Thoracic

Thoracic
Examination
Dr. Bushra Mehwish (PT)

MSAPT, DPT, CRCP –DUHS
Senior Lecturer - ZU
Role of Thoracic
region
Breathing
Protection for vital organs
Protection of the nerves that

control the ‘fight or flight’ response.
Let’s revise the
anatomy…
Thoracic region is located between?
How many vertebraes?
Which are more prone to fracture?

Principal differences
between the thoracic and the
lumbar and cervical spines
Visceral Vs.
musculoskeletal pain
First step?
To distinguish between these.
How?
Pain in lesions of moving parts is that it is brought on by posture and

movement.
But is it valid?
Exclusion of any visceral disorder through a thorough internal check-up

Examination strategy in thoracic pain
Discal Lesion
- Well known cause of cervical, thoracic
and lumbar pain
- Discodural lesions: Impinge on dura,

resulting in multisegmental pain
- Discoradicular lesions: Impinge on nerve

root, causing segmental pain and
paraesthesia
Thoracic disc lesions differ from
cervical and lumbar in presentation:
- Subtle articular signs due to thoracic
rigidity
- Rare neurological deficits or sensory
disturbances
- Absence of tendency for spontaneous
recovery
Non- discal lesions
Non-discal musculoskeletal
lesions are also
encountered frequently.
-Ribs
-Rib joints
-Cartilage
-Intercostal and abdominal
muscles
Referred Pain
Referred pain in MSK
or visceral lesions
✔ Thoracic disc lesions may

cause referred pain in the
thorax due to discodural or
discoradicular interactions.
✔ Cervical and lumbar discal

lesions can also be the
origin of thoracic referred
pain.
Cervical disc lesions
✔ Cervical disc lesions can cause thoracic
pain:
✔ Discodural interactions:
Unilateral interscapular pain, often referred
to sternum and precordial region.
✔ Discoradicular interactions:
C5, C6, C7 or C8 nerve root gives rise to
unilateral root pain characterized mainly by
a sharp pain down the upper limb +
Scapular.
Thoracic disc lesions
✔ Thoracic disc lesions commonly cause referred pain in

thoracic and abdominal regions:
✔ Discodural interactions:
Trunk pain, spreading anteriorly and/or posteriorly over
several segments.
✔ Discoradicular interactions:
Arm pain, with specific patterns depending on the
involved nerve root.
Can you point out some important
landmarks?
Referred pain from
Visceral structures
✔ Heart: Pain can radiate to

dermatomes C8–T4, often to
shoulder, anterior chest, back,
and ulnar side of upper limbs.
✔ Aorta: Pain behind sternum or

abdomen, may expand as lesion
progresses.
✔ Lungs: Insensitive;
pain from parietal
pleura inflammation
or chest wall tumor
invasion.
✔ Oesophagus: Pain at
sternum, between
scapulae into back.
✔ Diaphragm: Central part irritation felt
at shoulders and base of neck;
peripheral part pain in lower thorax
and upper abdomen.
✔ Stomach and Duodenum: T6-T10 in

epigastrium, upper abdomen,
occasionally substernally or lower
thoracic back.
✔ The liver, gallbladder and bile ducts:

T7-T9 --> right hypochondrium and
may radiate towards the inferior angle
of the right scapula
✔ Pancreas: Upper
abdominal pain,
referred to T8 level in
back.
✔ Spleen: Pain in left

hypochondrium or left
side at low thoracic
level.
✔ Small Intestine, Appendix,
Colon: Pain around umbilicus
for small intestine; in
neighborhood of lesion for
colon; appendix pain typically
felt in T10–L1 area.
✔ Kidneys and Ureters: Pain in

side, lower ribs, anterolateral
abdomen; may radiate to
testicles or labia.
✔ Reproductive System: Ovarian

disorders cause unilateral low
abdominal pain; testicular
problems result in scrotal pain,
sometimes radiating to groin.
History taking
What are you looking for?
✔ What made the pain come on?
Key
Questions for ✔ Where was the pain at the beginning, where
pain did it spread or shift to, and where is it now?
✔ Is the pain influenced by coughing, sneezing or

deep inspiration?
Paresthesia
- Protrusion of thoracic disc can cause paraesthesia in two ways:
- Compression of spinal cord leads both feet, often worsened by neck flexion.
- Compression of nerve root results in localized paraesthesia in corresponding

dermatome.
- Rare causes include spinal cord compression by tumors, hemorrhage, or vertebral

fracture.
- Localized paraesthesia may occur from nerve root compression, such as pins and
needles in groin from T12 nerve root compression.
Anticoagulant
treatment and
bleeding disorders
use of anticoagulants is
always an absolute
contraindication to
manipulation of the spine
Inspection and Palpation
What are you going to do now?
Inspection and palpation
Scoliosis may be detected, distinguishing between postural

and structural types.
Hyperkyphosis may suggest conditions like ankylosing

spondylitis, Scheuermann’s disease, or osteoporosis.
Localized angular kyphosis may result from vertebral

fractures, osteochondrosis, or trauma.
Functional examination
- Based on pain level.
-As already discussed, Pain above T6 level necessitates prior examination of

cervical spine and shoulder girdle due to anatomical and diagnostic
considerations.
- Upper thoracic pain may originate from lesions of thoracic apex or shoulder
girdle, requiring cervical spine and shoulder girdle examination first.
- Pain below T6 directs immediate attention to thoracic spine examination.

Dural tests in Standing
•Deep Inspiration: Patient takes deep breath, pain increase
indicates possible dural sign, especially in presence of disc lesion.
•Neck Flexion: Patient bends head forward, pain or paraesthesia

may indicate dural involvement, but not necessarily disc lesion.
•Lhermitte’s Sign: Electrical sensation down back or into limbs on

neck flexion or extension, indicative of cord or thoracic cord
problems.
Shoulder Movements:
Upwards, Forwards, and Backwards: Patient shrugs

shoulders and moves them forwards and
backwards.
Positive findings may suggest shoulder girdle

disorder, but pain during movements commonly
associated with thoracic disc lesion due to dura
mater stretching.
Active Trunk Movements:
-Patient is now asked to perform Six movements

involving both thoracic and lumbar spine:
- Anteflexion
- Extension
- Left side flexion
- Right side flexion
- Left rotation
- Right rotation
Articular
pattern:
-Equal pain and limitation in both side flexions and
rotations.
- Larger limitation of extension, little or no limitation

of anteflexion.
- Partial articular pattern:
- Any combination of abnormal tests asymmetrical.

- Expected in disc lesions; commonly only one
movement positive, often rotation.
- Differentiation needed from facet joint or
muscular lesion, where partial articular pattern also
observed.
When side flexion
away from the
painful side is the
only painful and
limited movement,
this always indicates
a severe
extra-articular lesion
such as a pulmonary
or abdominal tumour
or a spinal
neurofibroma.
Sitting position Examination
Passive Tests:
Passive Left rotation

Passive Right rotation
Patient's arms crossed in front, knees immobilized,

trunk twisted by examiner.
Noted: pain, range of movement, end-feel.
End feels
Normal end-feel: elastic.
Hard end-feel: ankylosing spondylitis or advanced arthrosis.
Empty end-feel or muscle spasm: severe disorder (neoplasm,

fracture, infectious disorders).
Painful arc: pain at half range, disappearing with continued

rotation; indicative of disc lesion when combined with partial
articular pattern.
Active forward head bending after passive rotations; increase in

pain regarded as dural sign if resisted tests.
Resisted Tests:
- Isometric contractions while examiner

applies counterpressure.
- Disc lesion: Passive rotations more

painful than resisted.
- Resisted movements more painful:

muscular problem likely, unless
psychogenic issue or rib fracture present.
Cord Sign
(Plantar Reflex):
- Sharp instrument glided

along lateral sole towards
big toe.
- Normal: toes stay still or

uniformly flex.
- Pathological: toes spread
apart, big toe extends.
- Positive test indicates
interruption of descending
motor fibres; warrants full
neurological examination of
lower limbs.
Lying Prone
Examination:
- Location of Affected
Level by Passive Extension
Thrust:
- Patient lies prone.

- Hyperextension thrust
given over every thoracic
spinous process.
- End-feel during
extension pressure noted:
- Normal: elastic.
- Muscle spasm
indicates more severe
disorders.
Accessory Tests:
-Stretching the T1 Nerve Root:
- Patient lifts arm sideways

from horizontal.
- Hand placed in neck by flexing
elbow.
- Movement stretches T1 nerve
root via ulnar nerve.
- Useful for differentiating
between cervical spine and upper
thorax problems:
- Pain indicates likely thoracic
problem.
Resisted - Resisted Side Flexion:
- Patient stands with feet slightly apart.
Movements and
- Examiner stands at patient's painless
Extension of the side, hips against each other.
Trunk: - Patient bends sideways away from
examiner while trunk side flexion is
resisted.
Resisted Movements
and Extension of the
Trunk:
Resisted Flexion:
- Patient sits down.

- Examiner places one hand
on proximal sternum and other
on patient's knees.
- Patient tries to bend
forwards against resistance
exerted by examiner.
Extension of the Trunk:
Resisted Extension:
- Patient prone, counterpressure applied at
proximal thorax and posterior knees.
Active Extension:
- Patient remains prone, hands on sacrum,
lifts trunk off couch using paravertebral
muscles.
Passive Extension:
- Patient pushes body up off couch with
arms, pelvis remains down.
Testing the Long Thoracic Nerve:
- Patient pushes against a wall with arms

stretched out horizontally in front.
- If medial edge of scapula moves away

from thorax, producing winged
appearance, disorder of long thoracic
nerve is present.
Neurological
examination
Beevor’s sign
The patient lies supine, crosses
the arms in front of the chest and
is asked to raise the trunk slightly
off the couch. The examiner pays
attention to the umbilicus, which
should not move during this test.
Any movement in a cranial or
caudal direction or to the side
may point towards a denervation
of the contralateral muscles.
Oppenheim’s sign:
This may confirm a positive Babinski’s sign. When the

fingers are slid downwards along the tibia, no movement
of the toes should occur. In cord compression, the big toe
extends while the others spread. However, this test is less
reliable than a Babinski’s sign.
Link for your ease...
https://www.orthopaedicmedicineonline.com/downloads/pdf
/B9780702031458000259_web.pdf

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Thoracic

Dr. Bushra Mehwish (PT)

Protection for vital organs

Protection of the nerves that

Thoracic region is located between?

How many vertebraes?

Which are more prone to fracture?

Pain in lesions of moving parts is that it is brought on by posture and

Exclusion of any visceral disorder through a thorough internal check-up

- Discodural lesions: Impinge on dura,

- Discoradicular lesions: Impinge on nerve

✔ Thoracic disc lesions may

✔ Cervical and lumbar discal

✔ Thoracic disc lesions commonly cause referred pain in

✔ Heart: Pain can radiate to

✔ Aorta: Pain behind sternum or

✔ Stomach and Duodenum: T6-T10 in

✔ The liver, gallbladder and bile ducts:

✔ Spleen: Pain in left

✔ Kidneys and Ureters: Pain in

✔ Reproductive System: Ovarian

✔ Is the pain influenced by coughing, sneezing or

- Compression of nerve root results in localized paraesthesia in corresponding

- Rare causes include spinal cord compression by tumors, hemorrhage, or vertebral

Scoliosis may be detected, distinguishing between postural

Hyperkyphosis may suggest conditions like ankylosing

Localized angular kyphosis may result from vertebral

- Based on pain level.

-As already discussed, Pain above T6 level necessitates prior examination of

- Pain below T6 directs immediate attention to thoracic spine examination.

•Neck Flexion: Patient bends head forward, pain or paraesthesia

•Lhermitte’s Sign: Electrical sensation down back or into limbs on

Upwards, Forwards, and Backwards: Patient shrugs

Positive findings may suggest shoulder girdle

-Patient is now asked to perform Six movements

- Larger limitation of extension, little or no limitation

- Partial articular pattern:

- Any combination of abnormal tests asymmetrical.

Passive Left rotation

Patient's arms crossed in front, knees immobilized,

Hard end-feel: ankylosing spondylitis or advanced arthrosis.

Empty end-feel or muscle spasm: severe disorder (neoplasm,

Painful arc: pain at half range, disappearing with continued

Active forward head bending after passive rotations; increase in

- Isometric contractions while examiner

- Disc lesion: Passive rotations more

- Resisted movements more painful:

- Sharp instrument glided

- Normal: toes stay still or

- Patient lies prone.

- Patient lifts arm sideways

- Patient sits down.

- Patient pushes against a wall with arms

- If medial edge of scapula moves away

This may confirm a positive Babinski’s sign. When the

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