Thoracic Assessment

Many of you would have come across clients with pain in the upper part of their back, the thoracic spine. This is sometimes present in the thorax alone, but is often accompanied by symptoms in the neck or lumbar spine. Symptoms range from feelings of stiffness to burning muscular pain, pain often associated with the retention of static postures. Assessment of the region which links the cervical and lumbar spines is crucial and yet overlooked by many therapists.

Twenty six assessment tips provided here include simple identification of bony landmarks, palpation, and range of movement (ROM) tests that you may be familiar with, but also includes unique ways to test for thoracic stiffness, rib excursion, and some quick tests to help you assess muscle length. A systematic approach to assessment is encouraged, but you do not need to use all of these assessments with each client.

These are safe assessments for most people with thoracic symptoms. However, as a practicing therapist you will no doubt be able to determine for yourself their appropriateness. For example, Adam’s test for scoliosis requires a subject to bend over, flexing at the waist. You would not wish someone with problems in their lumbar spine to do this, nor someone who experiences dizziness in such a position. Similarly, you would not wish to “rock” individual vertebrae to assess their mobility in a subject with osteoporosis or rheumatoid arthritis. These are commonsense contraindications, about which you are likely to be aware of. Nevertheless, where special caution is needed, this is noted in the text.

Once you have identified C7, simply palpate inferior to this point to try to locate the spinous process of the first thoracic vertebra, T1, the beginning of the thoracic spine. Although you may feel some soft tissue changes, T1 itself moves less than C7 with movement of the neck.

Locating T12: The 12th Thoracic Vertebra

Instead of having to “count down” every single spinous process from the occiput until you reach the 12th thoracic vertebra, remember that T12 has a floating rib attached to it on each side. Therefore, if you locate the 12th rib, it will be relatively easy to locate T12. Be careful as you palpate here, for, as you know, the kidneys lie in this region. The 12th rib can be difficult to find, but the 11th rib is more easily palpated and rests approximately horizontal with the spinous process of T12.

There are three positions in which you can do this.

The first position is with your subject standing. Ask him or her to abduct their arms a little and place your hands against the back of their rib cage. Palpate until you think you have found the lowest ribs. Then bring your hands inward, trying to differentiate between soft tissue and bone. The disadvantage of this method is that you are palpating through the thoracolumbar fascia and active erector spinae muscles. Also, when standing, your subject will have a tendency to lean back toward you in order to maintain balance as you palpate and this will further increase the tone in their muscles. You will also need to kneel or sit behind your subject to avoid stooping.

The third position is with your client prone. With your client in this position, the tone in the muscles of spinal extension is decreased and it is easier to palpate through them, to the ribs. Notice that the ribs are angled downward, so you will need to guestimate T12 as being slightly superior to the position in which you locate the lowest ribs.

Locating the Iliac Crest

With your subject either standing or prone, gently squeeze their waist with the web of your hand. Press your hands downward and when you hit bony resistance on either side, that is the iliac crest.

With your hands on the iliac crest, extend your thumbs and try to get your thumb tips to touch. Your thumb tips are pointing toward L4. Some people have an extra lumbar vertebra, in which case this assessment will be inaccurate, but for the general population this is a crude but useful way to locate L4. Once you have located L4, you can palpate superiorly to the spinous process of L3, L2, and L1, or inferiorly to L5.

Locating the Medial Border and Inferior Angle of the Scapula

On many people the scapula is prominent and its outline readily visible. On others, it may be difficult to distinguish due to overlying musculature or an excess of body fat. One quick way to identify the scapula is simply to ask your subject to place their hand behind their back. In doing so, the medial border and inferior angle of this bone become more prominent. Remember, however, as soon as your subject lowers their arm, the scapula position will change and become less prominent again. So use the test to identify the scapula but not to record its resting position.

The inferior angle rests approximately level with the spinous process of T8, the spine of the scapula approximately level with T3, and it has been suggested that the medial borders should be approximately 5 cm (2 in) lateral to the spinous processes of the spine.

Look at this cross section of the back of the thorax.

The spinous process is the most central bony protrusion. Place your finger or thumb on your subject’s spinous process. Now glide gently to one side of this and you will feel a dip. This is the spinal groove formed by the transverse process of that vertebra. If you slide your finger or thumb ever so slightly more laterally, you will feel the protrusion of the tip of the transverse process.

Locating Rib Articulations

If you glide even more laterally, you can feel the costotransverse groove, a useful point to be able to locate when trying to determine whether ribs are correctly aligned.

Although this section is about the thorax, as a therapist you know that body parts cannot be easily compartmentalized and that they impact on one another. This tip has been included near the start of the assessment section because it helps reinforce this point. In 1974, Robert Maigne studied the phenomenon of pain referred from the T10–T11, T11–T12, and T12–L1 regions of the spine.

How did Maigne suggest we identify a client with symptoms in their buttock, greater trochanter, or groin as suffering from thoracolumbar joint syndrome?

First, Maigne observed that if you apply gentle lateral pressure to the spinous processes (a), T12 to L2 will be uncomfortable when pressure is applied to the affected segment.

Second, he said cellulalgia will be present. Cellulalgia describes an area of thickened skin where skin rolling (b) elicits tenderness. The area in which these symptoms occur corresponds to the spinal nerve involved. If the thoracolumbar junction is involved, you would expect a thickening of skin in the iliac crest/superior buttock region.

On the next few pages are some questions that serve as a reminder of some of the key aspects to consider when carrying out a postural assessment of the thoracic region. Postural assessment of the upper body includes an assessment of the head and neck, so remember to observe your client’s head position, especially whether they have a forward head posture, as this affects how thoracic muscles function. You will need to examine all aspects of your subject’s thorax, observing them from the front, back, and side.

Question: Does it matter where I start my assessment—anterior, lateral, or posterior?

One of the key things to observe in a thoracic assessment is whether or not your subject has the normal thoracic curve. Many therapists are quick to spot kyphotic postures, and it is equally important to assess for a flat back. A flattened thoracic curve can contribute to localized pain. Observe how the spinous process of a normal thoracic vertebra points downward. Loss of the thoracic curve means that these processes come closer together. Sometimes, clients with flat back complain of pain on standing erect, and even greater pain on extension of their spine. Of course, it is important to rule out other causes of this pain, but pain could be the result of the soft tissues and spinous processes being jammed together on movements involving spinal extension.

True scapular winging is observed as a marked protrusion of the scapula from the posterior chest wall. It is unlike the mild protrusion of scapulae you sometimes see in a client with low body fat, or the slightly more prominent appearance of the scapulae in a client with a flat back. True scapular winging is the result of nerve palsy, frequently affecting the serratus anterior muscle so that it cannot hold the scapula against the rib cage. This may be due to a congenital abnormality or may be the result of injury to the long thoracic nerve.

Weakness in trapezius and rhomboids can also contribute to scapular instability. Shortening of pectoralis minor could tilt the scapula anteriorly, making the inferior angle more prominent.

The S-shaped lateral curvature of the spine known as scoliosis is varied and requires a specialist to diagnose the type and degree of the problem. Many people have spines with mild deviation from the midline, but these would not be described as scoliotic.

There are two types of scoliosis: functional and structural.

In functional scoliosis, sometimes called flexible scoliosis, there are no structural changes to vertebrae or pathology affecting ligaments or muscles.

Structural scoliosis, sometimes called rigid scoliosis, involves changes to the vertebrae.

William Adams (1820–1900) devised the forward bending test, which carries his name.

Ask your subject to bend forward as far as they are able as you observe their rib cage. A rib “hump” is revealed on the side of their spine that is convex.

In very general terms, functional scoliosis disappears on the Adam’s test (forward flexion) and on lying supine, and may be corrected by the subject. Structural scoliosis does not disappear on the Adam’s test—if anything, this test highlights the scoliosis; the scoliosis does not disappear when the subject rests supine and the curve cannot be corrected by the subject without assistance.

Generalized overview comparing functional and structural scoliosis

In the scoliotic spine, as the body of a thoracic vertebra starts to rotate counterclockwise (as it would with lateral flexion to the right), its spinous process moves counterclockwise also, appearing to the right of the midline. The ribs, attached to the vertebrae, also move: they become convex on the anterior, right side of the body, and convex on the posterior, left side of the body.

Changes in vertebrae and ribs associated with lateral flexion to the right or to the left, as you are standing behind the subject are shown in the following table.

Question: How can I measure the degree of scoliosis in order to help determine if my interventions have been helpful?

1. The spinous process of C7.

2. The spinous process of L4.

3. The superior angle of the scapula.

4. The inferior angle of the scapula.

5. The acromion (not shown).

6. The posterior superior iliac spines.

Note that this would only provide information about the change in relationship between body parts. You may wish to examine whether your intervention has had an impact on functional changes, such as improvements to respiratory capacity or a person’s ability to perform daily activities, for example.

Question: Does it matter where you stand when carrying out the Adam’s test assessment?

The Adam’s test is usually performed with the observer standing behind their subject. However, this could make some subjects feel uncomfortable. If you stand in front of your client, you can still observe whether they have evidence of scoliosis.

In complete contrast to the assessments for scoliosis in the previous tip, this trick is a crude and unorthodox method for quickly assessing the shape of the spine posteriorly. Gently run the side of your fingernail down each side of the subject’s spine, leaving a faint track mark on the skin—but obviously not breaking the skin. Then stand back and observe the tracks you have made. Deviations from vertical are sometimes immediately apparent in this crude and quick assessment.

Being able to assess whether a client has a hypomobile or hypermobile thoracic spine is useful as increased or decreased mobility in this part of the spine can cause or contribute to pain. However, unlike the cervical region of the spine, it can be difficult to accurately assess range of movement (ROM) in the thorax. When testing cervical ROM, you may instruct your client to look left or right, up to the ceiling or down to the floor, or to take their ear toward their shoulder. Performing the corresponding movements of rotation, flexion, extension, and lateral flexion in the thoracic spine is difficult to achieve in isolation as these movements are accompanied by movements in the lumbar spine too:

• Lateral flexion of the thorax is accompanied by lumbar rotation to the opposite side.

• Thoracic rotation is accompanied by lumbar lateral flexion to the opposite side.

Thoracic and lumbar movements