spinal deformity.
Numeric Pain Rating Scale (NPRS): Rates pain intensity from 0–10.
Patient-Specific Functional Scale (PSFS): Evaluates activity limitations over time.
Fingertips-to-Floor Test: Indicates spinal flexibility and global range of motion.
Conclusion
Thoracic spine and rib-related dysfunctions can cause complex symptoms due to the region’s connection to both musculoskeletal and visceral systems.A structured neurological examination — including reflex testing, neural tension tests, and visceral screening — ensures accurate differentiation between mechanical and systemic causes.Effective diagnosis depends on integrating clinical reasoning, functional testing, and patient history.
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