T1, 2, 3	At the same level as spinous process
T4, 5, 6	Between two successive levels
T7, 8, 9	Level with spinous process of vertebra below
T10	Level with vertebra below
T11	Between two successive levels
T12	At same level

As an approximate guide to levels, the AC joint is normally aligned with the C7–T1 interspace, the spine of the scapula at T3 and the inferior scapular angle at T7.

The rib angles gradually spread out from the spine with the eighth rib being furthest (about 6 cm) from the mid-line. The rib angles can be palpated at the same levels as the transverse processes down to the T8/T9, by pushing the soft tissue to one side. The facet joints lie in the paravertebral sulci, and the transverse processes, which overlie the costotransverse joints, are found 3–4 cm from the mid-line. Guidelines for rib palpation are shown in Table 14.2.

Table 14.2 Rib palpation

Rib structure	Region of palpation
1st rib	Above clavicle, within supraclavicular fossa
2nd	End level with manubriosternal joint (angle of Louis)
4th	Lies on nipple line
7th	End level with xiphisternal joint
11th	Tip lies in mid-axillary line
12th	Tip level with L1
Rib angle	3–4 cm lateral to end of transverse process
Costochondral (CC) joint	3 cm lateral to parasternal line at 2nd rib, 12 cm lateral at 7th rib, 18 cm lateral at 10th rib
Costotransverse (CT) joint	Depression between transverse process and rib

Modifications to the slump test for the thoracic spine

A variation of this test for the cervical and thoracic spine is to perform it in the long sitting position (Fig. 14.3A). From this position thoracic and lumbar flexion are added followed by cervical flexion (Fig. 14.3B). Altering the order of movement will change the neurodynamic demands (Butler and Slater, 1994), enabling the practitioner to refine the test. For example, performing cervical flexion before lumbar and thoracic flexion will challenge the cervical neural tissues more. The test can be further refined to place emphasis on the sympathetic trunk (Slater, Butler and Shacklock, 1994). This is especially relevant in the presence of sympathetic signs in conditions such as T4 syndrome, thoracic outlet syndrome and Raynaud’s syndrome, and in cases where cervicothoracic conditions mimic cardiac disease. Sympathetic testing is achieved by adding components of lateral flexion and rotation of the thoracic spine and lateral flexion of the cervical spine. Additional stress may be imposed by adding a minimal straight leg raise (SLR).

Figure 14.3 The slump test (long sitting). (A) Start. (B) Finish.

From Butler (1991) with permission.

Keypoint

Where sympathetic signs (skin changes, sweating, swelling) are present in conditions such as thoracic outlet syndrome (TOS) and Raynaud’s syndrome, modify the slump test to emphasize the sympathetic trunk. Add thoracic lateral flexion and rotation, and cervical lateral flexion to the standard slump test.

Injury to the ribcage

Direct trauma to the ribcage can result in damage to the ribs, intercostal muscles or, indirectly, to the rib joints. Deep breathing will usually reproduce the pain of rib or intercostal injury, and palpation can be used to reveal the exact site of injury as these structures are superficial. Trunk extension will open the ribcage and cause pain, and intercostal muscle tearing will generally give pain to resisted trunk flexion. Rib springing at a distance from the point of injury usually produces pain from a rib fracture.

Rib fracture

With rib fracture it is the tearing of the intercostal muscles which gives the pain rather than the fracture itself (Cyriax, 1982). The acute pain may be relieved by local strapping. Pre-stretched elastic adhesive strapping is applied across the area to restrict ribcage expansion and give the athlete a feeling of support. In the subacute phase active mobilization is required. If scar tissue formation is excessive and the source of pain, transverse frictions to the intercostal muscles along the line of the ribs are helpful. In addition, holding the rib down with the fingertips and practising deep inspiration will help to stretch the injured area. Exercises to expand the ribcage, such as deep inspiration and overhead reaching, or trunk lateral flexion to the contralateral side with or without rotation is also helpful to stretch the area.

Keypoint

Following rib injury, intercostal muscle stretching is useful. Deep breathing exercises coupled with manual therapy to isolate the movement to a single pair of ribs may also be used.

Where rib trauma is severe, there is a danger of pneumothorax. Here, air enters the pleural cavity changing the pressure within the thorax. The mediastinum is pressed away from the injured lung (mediastinal shift) with the potential to compress vital structures.

Definition

The mediastinum is the central compartment of the thoracic cavity, lying between the lungs. It contains the heart, major blood vessels, trachea, oesophagus, thymus and lymph nodes of the chest.

The athlete experiences severe chest or back pain and becomes breathless. They may begin to cyanose (lips going blue) and panic. First aid treatment is to cover the injured chest region with an airtight seal such as a sterile plastic film or watertight dressing. Examination with a stethoscope (auscultation) reveals an absence of lung sounds on the injured side indicating that air is not entering the lungs. Hospitalization is required, where a chest x-ray may reveal a deep sulcus sign showing that the costophrenic angle (junction of diaphragm and ribs) is abnormally deep. Treatment is by inserting a chest drain into the area outside the affected lung. The drain tube has a one-way valve allowing excess air to escape and the lung to re-expand.

Rib joints

The sternocostal joints may be sprained giving local swelling and tenderness, as may the costochondral joints (Tietze’s syndrome). True Tietze’s syndrome is a swelling of the costrochondral joints which contrasts to costrochondritis which is inflammation alone. Clinically however the two names are interchangeable.

Pressure on the sternum, or applied to the lateral aspect of the thorax, reproduces the pain, and palpation localizes the lesion. The injury can occur when performing exercises which force the arms into extension and abduction. Weight-training movements such as bench pressing and gymnastic exercises such as dips on parallel bars may both cause problems. Both the costovertebral and costotransverse joints may be subject to sprain, with pain occurring to rib movements and local palpation.

Costochondral pain must be differentiated from pain referral into the area from myocardial infarction, and from pathologies such as psoriatic arthritis or ankylosing spondylitis. In chest pain from myocardial infarction there is no history of sports trauma, and pain is vice-like and often described as a ‘clenched fist’ feeling which may refer up into the jaw. Pain of rib origin will be affected by rib movement and posture and is generally well localized. Medical pathologies affecting the ribs will generally have been present for some time and are differentiated by blood tests. Tests include the HLA-B27 genetic marker and erythrocyte sedimentation rate (ESR) which tests for non-specific inflammation throughout the body.

Keypoint

Ribcage pain must be differentiated from medical conditions affecting the ribs, and referred pain of visceral (internal organ) origin.

First rib injury

The first is the shortest and roundest of the ribs. It slopes downwards and forwards from its attachment to the first thoracic vertebra. It forms attachment for the scalene muscles, serratus anterior, and subclavius. Its superior surface bears a deep groove for the subclavian artery (posterior) and the subclavian vein (anterior). The arterial groove is the weakest part of the rib (Gurtler, Pavlov and Torg, 1985).

Fractures of the first rib may either be traumatic or the result of overuse. Overuse injuries have been reported as a result of repeated arm movements, such as heavy lifting and pitching (Bailey, 1985; Lankenner and Micheli, 1985; Gurtler, Pavlov and Torg, 1985). Symptoms are of pain associated with deep breathing, tenderness in the root of the neck, posterior aspect of the shoulder or axilla. Often the patient hears or feels a snap in the shoulder as when performing a sudden violent movement. Range of shoulder movement will usually be full but painful, especially to extension. Accurate diagnosis by radiographs in traumatic lesions is essential because of the proximity of the major vessels, nerves and lung. Bailey (1985) recommended serial radiographs for up to 6 months after stress fracture.

Keypoint

1st rib injury gives pain on deep breathing. Tenderness is common at the root of the neck, posterior aspect of the shoulder or axilla. Shoulder extension may also cause pain.

Management is by rest from the causal action, with shoulder support in a sling if pain is limiting. Gentle isometric shoulder exercises are used, and the condition usually resolves within 4–6 weeks.