CHAPTER 14 The thorax and thoracic spine
Rib movements
Ribcage shape at rest
Examination
Table 14.1 Palpation of the thoracic vertebrae
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 |
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.
Injury to the ribcage
First rib injury
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.
Rib displacement
Treatment note 14.1 Manual therapy techniques for rib displacement
Elevation
An elevated rib does not move down far enough during expiration. The aim is to encourage this movement and draw the rib down as the patient breathes out. For the 1st rib pressure is placed over the rib with the knuckle (key grip) (Fig. 14.4). The head is side flexed to relax the anterior scalene and the rib is pressed downwards with expiration. The 2nd rib is gripped within the axilla and pulled downwards as the patient exhales powerfully (Fig. 14.5). The remaining ribs may be gripped with the fingertips or pushed downwards using the knife edge of the hand (Fig. 14.6).
Depresssion
The depressed rib is bound down and stops moving upwards during inspiration. The aim is therefore to encourage further upward movement as the patient breathes in. For the 1st rib, stretch of the anterior scalenes is used (side flex the neck to the opposite side) to pull the rib upwards (Fig. 14.7). For the 2nd rib the finger or thumb pads press on the rib within the axilla (Fig. 14.8), and for the remaining ribs the thumb pad or pisiform presses on the rib undersurface within the intercostal space (Fig. 14.9).