Two joints, the costovertebral and costotransverse joints, attach the rib firmly to the vertebral column (Fig. 9.2). These assist stabilization of the intervertebral joint while being relatively unstable themselves. Minor subluxations of these joints may be responsible for the mechanical pattern of signs and symptoms associated with a thoracic pain. This minor instability may also account for the ease with which subluxations occur and can be reduced in this region.

The costovertebral joint is a synovial joint formed between the head of the rib and two adjacent vertebral bodies, except at the first, 11th and 12th ribs, where a joint is formed with a single vertebral body. The joint surfaces are covered by articular cartilage and surrounded by a fibrous capsule. The capsule is thickened anteriorly by the radiate ligament while the posterior aspect of the capsule blends with the nearby denticulation of the posterior longitudinal ligament. An intra-articular ligament divides the joint and attaches the transverse ridge of the rib head to the intervertebral disc.

The costotransverse joint joins the upper 10 ribs to the transverse processes of their corresponding vertebra. The joint is surrounded by a fibrous capsule that is reinforced posteriorly by the lateral costotransverse ligament. The joint is further stabilized by the costotransverse ligament which joins the transverse process to the neck of the rib, and the superior costotransverse ligament which connects the rib to the transverse process of the vertebra above. Movements occur concurrently at the costovertebral and costotransverse joints and are determined by the shape and direction of the articular facets. This amounts to small rotary and gliding movements in association with the ‘bucket handle’ action of the ribs during respiration.

Three thin musculotendinous layers occupy the intercostal space between adjacent ribs and may become symptomatic due to strain (Fig. 9.3). The external intercostal muscle is the most superficial, with fibres running in an oblique direction downwards and forwards. The internal intercostal muscle lies beneath with fibres running in the opposite direction, and the thinnest and deepest layer is formed by the innermost (intimi) intercostal muscle, which is thin and possibly absent, with fibres running in the same direction as the internal intercostal muscle.

Orthopaedic medicine treatment techniques for the thoracic spine are aimed at reducing a mechanical lesion, i.e. subluxation of a posterior rib joint or herniations of the intervertebral disc.

Cervical disc lesions commonly refer pain into the thoracic region and this is particularly indicative of dural reference producing unilateral or bilateral scapular pain. The patient has a typical mechanical picture, with cervical movements increasing the pain felt in the thoracic region. Pain is not reproduced by thoracic movements. Minor chest wall pain may frequently be recognized as referred from the cervical spine, and Yeung & Hagen (1993) reported two cases of herniated C6–C7 disc producing major neuropathic chest wall pain which were treated surgically.

Subluxations of the posterior rib joints are a common cause of thoracic pain. They tend to present with unilateral central pain and tenderness and a non-capsular pattern of pain and limitation of movement. They respond quickly to the manipulative techniques described below.

Arthritis presents with the capsular pattern of limited movement.

Serious non-mechanical conditions can affect the thoracic area and suspicions are alerted when the patient appears unwell, has a fever, night pain with or without night sweats, or reports an unexpected weight loss. The pain is not affected by movement or postures and is often unrelenting.

Bone conditions can include acquired conditions or congenital abnormalities. These conditions may be asymptomatic and a chance finding on X-ray.

Fracture may present with a history of trauma. The fracture may involve elements of the vertebra or the ribs. The position of the pain and local tenderness will give an indication to the site of possible fracture.

Visceral disease can produce local thoracic pain or pain referred to the thoracic region that mimics mechanical pain, making diagnosis difficult. In visceral conditions the patient is usually unwell, which will aid diagnosis, but this is not always so.

Shingles (herpes zoster) is related to a chickenpox virus infection affecting one posterior nerve root. The patient presents with a dermatomal reference of pain that may be present for some days before the typical rash appears. The rash consists of vesicles following a segmental course related to the affected nerve root. Shingles can be recurrent and may provide a persistent cycle of thoracic pain.

Soft tissue conditions can produce thoracic pain.

A general observation of the patient is made, assessing the face, posture and gait. Serious pathology should show in the face with the patient appearing tired and drawn. An assessment of the gait is important; the presentation of a disc lesion at the thoracic spine may present a serious threat to the spinal cord and signs of myelopathy may show in the gait pattern, which if severe will be spastic in nature.

See the Box on p. 231 listing ‘red flags’ for the possible presence of serious pathology that should be listened for and identified throughout the subjective and objective examination. In isolation, many of the flags may have limited significance but it is for the clinician to consider the general profile of the patient and to decide whether contraindications to treatment exist and/or whether onward referral is indicated.

The age, occupation, sports, hobbies and lifestyle of the patient will indicate possible lesions and any contributing factors to the condition that may need to be addressed to prevent recurrence. Mechanical lesions tend to be found in the middle-aged group. Osteoporosis can affect postmenopausal women. Serious conditions may present in both the very young and the elderly, and caution is required if these particular age groups present with symptoms mimicking a mechanical lesion. Habitual postures may have relevance to the symptoms, as will the patient’s sports or hobbies.

The site and spread of symptoms may indicate the site of the lesion. The initial site of the symptoms may be different to the current situation and it may be helpful to know this. Mechanical lesions can produce central pain, anterior pain or both. Pain may radiate around the chest wall and this may be indicative of nerve root involvement. Progressively increasing and radiating pain is usually sinister. Symptoms may spread in a multisegmental distribution, indicating dural involvement, or separate satellite areas of pain may be related to visceral causes. Cardiac pain characteristically radiates from the chest into one or both arms. Mechanical lesions of the posterior rib joints produce relatively local pain, but movement may provoke sharp, shooting or twinging pain.

The nature of the onset and duration of the symptoms will assist differentiation of mechanical lesions from more serious pathology. Minor subluxation of the posterior rib joints usually has a sudden onset, with the patient recalling the exact time of onset. The mode of onset is usually trivial and is often associated with a popping or cracking sound. The duration is generally short; patients seek help as they realize the mechanical nature of the problem, having ‘felt it go’. Minor subluxation may present gradually following the adoption of an awkward posture for some time. A disc lesion may have a gradual or sudden onset. A history of trauma may indicate possible fracture. More serious pathology generally starts insidiously for no apparent reason and the duration of the symptoms may be many weeks or months. Recurrent episodes may be indicative of mechanical instability or inflammatory arthritis.

The behaviour of the pain is important since mechanical lesions produce a recognizable pattern of behaviour. The pain is better for rest and worse for activity. Providing the mechanical lesion does not wake the patient on turning, night pain is not a feature and the patient is usually well rested. The provoking activities are consistent and every time the patient repeats a particular aggravating movement, the pain is produced.

The 24 h pain pattern gives an indication of severity and irritability of the condition. Inflammatory symptoms are worse at night, but if the patient does get to sleep there is stiffness on waking which may take some time to wear off. This would be generally indicative of inflammatory arthritis. If night pain is a feature, the patient will look tired and this generally indicates serious pathology.

Other symptoms may indicate a mechanical lesion, be it either a minor posterior rib joint subluxation or a minor disc lesion. A deep breath may aggravate the pain, and needs to be distinguished from such conditions as pleurisy and pulmonary embolism, for example. These conditions may also produce pain on a deep breath, but the subsequent findings on the objective assessment will confirm whether the lesion is mechanical. Although movements are small at the posterior rib joints, the length of the ribs produces a greater proportion of movement at the anterior ends. This movement may also be painful in an intercostal muscle strain. A cough or sneeze increasing the pain could be indicative of minor subluxation or, more commonly, dural irritation, and symptoms are generally increased with activity and relieved by rest.

As the vertebral canal in the thoracic spine is small, disc displacement can threaten the spinal cord and produce symptoms of myelopathy; these must be ruled out. The patient is asked about the presence of paraesthesia in the feet, weakness in the legs and difficulty in walking. A specific question must be asked about bladder and bowel function, to rule out myelopathy (Oppenheim et al 1993). If any impairment is noted, the patient should be referred for neurosurgical opinion.

Other joint involvement may give an indication of any polyarthritic condition.

Past medical history will give information concerning conditions that may be relevant to the patient’s current complaint or reveal possible alternative diagnoses and contraindications to treatment. An indication of the patient’s general health will indicate any systemic illness. It may be pertinent to take the patient’s temperature. The patient should be asked about any recent unexplained weight loss. As well as past medical history, establish any ongoing conditions and treatment. Explore other previous or current musculoskeletal problems with previous episodes of the current complaint, any treatment given and the outcome of treatment.

On considering medications, the patient should be specifically asked about anticoagulants, long-term oral steroids, antidepressant medication and the current intake of analgesics, as an objective measure of pain control requirement.

The patient should undress to underwear and an inspection carried out in a good light. A general inspection of the posture is made assessing bony deformity. Note the position of the head and neck, cervical, thoracic and lumbar curves. Is there any evidence of cervical protraction or dowager’s hump, excessive or local thoracic kyphosis? Note the position of the scapulae and any evidence of scoliosis.

Colour changes or swelling would not be expected unless associated with a history of recent trauma. The typical appearance of shingles may be seen or the mottled reddening (erythema ab igne) produced following prolonged application of excessive heat, giving an indication of the severity of the pain.

Muscle wasting may be seen in the scapular area associated with neuritis.

Before any movements are performed, the state at rest is established to provide a baseline for comparison.

The suggested sequence for the objective examination will now be given, followed by a commentary including the reasoning in performing the movements and the significance of the possible findings.

The cervical spine is a possible source of pain felt in the thoracic region and it must first be eliminated. If cervical flexion is the only movement to reproduce the thoracic pain, it is considered to be a dural sign for the thoracic spine since neck flexion draws the dura upwards (Fig. 9.4f). Scapular approximation is conducted as a dural test since it pulls on the dura via the T1 and 2 nerve roots and may be positive in a disc lesion at these levels (Fig. 9.5) (Cyriax & Cyriax 1993).

In common with other regions of the spine, the thoracic spine is considered to be an ‘emotional’ area and the movements are assessed actively to observe willingness to perform the movements, as well as assessing the articular signs for pain and limited range of movement. The capsular or non-capsular pattern will become evident through these movements.

Resisted side flexion is assessed looking for evidence of a muscle lesion. Resisted tests may also be applied if serious pathology or psychological factors are suspected.

The patient sits to fix the pelvis while the rotations are assessed for pain, range of movement, end-feel and the capsular pattern. End-feel, which is normally elastic, is particularly pertinent to the rotations since these movements may show minimal limitation and pain in minor subluxations of the posterior rib joints. Passive overpressure can be applied to any of the other movements if appropriate. Resisted flexion may also be assessed in this position.

The non-capsular pattern involves pain and/or limitation of at least one of the rotations.

A convenient shorthand for recording the findings of the objective examination can be found in Appendix 3 where the ‘star diagram’ is explained.

The patient is positioned in supine lying to test for the Babinski reflex, the extensor plantar response, by stroking up the lateral border of the sole of the foot and across the metatarsal heads. If the response is extensor, i.e. upgoing, it is indicative of an upper motor neuron lesion; the normal response is flexor.

The patient is positioned in prone lying to complete the examination. Resisted extension is applied and the spinous processes are palpated assessing pain, range of movement and end-feel at each segmental level.

Any other tests can be added to this basic routine examination of the thoracic spine, including repeated, combined and accessory movements and neural tension testing as appropriate.

It is impossible to be definitive about all contraindications to thoracic manipulation and nothing can substitute for a rigorous assessment of the presenting signs and symptoms and an accurate diagnosis.

‘Red flags’ are signs and symptoms found in the patient’s subjective and objective examination that may indicate serious pathology and provide contraindications to thoracic manipulation (Greenhalgh & Selfe 2006, Sizer et al 2007) (see Red flags p. 231).

The absolute contraindications are highlighted in the discussion below but there are several relative contraindications that should be considered as well. It may be useful to use the mnemonic ‘ COINS’ (a contraction of ‘contraindications’), as an aide-mémoire to be able to create mental categories for the absolute contraindications: Circulatory, Osseous, Inflammatory, Neurological and suspicious features indicating Serious pathology. If the first and last two letters are pushed together as ‘ CONS’, the crucial need for consent is emphasized.

The treatment regime discussed below is absolutely contraindicated in the absence of informed patient consent. The patient should be given all details of their diagnosis together with the proposed treatment regime and a discussion of the risks and benefits should ensue to enable them to give their informed consent. Consent is the patient’s agreement, written or oral, for a health professional to provide care. It may range from an active request by the patient for a particular treatment regime, to the passive acceptance of the health professional’s advice. The process of consent, within the context of the orthopaedic medicine, is ‘fluid’ rather than one instance in time when the patient gives their consent. The patient is constantly monitored and feedback is actively requested. The treatment procedures can be progressed or stopped at the patient’s request or in response to adverse reactions. Reassessment is conducted after each technique and a judgment made about proceeding. The patient has a right to refuse consent and this should be respected and alternative treatment options discussed. For further information on consent, the reader is referred to the Department of Health website: www.dh.gov.uk/consent.

Signs and symptoms of spinal cord compression require urgent neurosurgical referral. Inflammatory arthritis affecting the thoracic synovial joints is not appropriate for manipulation but is a relative contraindication to treatment.

Suspicious features indicative of non-mechanical lesions would be an absolute contraindication to the orthopaedic medicine treatment regime. These symptoms should not be considered in isolation but in the general context of the whole examination procedure and may include unexplained weight loss, poor general health, pain unaffected by posture or activity, constant pain of which night pain is a feature and cord signs such as spastic gait and/or abnormal plantar response. Secondary tumour needs to be eliminated as a cause of pain in patients with a past history of primary tumour but the patient with a past history of primary tumour is not strictly contraindicated. Diagnosis of a mechanical lesion must be certain before proceeding with the treatment regime since bony metastases can form in the thoracic cage and may mimic mechanical pain.

The ill patient should be investigated for the cause of the systemic illness. As mentioned above, Horner’s syndrome is a contraindication to manipulation or mobilization of the thoracic joints until the cause of the symptoms has been determined, due to its association with more serious pathology. Anticoagulation therapy and blood clotting disorders are absolute contraindications unless medical advice is sought. Known osteoporosis with prolonged corticosteroid therapy is an absolute contraindication to manipulation and a sensible selection of less aggressive techniques is advised in mechanical lesions; however, pathological fracture will need to be excluded.

Safety recommendations for spinal manipulative techniques are included in Appendix 2.

Thoracic traction is difficult to apply and is not as effective as in the cervical and lumbar joints, probably due to the comparative rigidity of the spine and to the sternal and vertebral attachments of the ribs.

Cyriax devised a method of applying distraction before performing the straight extension and the extension with rotational component techniques, using two assistants to pull longitudinally through the patient’s arms and legs before the technique is applied (Cyriax 1984, Cyriax & Cyriax 1993). In practice, two assistants are rarely readily available and the added benefit of the distraction is unproven. However, the added distraction may be considered for patients with symptoms that are resistant to other treatment techniques.

The higher and lower thoracic levels form part of the cervicothoracic and thoracolumbar transition levels respectively, and traction, or mobilization under traction, applied to the cervical and lumbar regions will affect these levels. For mid to lower thoracic levels the thoracic harness needs to be placed higher on the rib cage, which can lead to uncomfortable pressure in the axillae that is not well tolerated by the patient.

If the history, signs and symptoms do warrant its use, it is applied on the same lines as for the lumbar spine (see Ch. 13).