A perceptive clinician elicits often scant objective signs and interprets them correctly, but the easiest way to the diagnosis is to think of it.
NE Shaw J Bone Joint Surg. 1975;57B:412
As with neck pain (Chapter 20) and low back pain (Chapter 26), it is frequently difficult for the clinician to make a precise diagnosis in patients with pain in the region of the thoracic spine, given the interplay between the thorax, upper limb, neck, low back, and the cardiorespiratory and visceral systems. Perhaps the most common musculoskeletal problems are disorders of the thoracic intervertebral joints and the numerous rib articulations, as this region of the spine is primarily required to contribute stability to the axial skeleton. Injury to the intervertebral disk, the facet joints (also named zygapophyseal joints), or other nociceptive structures of the thoracic spine may contribute local or referred pain. Clinical presentation of these, often articular, problems is varied, with combinations of pain and altered motion the dominant feature involving one or more intervertebral segments or rib joints. There may be associated abnormalities of the paraspinal and periscapular muscles, as well as increased neural mechanosensitivity (Chapter 6). Thoracic intervertebral joint problems frequently refer pain to the lateral or anterior chest wall. Prolapse of a thoracic intervertebral disk is rare in sportspeople; however, it may be under-reported given the often diffuse symptoms that arise.1,2 Cross-sectional imaging studies are often necessary to rule out this diagnosis.
In adolescents, the most common cause of pain in the area of the thoracic spine is Scheuermann’s disease, a disorder of the growth plates of the thoracic vertebral end-plates associated with an accentuated lower thoracic kyphosis. A list of the causes of pain in the region of the thoracic spine is shown in Table 25.1. The surface, muscle, and cross-sectional anatomy of this area are shown in Figure 25.1).
Causes of thoracic pain
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Causes of thoracic pain
|Common||Less common||Not to be missed |
Intervertebral joint sprain
• Zygapophyseal joints
Paraspinal muscle strain
Costovertebral joint sprain
Scheuermann’s disease (adolescents)
Fracture of the rib posteriorly
Thoracic disk prolapse
Tumor (e.g. carcinoma of the breast, secondary deposits)
Anatomy of the thoracic spine region
(a) Surface anatomy
(b) Muscles of the thoracic spine region
(c) Axial CT image of the typical motion segment from the lower thoracic region. The most accessible rib articulation for palpation and mobilization is the costotransverse joint (CTJ), with the costovertebral joint (CVJ) attached firmly ...
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