Thoracic Spine Exam
How many degrees anterior to the frontal plane do the articular facets of the typical thoracic vertebrae sit?
20 degrees
What is the cutoff for scoliosis treatment?
20 degrees
What angles constitute moderate scoliosis?
25-45 degree Cobb angles
What is the ratio of IV disc height to vertebral body height in the c spine?
2:5
How much opening of the mandible is typical?
3 knuckles
When is bracing for scoliosis indicated?
30-40 degree curves Curves that are smaller than 30 degrees but progress 5 degrees or more over 12 months Skeletally immature
How much can each segment of the typical T spine flex/ext?
4-6 degrees
What is the cutoff for severe scoliosis?
45 degree Cobb angle
What is the risk and cause of mortality with anklyosing spondylitis?
50% Circulatory, malignant or infectious disease
How much can each segment of the typical thoracic spine side bend?
6 degrees
How much protrusion is normal?
6-9mm beyond upper central incisors
How many degrees superior to the transverse plane to the articular facets of the typical thoracic vertebrae sit?
60 degrees
How much can each segment of the upper T spine rotate?
8-9 degrees
How much can the T11-12 and T12-L1 segments of the T spine side bend individually
8-9 degrees
What angles constitute mild scolisosis?
<25 degree Cobb angle
What does conservative treatment for scoliosis entail?
Bracing, exercise therapy and monitoring with xrays
Where are the tension points in the dura mater of the spinal cord?
C6, T6 and L4
What does a C-curve when opening the TMJ typically indicate?
Capsular pattern
What is ankylosing spondylitis?
Chronic rheumatic inflammatory disease that affects the spine and sacroiliac joints
What are the vascular s/s of TOS?
Cold Pallor Weakness Swelling Finger stiffness Cyanosis Early fatigue Pain Weak radial pulse
What ligaments connect the ribs to the transverse processes of the thoracic vertebrae?
Costotransverse ligaments
When is surgery indicated for scoliosis?
Curves greater than 45-50 degrees Severe rotational abnormality
What motions are assessed with passive mobility testing of the thoracic spine?
Flexion Extension Rotation Sidebending Spring testing of thoracic spine Spring testing of first rib Cerical rotation lateral flexion test
What type of joint is the TMJ?
Ginglymodiarthrodial joint
What animal do the thoracic spine vertebrae resemble?
Giraffe
Arthrokinematics of opening of the TMJ
Head of mandible rolls posterior and slides anterior
How do wee treat a capsular pattern of the TMJ?
Heat/ice, estim, US, HEP stretching, mobilizations
What causes torsional dysfunctions of ribs?
Hyper or hypo-mobility
What causes respiratory dysfunctions of the ribs?
Hypomobility between the ribs or at the costotransverse or costovertebral joints
Are idiopathic or secondary cases of scoliosis more common?
Idiopathic
Which vertebrae does rib 4 articulate with?
Inferior costal facet of T3 Superior costal facet of T4 and transverse costal facet of T4
How many pairs of ribs do frogs have?
0
Treating TMJ
1. Eliminate spasms and pain 2. Counseling, relaxation training 3. Correcting the way the teeth fit together 4. Surgery 5. PT
When does adolescent scoliosis usually present?
11-14 years old
How many thoracic vertebrae?
12
How much can the T11-T12 and T12-L1 segments of the T spine flex/ext individually?
12 degrees
How many articulations does each typical thoracic vertebrae have?
12: 4 zygopophyseal, 2 costotransverse, 4 costovertebral, 2 between the body and the intervertebral disc
What is the ratio of IV disc height to vertebral body height in the T spine?
1:5
How much can each segment of the lower T spine rotate?
2 degrees
How much mandible opening is required to be functional?
2 knuckles
What is the prevalence of idiopathic scoliosis in children?
2-3%
How do the inferior articular facets of T2-T10 face?
Inferior, anterior, and slightly medial
How do the inferior articular facets of T1 face?
Inferiorly and anteriorly
What are the most common locatios for neurovasculature to be compressed with thoracic outlet syndrome?
Interscalene Triangle Costoclavicular spine Subpectoral tunnel
What muscles laterally deviate the mandible?
Ipsilateral posterior temporalis Contralateral pterygoids
S/S of TMJ disk displacement
Joint noises Limited opening Ipsilateral deviation
How do the inferior articular facets of T11-T12 face?
Laterally
Which side has decreased intrathoracic space with left scoliosis?
Left
Which side is the rib hump on with left scoliosis?
Left
Arthrokinematics of left lateral deviation
Left condyle spins around an ant-post axis in the mandibular fossa while the right condyle translates forward and inferiorly
What are some examples of TMJ dysfunction?
Mandible deviation Disk displacement Inflammatory conditions Myofascial pain Arthritic conditions
How is muscular imbalance of the TMJ treated?
Muscle re-education: 1. Clicking sound with tongue to relax the jaw 2. Fill cheeks with air and push it out in a puff 3. Tongue proprioception by drawing tiny circles on the anterior hard palate 4. Practice resting position of jaw with diaphragmatic breathing 5. Practice movement symmetry with mirror 5. Active motions with gentle resistance
What are some causes of functional scoliosis?
Muscle spasm Leg length discrepancy
What does an S curve when opening the TMJ typically indicate?
Muscular imbalance
Which is most common neurological or vascular symptoms of TOS?
Neurological
What muscles retrude the mandible?
Post. temporalis
What can cause TMJ?
Nocturnal bruxing Emotional distress Acute trauma Hyperextension trauma Poor general health and posture
Transverse Abdominis OINA
O - Costal cartilage 7-12, thoracolumbar fascia, iliac crest, ASIS I - Linea alba, pubic crest N - Intercostal nn A - Rotates trunk ipsilaterally
Upper Trapezius OINA
O - Occipital bone, SPs of C1-C7 I - Lateral third of clavicle N - CNXI A - pull scapula upward, rotate glenoid sup, tilt head ipsilat and rotate head contralat
Serratus Anterior OINA
O - Ribs 1-9 I - Med border of scapula N - Long thoracic n A - Holds medial border against thoracic wall
Pectoralis Minor OINA
O - Ribs 3-5 I - Coracoid process N - Medial pectoral N A - Protract scapula
External Oblique OINA
O - Ribs 5-12 I - Iliac Crest, pubic tubercle, linea alba N - Intercostal nn A - Contralateral rotation of the trunk
Rhomboid Minor OINA
O - SPs of C6-C7 I - Medial border of scapula below scapular spine N - Dorsal scapular N A - Retract scapula
Middle Trapezius OINA
O - SPs of C7-T3 I - Acromion N - CNXI A - Retract scapula
Rhomboid Major OINA
O - SPs of T1-T4 I - Medial border of scapula below spine N - Dorsal scapular nerve A - Retract scapula
Lower Trapezius OINA
O - SPs of T3 - T12 I - Scapular spine N - CNXI A - Retract and depress scapula
Latissimus Dorsi OINA
O - SPs of T7-T12, thoracolumbar fascia, Inf angle of scapula, Ribs 9-12, Iliac crest I - Intertubercular groove N - Thoracodorsal N A - ADD, Ext, and IR humerus
Internal Oblique OINA
O - Thoracolumbar fascia, iliac crest, ASIS I - Ribs 10-12 N - Intercostal nn A - Ipsilateral flexion
Which vertebrae does rib 1 articulate with?
Only T1
Risser Classification
Ossification stage of iliac epiphysis Used to judge how much more skeletal growth will occur Type I: ossification of lateral 25% Type V: Fusion to ilium
What are the neurological s/s of TOS?
Pain and paresthesia following distribution of involved nerve roots Loss of dexterity Muscle weakness Spasms in neck and scapular muscles Heavy feeling Symptoms occur most often with arm abducted more than 90 degrees or when carrying weight
What ligaments connect the ribs to the vertebrae bodies?
Radiate ligaments
Ribs 4 and 5 appear to be elevated, which one is likely the culprit?
Rib 5
Concavity/convexity of T1-T6 costotransverse joints
Rib is convex Costal facet of transverse process is concave
True Ribs
Ribs that directly articulate with the sternum Ribs 1-7
Floating Ribs
Ribs that don't attach to sternum Ribs 11-12
Pushing the SP of a vertebra toward the left rotates the vertebrae which direction?
Right
How do ribs in general tend to move with right side bending?
Right ribs: upper ribs move inferiorly and rotate anteriorly, ribs approximate causing superior glide of the rib facet at the costotransverse joint Left ribs: upper ribs move superiorly and rotate posteriorly until intercostal muscles resist movement causing an inferior glide of the rib facet at the costotransverse joint
How do ribs in general move with exhalation?
Rotate anterior with superior glide of costotransverse joint
How do ribs in general tend to move with inhalation?
Rotate posterior and inferior glide of costotransverse joint
Which symptoms occur first with TOS: sensory or motor?
Sensory
What are the stages of TMJ dysfunction?
Stage 1 - disk slightly anterior on mandibular condyle +/- click, +/- mild pain Stage 2 - disk anterior on condyle, early click on opening, late click on closing, severe consistent pain Stage 3 - disk farther anterior, later click on opening, earlier click on closing, most painful Stage 4 - disk dislocated, click rare
Treatment for TOS
Stretch and strengthen shoulder girdle muscles Cervical exercises and mobilizations Modification of movement patterns Bracing
How is ankylosing spondylitis treated?
Stretching (flexion, extension and rotation) of posterior and anterior spinal muscles Neural mobilization of median nerve Eccentric erector spine muscle exercises Breathing exercises Mobilizations of spine
What causes structural dysfunctions of ribs?
Subluxation or dislocation
How do the superior articular facets of T2-T10 face?
Superior, posterior and slightly lateral
How do the superior articular facets of T1 face?
Superiorly and posteriorly
Rule of 3s for the SPs of the T spine
T1-T3 SPs project directly posteriorly from their TPs T4-T6 SPs project halfway to the next TPs T7-T9 project down to the next level T10 is like T7-T9 T11 is like T4-T6 T12 is like T1-T3
Which vertebrae does rib 12 articulate with?
T12
Where is the thoracic spine the narrowest?
T4 and T9
Where is the apex of the kyphotic curvev of the thoracic spine?
T7-8
What is an open lock of the TMJ?
The condyle is locked open and can't close Cause: overstretching lateral pterygoid or posteriorly displaced disk
What is the convexity/concavity of the TMJ?
The convex head of the mandible moves on the concave mandibular fossa
What helps control the movement of the articular disk in the TMJ?
The lateral pterygoid muscle attaches anteriorly to move it forward and the retrodiskal laminae attaches posteriorly to passively control forward motion
T/F Rib 10 articulates with the disc between T9 and T10
True
T/F Thoracic spine mobilization may help with shoulder conditions
True: at least in the short term there are decreases in pain, increases in shoulder range of motion and increases in patient perceived global rating of change
What is internal derangement of the TMJ?
When the posterior band of the disk is anteriorly displaced in front of the condyle
How does the thoracic spine move with exhalation?
Flexion Inferior articular facets of the superior vertebrae move up and forward
What are some functional causes of TOS?
Muscle imbalances Forward head posture Short SCM, scalenes or pec minor Weak lower and middle traps
How do ribs 7-10 tend to move with inspiration?
"Bucket handle motion" Rotate to increase the left to right diameter of the chest
How do ribs 11 and 12 tend to move with inspiration?
"Caliper motion" They tend to move laterally to increase the lateral diameter of the chest
How do ribs 1-6 tend to move with inspiration?
"Pump handle motion" Rotate to increase anterior to posterior diameter of the chest
How do we test for scoliosis?
Adam's test Measure Cobb angle with xray
What special tests suggest TOS?
Adson's test - scalenes Costoclavicular assessment Pectoralis minor assessment Anterior capsule Roos
Where is the axis for rib rotation?
Around a line drawn between the costotransverse joint and the costovertebral joint
Interchondral Liagments
Attach adjacent costal cartilage segments
False ribs
Attach to sternum indirectly through the costal cartilage of rib 7 Ribs 8-10
Chondrosternal joint
Between the costal cartilage and the sternum
Costrochondral joint
Between the rib and the costal cartilage that attaches it to the sternum
What muscles depress the mandible?
Digastric Lateral Pterygoid Suprahyoid
Enthesopathy
Disease that affects the insertion of ligaments into bone
What do clicking and joint noises in the TMJ indicate?
Disk displacment or arthritis
What are the motions assessed with active mobility testing of the thoracic spine?
Flexin/ext of upper and lower thoracic spine Rotation Sidebending
How does the thoracic spine move with inhalation?
Extension Inferior articular facets of the superior vertebrae move down and back
T/F Adolescent scoliosis typically presents with back pain
False
T/F Posture of the C spine has no effect on TMJ
False
T/F Surgical treatment is first line of defense for TOS
False
T/F The natural curvature of the thoracic spine can be described as lordotic?
False
T/F The thoracic cavity is the most segment of the spine
False
T/F Moderate and severe scoliosis is more common in males
False 1:10 males to females for curves over 30 degrees
T/F If scoliosis is over 15 degrees at the end of adolescence the risk of problems in adulthood increases significantly
False 30 degree Cobb angle
T/F Mild scoliosis is more common in females
False The ratio of males to females is 1:1 with 10 degree curves
T/F Ankylosing spondylitis is more common in females
False, 2-3X more common in males
What does the cervical rotation lateral flexion test assess?
First rib
What muscles protrude the mandible?
Masseter Med and Lat pterygoid
What muscles elevate the mandible?
Masseter Temporalis Medial pterygoid
How is scoliosis objectively quantified
Measuring the Cobb angle with an xray
What are some brace types used for scoliosis?
Milwaukee Brace Boston Brace Charleston Bending Brace RSC Brace Providence
How do the superior articular facets of T11-T12 face?
More medially than the rest of the T spine
What are some structural causes of TOS?
Morphological changes in the scalenes Prominent C7 TP Malformations of first rib Cervical rib Callus formations on clavicle or ribs
What is the resting position of the TMJ
Mouth slightly open, lips together, teeth not touching
What are the arthrokinematics of jaw retrusion?
The head of the mandible glides posteriorly
3 ribs appear to be depressed which one is the likely culprit?
The highest rib
What is a closed lock of the TMJ?
The mouth can't be closed Cause: capsular problem Treatment: ice/heat, estim, US, ST release, joint mob, self stretching
What increases the risk of scoliosis progression?
Younger patient Larger curve Number of curves (S curves are more likely to progress) Lower Risser sign (more room to grow) Curves that begin before menarche
