The thoracic spine is the longest region of the spine, and by some measures it is also the most complex. Connecting with the cervical spine above and the lumbar spine below, the thoracic spine runs from the base of the neck down to the abdomen. It is the only spinal region attached to the rib cage.

1. PRESENTING BY;RANJAN KUMAR MISHRA
Neurophysiotherapist
AIIMS Patna

2. Contents
 Biomechanics
 Pathomechanics Of Diseases Of Thoracic Spine
i. Thoracic Outlet Syndrome
ii. Scheurmann’s
iii. T4 Syndrome
iv. Scoliosis
v. Movement Impairment Syndrome

3. General structure and function
Rib Cage
 The rib cage is a closed chain that involves many joints
and muscles. The anterior border of the rib cage is the
sternum, the lateral borders are the ribs, and the posterior border is
formed by the thoracic vertebrae. The superior border of the rib cage is
formed by the jugular notch of the sternum, by the superior borders of
the first costocartilages, and by the first ribs and their contiguous first
thoracic vertebra. The inferior border of the rib cage is formed by the
xiphoid process, the
shared costocartilage of ribs 6 through 10, the inferior portions of the
11th and 12th ribs, and the 12th thoracic vertebra .
 The sternum is an osseous protective plate for the heart and is
composed of the manubrium, body, and xiphoid process . The
manubrium and the body form a dorsally concave angle of
approximately.
 There are 12 thoracic vertebrae that make up the posterior aspect
of the rib cage with costal articulating surfaces.

4.  vertebrosternal (or “true”) (1st through 7th)
 vertebrochondral (or “false”) ribs
 vertebral (or “floating”) ribs(11th 12th)

5. Kinematics
MOVEMENT OF THORACIC SPINE AND THORAX
Thoracic spine motion
 Segmental motion
 Total motion
Motion of rib cage
 Elevation and depression of the ribs.
 Motions of rib with thoracic motion
 Movement of costal cartilages and sternum

6.  All motions are possible in the thoracic region, but the range of flexion
and extension is extremely limited in the upper thoracic region (T1 to
T6), because of the rigidity of the rib cage and because of the
zygapophyseal facet orientation in the frontal plane. Lateral flexion
and rotation are free in the upper thoracic region.
 In the lower part of the thoracic region (T9 to T12), the zygapophyseal
facets lie more in the sagittal plane, allowing an increased amount of
flexion and extension.
 The ROM in lateral flexion is always coupled with some axial rotation.
The amount of accompanying axial rotation decreases in the lower part
of the region because of the change in orientation of the zygapophys
eal facets at T10 or T11.

7. Osteokinematics

9. COUPLED MOTION
 Coupled motion consist of a primary motion occur in one plane
and it accompanied automatically by motion in at least one other
plane. Coupling motion greatest in side bending and rotation.
 UPPER THORACIC SPINE;SIDE BENDING IS COUPLED WITH
IPSILATERAL ROTATION BUT IN MID AND LOWER THORACIC
REGION SIDE BENDING IS ACCOMPANY BY IPSILATERAL OR
CONTRALATERAL ROTATION.
APPLEID
 clinical relevance of coupled motion with idiopathic
scoliosis in thoracic spine;
 scoliosis is characterized by frontal plane curve accompany by
transverse plane rotation and side bending and contra lateral
rotation is systematically coupled in individual with idiopathic
scoliosis.

10. FLEXION

12.  forward sagittal rotation (flexion) around the X axis
coupled with anterior translation along the Z axis and very
slight distraction. Anterior translation along z axis induce
forward sagittal rotation along x axis and slight
compression along y axis.
 During flexion of the mobile thorax , forward sagittal
rotation of superior vertebrae couples with anterior
translation and inducing anterior rotation of rib.
 Flexion in the thoracic region is limited by tension in
the PLL, the ligamentum flavum, the interspinous
ligaments, and the capsules of the zygapophyseal
joints.

13.  stiff thorax?
the ribs are less flexible than the spinal column. At the costotra
nsverse joints , As the thoracic vertebrae continue to forward flex,
the concave facets on the transverse processes travel superiorly
relative to the tubercle of the ribs. The result is a relative inferior
glide coupled with a posterior roll of the tubercle of the rib at the
costotransverse joint .
 when the relative flexibility between the spinal column and
the rib cage is the same?
During flexion of the thorax the quantity of movement is reduced an d
there is no apparent movement between the thoracic vertebrae and the
ribs . Some superoanterior gliding occurs a t the zygapophyseal joints,
however very little , if any, cost transverse joint motion can be felt .
What biomechanical alteration happens during flexion in…

14. Extension

17.  Extension of the thoracic vertebra occurs during backward
bending of the trunk and during bilateral elevation of the arms.
 Extension around the X axis coupled with posterior translation
along the Z axis and very slight distraction. posterior translation
along z axis induce backward sagittal rotation along x axis and
slight compression along y axis.
 During extension 0f the mobile thorax, extension of the superior
vertebra occurs. The ribs posteriorly rotate about a paracoronal
axis along the line of the neck 0f the rib such that the anterior
aspect travels superiorly while the posteror aspect travels
inferiorly. At the limit of backward bending, the vertebrae stop
and the ribs continue to posteriorly rotate relative to the
vertebrae.

18.  Extension of the thoracic region is limited by contact of the
spinous processes, laminae, and zygapophyseal facets and by
tension in the anterior longitudinal ligament, zygapophyseal
joint capsules, and abdominal muscles.

19.  stiff thorax?
The arthrokinematics of the zygapophyseaJ joints remain same
but at the costotransverse joints different. As the thoracic
vertebrae continue to extend, the concave facets on the
transverse processes travel in feriorly relative to the tubercle of
the ribs . The result is a relative superior glide coupled with an
anterior roll of the tubercle of the rib at the costotransverse joint.
 when the relative flexibility b/n spinal column and ribcage is same?
During extension of the thorax, the quantity of movement is
reduced and there is no apparent movement between the thoracic
vertebrae and the ribs.Some inferoposterior gliding occurs at the
zygapophyseal joints only , however very little,
if any, costotransverse joint motion can be felt .
What biomechenical alteration happens
during extension in……

20. What r the importance of independent movement
of the sternum and the spine??
 There can be considerable independent movement of the
sternum and the spine is possible, "thus allowing mobility of the
spine without forcing concomitant movements of the rib cage".
 It is possible for individuals to voluntarily change their pattern of
motion. For example, in the mobile thorax the spine can extend
inducing a posterior rotation of the ribs in space and then while
holding this position, it is possible to anteriorly rotate the ribs.
This flexibility allows the thorax to accommodate the demands
coming From
 respiration ,
 movements of the upper extremities and
 movements of the head .

21. Side flexion

22.  Sideflexion of the thoracic vertebrae occurs during lateral bending of
the trunk.
 In lateral flexion, the superior vertebra laterally tilts, rotates, and
translates over the adjacent vertebra below.
 The direction of rotation that accompanies lateral flexion differs
slightly from region to region because of the orientation of the facets.
 In the upper part of the thoracic region, lateral flexion and rotation are
coupled in the same direction, whereas rotation in the lower region
may be accompanied by lateral flexion in the opposite direction.In this
region, however, the direction of coupled rotation may vary widely
among individuals.
 R side flexion, around the Z axis, coupled with contralateral rotation
around the Y axis and ipsilateral translation along the X axis in
midthoracic region.R lateral translation along x axis induce R side
flexion along Z axis and and contralateral rotation around Y axis.

23. rotation

24.  Rotation occurs in transverse plane around a vertical axis.
 During right rotation of the trunk the followingbiomechanics are proposed to
occur in the midthorax. The superior vertebra (eg. T5) rotates to the right and
translates to the left .The left (6th) rib anteriorly rotates and translates
posterolateral relative to the ipsilateral transverse process of inferior vertebrae.
 Rotation of thoracic vertebra in transeverse plane affects the paired ribs
attached to it’s asymmetrically. rotation of vertebrae is named according to
side to which vertebral body turns; hence right rotation indicates that the
vertebral body turns to right.rotation to right is accompained by anterior
movement of left transverse process and posterior movement of right
transverse process producing asymmetric movement of left and right ribs.

25. Motion of rib cage
 Elevation and depression of the ribs.
 Motions of rib with thoracic motion
 Movement of costal cartilages and sternum

26. Elevation and depression of the ribs

29.  Ribs exhibit completes three dimensional motion.
 According to what appears to be the more commonly accepted theory,
there is a single axis of motion for the 1st to 10th ribs through the center
of the CV and CT joints.
 The axis for the upper ribs lies close to the frontal plane, allowing
thoracic motion predominantly in the sagittal plane.therefore
elevation of these ribs markedly increase the AP diameter of
thorax.
 The axis of motion for the lower ribs is nearly in the sagittal plane,
allowing for thoracic motion predominantly in the frontal plane,so
that elevation of ribs increase the transeverse diameter of thorax.
 In midth0racic region the axis running obliquely at 450 to sagittal
plane so transverse and AP diameter increases.
 the motion of ribs in depression and elevation can be described
mechanically as a hinge like.the ribs movement is clasically
compared to the hinged movements of a pump handle and a
bucket handle. Pump handle motion of ribs refers to motion of
ribs in sagittal plane and bucket handle motion represents
frontal plane excursion.

30. Movement of costal catilage and of sternum
 Movement of ribs relative to sternum and costal cartil??
 During inspiration the costal cartilages undergoes angular
displacement and torsion around their long axes.this torsion is
imporatant in mechanism of expiration.
 During rib elevation the angular movement of costal cartilage relative
to sternum occur at costosternal joint.at the same time there is another
movement of angular rotation around the axis of cartilage taking place
at costochondral joints .
 Sternum rises during rib elevation ,it’s movement is less than
movement of ribs .the difference of movement between ribs and
sternum twists costal cartilage .the passive torsion applied to costal
cartilages allow the cartilage to store elastic energy that is released as
the cartilage recoil .their passive recoil helps lower the ribs reduce
thoracic volume during exhalation ,without need for muscle
contraction.
 the costal cartilage twist on it’s on axis thus behave like a torsion rod
,thus

31. Motions of rib with thoracic motion

32. Pathomechanics of muscle of thoracic spine
 Erctor spinae become electrically silent during forward flexion when
the trunk reaches approximately two third of maximum available
excursion ,and remain silent as the trunk initiate the return to erect
posture. Only after the trunk reaches approximately 45o do the muscle
resume activity .
 the posterior ligaments of spine and intervertebral disc provide
primary support to spine in maximally flexed positon and the passive
recoil of these tissue ,combined with action of superficial back muscles
and hip extensors ,helps initiate return of upright posture.
 The lattismus dorsi exhibit extension moment arm in lumbar region
and participates in extension of lumbar spine. But it’ role is
controversial in thoracic region.

33. Articulations of thoracic spine
Joints b/n adjacent vertebrae
Interbody joints
Facet joints
 Interbody Joints -cartilagenous joints of symphysis type between
vertebral bodies
 The interbody joints of the thoracic
spine involve flat vertebral surfaces
that allow for all translations to occur.
 The intervertebral disk allows for
tipping of the vertebral bodies;
however, the relatively small size
limits the available motion.

34. Supproting structures-
ligaments
Beside capsular ligaments ,the
thoracic spine is supported by
several sets of ligaments common
to rest of vertebral column.
 Capsule of apophyseal joint
 Anterior longitudinal ligament
 Posterior longitudinal ligament
 Ligamentum flavum
 Supraspinus ligament
 Interaspinus ligament
 Intertransverse ligament
 Costotransverse ligament
 Radiate ligament
ligamentum flavum and anterior longitudinal ligaments are thicker in the thoracic region than in
the cervical region.

35. Articulations of the Rib Cage
 The articulations that join the bones of the rib cage
include the
manubriosternal (MS)
xiphisternal (XS),
costovertebral (CV),
costotransverse (CT),
costochondral (CC)
chondrosternal (CS)
interchondral(IC)

38. What mechanical factors that play a role in compression
fractures as well as progressive kypotic deformities of
thoracic spine?
The normal thoracic kyphosis subject the vertebral body to compressive
load .
Two dimensional analysis of the force on thoracic spine
 in upright posture supeincumbent weight of head and neck and
the anterior concavity of the thoracic spine place center of gravity of the
head and cervical spine anterior to much of thoracic spine there by
producing flexion movement of thoracic spine
 3; in static equilibrium, external moments produced by weight of body
segment or external load must be balanced by internal moments
produced by muscle and ligament.
 4;a increase in external flexion moment on thoracic spine resulting from
increased thoracic kyphosis is balanced by an increased extension moment
to keep spine from flexing.

39.  5; A compressive failure in thoracic region commonly occur in anterior
portion of vertebral body creating wedge facture ,it increase kypotic
deformity.
 Clinical relevance; compression fracture in the thoracic spine,
wedge and burst fractures
 Fracture of vertebral body in thoracic spine result from compressive
loading. when load accompany by significant flexion lead to
compressive fracture, when compressive force on straight spine
produce burst fracture, in which end plate of vertebral body fracture,
nucleus pulpous forced in to vertebral body.
 6; ultimate strength of bone is the maximum load the bone can
support with out getting fracture.
 Clinical relevance; spontaneous vertebral fracture;
 Individual reach there peak bone mass at mid 20s.after reaching their
peak bone mass, premenopausal women begins to loss .3% of bone
mass. Menopausal and postmenopausal experience accelerated bone
loss that is 2% per year this lead to osteoporosis and patient at risk of
vertebral fracture or may complain of sudden sharp pain.

41.  More commonly fractures fo thoracic vertebrae are fragility
fracture produced by normal loads applied to bones
weakened by osteoporosis.

42. Thoracic outlet syndrome

43.  The thoracic outlet syndrome (TOS) complex refers to a
series of neurovascular compression syndromes in the
shoulder region.
 The specific nomenclature for this pathologic condition
include cervical rib syndrome, scalenus anticus syndrome,
subcoracoid pectoralis minor syndrome, costoclavicular
compression syndrome, scalenus medius syndrome, first
thoracic rib syndrome, hyperabduction syndrome, Paget-
Schroetter syndrome, and droopy shoulder syndrome.
 Today, TOS is recognized as an entrapment compression
vasculopathy of the of the subclavian vessels but more
commonly involving the lower trunk or medial cord of the
brachial plexus at anyone of four site.

44. What relevant anatomy is requisite to understanding this
disorder?
 The thoracic outlet is bounded by the anterior scalene muscle anteriorly,
medial scalene muscle posteriorly, clavicle superiorly, and first rib
inferiorly".
 The uniting of the ventral primary rami of the 5th cervical through the first
thoracic roots to form the superior, middle, and inferior trunks of the
brachial plexus occurs supraclavicularly in that part of the neck known as
the posterior triangle.
 The brachial plexus travels away from the spinal cord by passing between
the cleft of the scalenus anticus and medius muscles into the supraclavicular
region. Here the ventral primary rami unite to form the superior, middle,
and inferior trunks. The ventral rami of C8 and 1'1 unite to form the inferior
trunk, which exits the neck to enter the axilla by crossing between the first
rib and the clavicle (costoclavicular space)' on its way to the upper extremity.
 After leaving the costoclavicular space those nerve fibers composing the
inferior trunk pass infraclavicularly underneath the muscular fibers of
pectoralis minor en route to their distal destination by way of the
coracopectoral space.
 Upper plexus involvement may occur after spasm of the scalenus muscles,
whereas lower plexus involvement may occur in the costoclavicular space or
underneath the pectoralis minor.

46. The thoracic outlet has four sections:
(1) The sternocostovertebral space.( Pancoast
tumors) present themselves here .
(2) The scalene triangle is narrower in many
patients with resulting in the emergence and
rubbing of the neurovascular bundle against
the apex of this triangle. Additionally, nerve
adhesion to muscle may occur at this site.
(3) The costoclavicular space contains all the structures of the scalene
triangle plus the subclavian vein.
(4) The coracopectoral space containing the inferior trunk of the brachial
plexus

48. What are the three categories of risk factors in the
development of thoracic outlet syndrome (TOS)?
Congenital-structural anomaly
Traumatic-structural alterations in the size of the thoracic outlet
Postural alteration in the size of the thoracic outlet
congenital factors directly predispose for TOS?
 Anatomic anomalies include the presence of a cervical rib , unusually long
transverse processes of the seventh cervical vertebrae, or soft tissue in the
form of an anomalous fibrous band (This band is located near the cervical rib
and may cause as much trouble as a bony rib though it is radiographically
undetected because it is not ossified).
 Cervical ribs, which articulate with the seventh cervical vertebra , are present
in 1% of the population, where they extend into the neck where their anterior
end may either be free or attach to the first rib or sternum. Although the
presence of these variations may cause little or no trouble under normal
circumstances, after injury and loss of normal posture they represent a risk
factor in the development of TOS.

50. How do forms of local and distant trauma alter the local anatomy
of the thoracic outlet?
 Posttraumatic alterations of local anatomy may be caused by a
malunited clavicle fracture resulting in exuberant callus formation and
significantly diminishing the space between the clavicle and the first rib.
 Another common example of local trauma is whiplash tears to the
scalene muscle, which often result in protective spasm. Increased
scalene muscle tone will excessively elevate the first rib and reduce the
thoracic outlet aperture.
 A delayed onset of local trauma would be whiplash-caused tears of the
scalene muscle. The resultant tear fills in with scar tissue that, over
time, undergoes contractures and fibrosis, strangling that portion of the
plexus that travels through its substance. Compression within the
interscalene space may occur after reflex muscle spasm of the scalenes,
cervical spondylosis because of facet joint inflammation attributable to
degenerative disk disease or cervical radiculopathy, overhead work
postures, or heavy lifting.

51. What is the relationship between posture and TOS?

52. What anatomic sex differences might account for a
higher incidence of TOS in certain females?
 The upper margin of the sternum is level with the lower
part of the second dorsal vertebra in males and on the
lower part of the third dorsal vertebra in females.
 In the female, the medial third of the clavicle is lower than
that in the male and thereby decreases the available space
between the clavicle and the first rib (costoclavicular
space).
 scapular ptosis may be greater in females with large
breasts. Attaching to the pectoralis major muscle, the
breasts exert a downward pull of the superior proximal
attachment off the sternal half of the clavicle and thus
further reduce the thoracic outlet aperture. This problem,
referred to as droopy shoulder syndrome, may be
accelerated by increased pressure from a narrow brassiere
strap.

54. What is the typical presentation of the postural
variety of TOS?
 The patient, nearly always a middle-aged woman, succumbs to inferior trunk
compression by day resulting from stooped posture. Complaining of waking
up anytime at night from severe "pins and needles" in one or both hands, the
patient finds relief by letting her arms hang over the edge of the bed or by
sitting or standing up. She then falls back asleep only to be awakened several
hours later with recurrence of symptoms, or she may sleep uninterrupted
until morning. On waking, the hands may feel numb for half an hour and
exhibit clumsiness during small motions such as turning on the light or
holding a toothbrush.
 The nocturnal symptoms may be a release phenomenon representing
ischemic recovery of the nerve trunk, manifesting during sleep when the day's
constant downward strain is relieved by the recumbent position. Thus the
lower brachial plexus trunk moves upward and out of contact with the first
rib in the gravity-eliminated, recumbent position.

55.  By day the patient is little troubled unless he or she wears a
heavy overcoat, carries a heavy weight, or simply holds the
arm in a dependent position for any length of time. The
patient may eventually come to realize that the more she
exerts herself physically by day the more pain she is likely
to experience that night.

56. What are the clinical signs and symptoms?
 Thoracic outlet syndrome is an affectation of the brachial plexus and not
of the cervical nerve roots. Consequently the patient will not experience
symptoms at the base of the neck (supraclavicular fossa) where the
lesion lies but rather distally along the upper limb. The cutaneous
distributions affected are those of the ulnar nerve and the medial
cutaneous nerve of the forearm corresponding to the ulnar distribution
in the hand and medial aspect of the forearm.?These two nerves
represent the last two adjacent branches off the medial cord of the
brachial plexus before that cord joins with the lateral cord to form the
median nerve.
 Paresthesias may later be accompanied by aching pain that is either
poorly localized or over the whole arm. Paresthesia is often confined to
the medial area of the forearm as well as hypothenar region of the hand.
Either symptom may be exacerbated by such use of the arm as lifting and
carrying heavy objects such as a container of milk or a suitcase or just
standing about or walking.

57.  Motor deficits are not usually pronounced with TOS and, when
present, consist of a sense of weakness and clumsiness in the fingers.
The patient may state that his or her grip or pinch strength is reduced.
Atrophy, reflective of long-term TOS, will affect all the intrinsic hand
muscles, since the involved plexus fibers are derived from the C8 and
T1 roots, which furnish intrinsic hand innervation. Atrophy may also
manifest in either the thenar, hypothenar eminences. Tendon reflexes
remain normal.

58. Special test
1. Adson maneuver: the examiner locate radial pulse.the
patients head is rotated to face the test shoulder .the
patient is then extend the head while examiner laterally
rotates and the patient’s shoulder.Feel the obliteration of
radial pulse
2. Wright test: hyper adbuction of shoulder to 180 degree
and elbow flexed. Test positive with obliteration of radial
pulse
3. Roos test: elevation of arm for 3 mins with 90 degree
shoulder abduction and elbow flexed. Patient asked to
open and close hands rapidly

60. Scheuermann's disease

61.  Scheuermann's disease describes a condition where the vertebrae grow
unevenly with respect to the sagittal plain;This uneven growth results
in the "wedging" shape of the vertebrae, causing kyphosis, and is
considered to be a form of juvenile osteochondrosis of the spine.
 The name of this condition comes from Scheuermann, the person who
in 1921 described changes in the vertebral endplates and disc space
that can occur during development and lead to kyphosis, or roundback
deformity of the thoracic spine (upper back).
 Scheuermann's disease, or Scheuermann's kyphosis, is a condition in
which the normal roundback in the upper spine (called a kyphosis) is
increased. Most people with Scheuermann's disease will have an
increased roundback (e.g. a hunch back or hump back) but no pain.
 There is some confusion in terminology, however, as Scheuermann also
described changes that occur in the disc spaces of the lumbar spine
that can lead to back pain. This is really another condition, called
juvenile disc disorder, but is often confused with Scheuermann’s
kyphosis and is sometimes called Lumbar Scheuermann’s disease.

62. Scheuermann’s disease does not spread and is not really a “disease” but a
condition that can arise during growth. It is more common in males and
appears in adolescents usually towards the end of their growth spurt.it is a self-
limiting skeletal disorder. presents a significantly worse deformity than postural
kyphosis. The apex of their curve, located in the thoracic vertebrae, is quite
rigid.
The sufferer may feel pain at the apex of the curve, which can be aggravated by
physical activity and by long periods of standing or sitting; this can have a
significantly detrimental effect to their lives as their level of activity.
The cause of Scheuermann's disease is unknown, but is thought to occur due
to a growth abnormality of the vertebral body. This condition occurs when the
front of the upper spine does not grow as fast as the back of the spine, so that the
vertebrae become wedge-shaped, with the narrow part of the wedge in front.
The wedge-shape of the vertebra creates an increase in the amount of normal
kyphosis (front angulations of the thoracic spine)
A heriditary predisposition is major factor in aetiology of scheurmann’s
disease. there is an evidence that this condition follows an autosomal dominent
pattern of inheritence.

63.  The role of strenous physical activity, whether the result of occupation
,sport or other activity has been emphasised by many authors .
 The normal curvature of the thoracic spine is between 20 and 50
degrees. A curvature of more than 50 degrees, where the spine has
three contiguous vertebral bodies that have wedging of 5 degrees or
more, constitutes Scheuermann’s disease.
 Often have an excessive lordotic curve in the lumbar spine; this is the
body's natural way to compensate for the kyphotic curve above.
Interestingly, many with Scheuermann's disease have very large lung
capacities and males often have broad, barrel chests. Most people have
FVC scores above average. It has been proposed that this is the body's
natural way to compensate for a loss of breathing depth.

64. pathogenesis
 A number of theories have been proposed as to mechanism leading to vertebral
wedging, considered to be pathognomics of SD. these theory must also attempt
to explain endplate irregularity which is found to upto 95% of patients with SD.
 A likely explanation for the disruption of the endplate is congenital defect
allowing disc material to protude into the VB. Schmorl believed that SD occurs
chiefly in those persons who had congenital indentations in the disc in the
region of nucleous pulposus .he reported that in the region of these
indentations the end plate was thinner than normal and that this created a
region of decreased resistence .he belived that the stress of physical labour or
sport during early adolescents then cause fissuring of the end platewith
resulting prolapse of of the nucleus pulposus into the spongiosum of vertebral
body .as the facet joints blocked the VB posteriorly ,only the anterior edges of
vertebral body moved towards each other,and resulting damage of the
growthplate, this led to wedging.

65. Diagnostic criteria
Butler described as follows;
 Wedge shaped vertebral bodies
 Increased anteroposterior diameter of the vertebral body.
 Irregular shaped and narrow disc spaces ,kyphosis or loss of lordosis
 schmorl’s nodes
 A flattened area on the superior surface of vertebral body in the region
of epipyseal ring anteriorly.
in milder and localised form of SD there may not be
any deformity,and all parts of spine may be affected.

66.  Scheuermann's disease is self-limiting after growth is complete,
meaning that it generally runs its course and never presents further
complication. Typically, however, once the patient is fully grown, the
bones will maintain the deformity. For this reason, there are many
treatment methods and options available that aim to correct the
kyphosis while the spine is still growing, and especially aim to prevent
it from worsening.
 less extreme cases, manual medicine, physical therapy and/or back
braces can help reverse or stop the kyphosis before it does become
severe. Because the disease is often benign, and because back surgery
includes many risks, surgery is usually considered a last resort for
patients. In severe or extreme cases, patients may be treated through an
extensive surgical procedure in an effort to prevent the disease from
worsening or harming the body.
 In Germany, a standard treatment for both Scheuermann's disease and
lumbar kyphosis is the Schroth method, a system of specialized
physical therapy for scoliosis and related spinal deformities. The
method has been shown to reduce pain and decrease kyphotic angle
significantly during an inpatient treatment program.

67. Conservative Treatments for Scheuermann's Disease
 Considerable improvement of the kyphosis is possible with exercises alone
,however successful conservative correction of deformity is only possible in
skeletally immature patient.
 Pelvic tilting to decrease lumber lordosis ,musvle stretching to overcome
con tractures (pectoralis and hamstring,strengthening of thoracic extensors
.postural correction.
 For patients with more than one year of growth left, the kyphosis can be partially
reversed by wearing a brace (e.g. a Milwaukee brace). The brace can improve the
curve during the growing years by restoring height to the front of the vertebral body
and sometimes can reduce pain if present. Th brace is worn full time (16-22 hours a
day)usually for a period of atleast one or two years.once correction is achieved ( the
kyphosis is less than 400 and wedging is approaching normal ;50 or less)weaning
from brace is begin.
 An exercise program, including specific strengthening and hamstring stretching
exercises, may be recommended in conjunction with bracing. While exercise won’t
correct the deformity, it can be helpful in alleviating back pain and fatigue.
 For patients who are already skeletally mature, bracing is not an effective treatment.
 Depending on the severity and progression of the curve, patients may be prescribed a
brace for one to two years.

68. Surgery for Scheuermann's Disease
 considered for patients with severe deformities (e.g. more than 70 degrees
for thoracic kyphosis),unresponsive to conservative treatment,if
neurological deficits are present, and occasionally if pain is present with
the deformity. The goal of the surgery is mostly to reduce the deformity,
although some feel it can lessen pain if present.
 Because Scheuermann’s disease usually occurs in the thoracic spine, which
has almost no motion, a fusion in this area does not affect the normal
motion of the spine and typically does not lead to pain later in life.
 in order for surgery to be effective ,particularly in the skeletally immature
patient ,a two stage procedure is necessary.
A frontal thoracotomy (approach through the chest) to release the tissues,
remove the discs, and place bone graft in the spaces to fuse the thoracic
spine.
During the same surgery, (as soon as performed when patient
recovered from first one)the spine is then approached from the back and
instrumentation (such as rods, bars, wires, or screws, which hold the spine
straight during the fusion process) is put in place.

69. Case report
 By;jenny louise conroy,Anthony G.schneiders
School of physiotherapy, university of otago,New zealand
 History
A 28 year old female university student presented to
physiotherapy with pain across both shoulder(PA) and
bilaterally down the arms these symptoms were preceded
by paresthesia in the form of tingling in palm of both hand
and if the pain is worsened a head ache and tingling across
the face would develop.

70. There was no associated dizziness blurred vision or nausea.
 Symptom begin within couple of hour of arising in morning ,sitting in lecture
or studing for more than one hour pain across patint shoulder.
 Past history
Long standing anxiety and lower back left leg pain .6 month back pt had
suspected lumber disk prolapsed
Physical examination
 Postural examination in sitting revealed an increased lumber lordosis, decrese
upper thoracic kyposis ,increased angulation at cervicothoracic junction and
increase cervical lordosis,palpation found the upper fiber of trapezius to be
taut elicited pain bilaterally.cervical extension and right rotation were full and
pain free, cervical flexion is pain full and limitaed

71.  Clinical interpretation
 T4 syndrome typically present with unilateral or bilateral glove
distribution of paraesthesia in to hand
 Teatment 1
 Grade 3 central posterolateral mobilization of 4th thoracic verterbrra
was performed for 20 s
 On reassement thoracic movement were unchanged. full lt rotation
was achieved along with increase of 10* of side flexion
 Treatment 2
 2 days later cpa was reapeted with slite flexed position of thorax
 Full rotation of both cervical and thoracic region achived but thoracic
flexion remain unchanged

72.  Full range of motion of thoracic and cervical region achieved by
6 treatment session at 3 week
Conclusion
 Unilateral or bilateral upper limb paraesthesia and pain in
associated with dysfunction of upper thoracic vertebrae known
as t4 syndrome.hypomobile or surronding tissue is casative
factor.central PA over t4 improve mobility and reducing pain.
 Introduction
The term t4 syndrome is clinical pattern that involves upper
extrimity paraesthesia and pain with or with out symptom into
neck or head [Maitland 1986] mobilization of upper thoracic
verttebrae reproduce or eliminate symptoms.

73. mechanism of T4 syndrome?
 certain movements of the spine, stretching or compressive forces are placed on the
facet joints and discs at the T4 level. this results in irritation or damage to the
adjacent nerves at the T4 level and the patient experiences diffuse arm pain, pins
and needles or numbness in the upper arm the condition is known as T4 syndrome.
 T4 syndrome typically occurs due to injury to the facet joints or disc at T4 which
then affects the nerve root at that level.
 The exact mechanism of T4 syndrome is unclear but it is hypothesized
that sustained or extreme postures can lead to relative ischemia within
multiple tissues contributing to symptoms of sympathetic origin.
Symptoms originating from the sympathetic nervous system are
distinctly different from somatic referred symptoms. The sympathetic
nervous system provides pathways for referral of symptoms from the
thoracic spine to the head and upper extremities. Symptoms may not
be derived solely from the fourth thoracic vertebra, but also other
upper thoracic vertebra. Hence “T4 syndrome” may also be referred to
as “upper thoracic syndrome”.

76. Branches from the sympathetic chain pass over the costovertebral
joints to supply the heart, esophagus, and abdominal viscera. It is not
uncommon for these branches to become stretched or affected by
neighboring osteophytes. The sympathetic chain fibers ascend or
descend a variable number of segments, synapse in a ganglion, and
leave the chain to join a peripheral nerve.
Signs and symptoms of T4 syndrome
1.diffuse arm pain and sensory symptoms such as pins and needles or
numbness in the upper arm. Pain may also be felt in the upper back
and occasionally, the neck may be affected.
2.pain and stiffness after the provocative activity, particularly the next
morning.
3.Symptoms are typically felt in one arm or on one side of the upper back
although occasionally both sides may be affected.
4.Muscle spasm, stiffness and restricted spinal movement.
5. Symptoms are generally exacerbated with activities that involve
twisting, lifting, arching backwards, bending forwards or sideways,
sitting for prolonged periods of time, coughing or sneezing, or
performing activities that involve using the hands in front of the body
such as driving or ironing.

77. Diagnosis of T4 syndrome
A thorough subjective and objective examination from a physiotherapist
is usually sufficient to diagnose T4 syndrome. Investigations such as an
MRI or CT scan may be required to confirm diagnosis.
TREATMENT
 soft tissue massage
 mobilization
 manipulation
 electrotherapy (e.g. ultrasound)
 postural taping or bracing
 dry needling
 education
 activity modification advice
 ergonomic advice
 the use of a lumbar support for sitting
 Clinical Pilates
 hydrotherapy
 exercises to improve flexibility, strength, posture and core stability
 a gradual return to activity programy exacerbated with activities

79. What r d different area which should be assessed
for scoliosis?
Observation
 Posture
Examination
 shoulder level
 balance of thorax over pelvis
 Range of motion of spine
 Spinal flexibility
 Inspection of back
 Joint flexibility
 Forward bending test
 Leg length measurement
 child’s maturity
 Neurological evaluation
 Radiological evalution
curve evaluation
curve pattern
curve measurement(cobb-lippman technique)
vertebral rotation


80. Terminology essential to defining various type of
scoliotic curve??
Primary curve/major curve is the most significant abnormal lateral
Curvatue,May be accompanied by compensating secondary
curve,that
develop in opposite directions above and below the primary curve.
Compensating curves may be structural or functional in nature .
Development of secondery curves allow for scoliosis to be
compensated
and refer to the facts that shoulders are at level and position directly
above the pelvis.
Scoliosis is said decompensated when the sum of the compensatory
curves isless than degree of deformity of major curve,resulting in
shoulders that are not level and accompained by a lateral shift or
list of the trunk to one side.
Structural vs functional curve

81. Pathomechanics behind scoliotic deformity?
 The deformity is characterized by a frontal plane curve that is
accompanied by transverse plane rotation of involved thoracic
vertebrae to the side of convexity.
 The deformity in structural scoliosis typically has a fixed contralateral
spinal coupling pattern involving lateral flexion and axial rotation . the
spinous process of the involved vertebrae are typically rotated in
horizontal plane ,toward the side of concavity of fixed thoracic
curvature.this explain why the rib hump is typically on the convex side
of frontal plane curvature.The ribs are forced to follow the rotation of
thoracic vertebrae .the mechanism for fixed coupling pattern is not
completely understood.
 rotation apply posterior directed stresses to the rib on the convex side
and anteriorly directed stresses to the rib on concave side.the angle of
rib on the convex side become more prominent and produces
characteristic rib hump. the rib hump always found on the convex side
of the curve ,is the result of asymmetrical stress on attached ribs,
contributing to asymmetrical growth of the ribs.

83.  What are four distincts idiopathic curve patterns of
adolescent idipathic scolisis?
Right thoracic curve
Thoracolumber curve
Lumber curve
Double primary curve

84. 1.Right thoracic curve
(curvature are associated with rib distortion.)
containment entirely within thoracic spine,(t4 and t12)
 Convexity on right(major curve).
 Right thoracic curve pattern is the most commonly encontered scoliotic
curvature in adolescent girls.
 May or may not be accompained by secondary minor curves above or below
major curve as a compensatory strategy
 Because of significant concurrent vertebral rotation ,the right ribs on
convex side are prominent posteriorly and recessed anteriorly whereas left
ribs decline dorsally and are prominent ventrally.(rotated vertebrae
demonstrate spinous processes and pedicels toward the left concavity..
IDIOPATHIC SCOLIOSIS
 Idiopathic scoliosis is the most common form of scoliotic deformity
,typically arising in adolescent girls with apparently normal
musculoskeletal system.
 Better understanding of etiology is not fully understood.
 This represents between 80-90 % of all scoliosis.

85. 2.Thoracolumber curve
 PRIMARY CURVE OCCURS ACROSS THORACOLUMBAR JUNCTION.
 Extending between T4 and L4.
 Uneven waistline and apparent difference in iliac crest height are most common
prominent findings.
3.LUMBER CURVATURE
Curvature is mostly confined between to lumber spine between T12- L5.
Characteristics features include waisteline asymmetry ,apperenth leg length
discrepancy,and spinal decompensation.
4.Double primary curve
Two structural curves of almost equal prominence that occur as a number of
thoracolumbar combinations .
Double major curve balance each other so that the shoulders are level over pelvis while rib
and lumber prominence s are not too severe.
Trunk shortening.

86. What pathological structural changes typically occur in
idiopathic scoliosis?
 Fundamental aspect of pathogenesis of scoliotic deformity is it’s
progression with skeletal growth so that as lateral curvature and
vertebral rotation occur secondary changes develop in vertebrae and
ribs.
 Progression of lateral curvature causes rotation of the vertebrae
,pedicles and spinous processes in the area of major curve toward the
concavity of curve.
 The disk space on concave side of the curve becomes narrower , the
pedicles and lamina are shorter and thinner ,while vertebral canal is
narrower .lateral displacement of nucleus pulposus may occur in
concave side.
 Claw type osteophytes develop in concave side .
 Superior and inferior articular surfaces of the facet
joints on concave side undergo osteoarthritic changes as the
They become overloaded. .

87. Other forms of scoliosis
 sciatic scoliosis
 Postural scoliosis
 osteopathic scoliosis
 congenital scoliosis
 neuromuscular scoliosis

88. Many elderly patients frequently present in the fifth or sixth decade with
complain of back pain and radicular symptoms.the majority of these patients
have left lumber curvature.

89. Spinal rotation- (forward bending test)
 Deviation of spine and rib distortion more evident in forward bend.
 Notice assymmetry of ribs.
 check truncal and spinal asymmetry.
(Whether the trunk straightens out as the child bend forward while keeping
both palms together ?

90. Spinal curve flexibility
 Spinal curve flexibility refers to the ability of spinal curvature to be
straighten.
 Curve flexibility is an important determinant of curve prognosis and
response to treatment.
 Lateral bending test/traction
 Assessed by side bending towards convex side while in forward flexed
posture,the flexible curve unwind whereas structural curve will not.

91. Curve in Degrees Treatment
 0-20 Observe for progression
 20-25 Brace if progression documented,
and substantial growth remaining
 25-30 Brace if progressiveand growth
remains
 30-40 Brace if growth
 remains
 40-45 Brace if growth remains vs. surgery

92. MOVEMENT IMPAIRMENT SYNDROMES

93. Pathomechanics of movement impairment syndrome of
thoracic spine?
 Sharman and associates have proposed that the primary cause of
mechanical pain syndromes is movement patterns that deviates
from normal kinesiological standard.
 The primary changes in muscle induced by repetitive movements
and sustained postures are alteration in tissue length, strength
and stiffness that affects movement pattern of specific joints and
the interactions of multiple joints.
 The key factor is that the joint develops a high degree of
susceptibility to movement in specific directions. a vicious cycle
develop because once a joint motion develop direction
susceptibility to movement ,the more the joint moves the more is
flexibility increases and the more it’s kinesiological behaviour
deviates from ideal standard.

94.  Repeated movements and slight deviations in movement
characteristics lead to microtrauma and eventually to
macrotrauma. the result is that the joint movement in
affected directions.
 Changes in discs and ligament restrains can contribute to
subtle alteration is degree of rotation and lateral glide as
well as anterior and posterior glide of vertebrae.
 The movement impairment syndrome is categorized and
named according to movement direction that most
consistently produce pain and that is most consistently
produce pain and that is most susceptible to motion.

95. ROTATION-FLEXION SYNDROME
Contributing activity
Throwing, playing tennis, volleyball ,always working in a position that
require rotation to one side
Symptoms and associated diagnosis
1.pain in thoracic spine that may increase when lying down or during
activity such as reaching.
2.sign of rotation is positive
3.during night pain due to rotation which exert pressure on spine.
Associated diagnoses
1] Scapular muscle strain
2] rib pain
3] intercostals nerve radiculopathy and costochondritis.
Movement impairment
1.rotation range of motion is greater than one side in standing or sitting.
2.quadreped position rotation, will occur in thoracic spine when patient
flex the arm.

96.  ACQUIRED IMPAIRMENT
most often pt have thoracic kyphosis and bz of rotation
the ribs are more prominent on one side leads to rib
hump.
MUSCLE IMPAIRMENT
1.abdominal muscle length is asymmetrical.
2.external obliqe muscle is usually longer or less stiff
on the side of rotation than on contra lateral side.
3.latissimus dorsi is short or stiff
Relative flexibility
one side rotation is more than other side

97. ROTATION SYNDROME
 patient has pinching or sharp pain in thoracic spine pain that
run around rib cage from irritation of intercostals nerve.
CONTRIBUTING ACTIVITIS
 It include throwing ,playing tennis ,required rotation to one side.
MOVEMENT IMPAIRMENT
 There is usually asymmetry in the degree of rotation to one side
verses to other side.
Relative flexibility-
 there is rotation of segement of thoracic spine that has most
flexible site for motion.
MUSCLE IMPAIRMENT
1]Hypertrophy or stiffness of lower thoracic and lumber paraspinal
muscle muscle
2]stiffness of LD, trapezius ,rhomboids and abdominal muscle is
asymmetrical

99.  Extension rotation syndrome
Symptoms
Pain in posterior aspect of midthoracic area which occur with
movement of thorax or some time with unilateral arm movement
Pain along the rib cage radiates in lateral aspect of thorax
Contributing activity
Work or recreation activity of rotation
MOVEMENT IMPAIRMENT
The rotation is greater in one side than other
ALIGNMENT
Thoracic spine is flat ,but there is possible slight malalignment of
thoracic vertebrae in the area of pain.
Rotation is most flexible motion
Muscle impairment-Stiff back extension
Treatment
Rotation of spine is avoided

100. FLEXION SYNDROME
SYMPTOMS
It is primary postural problem, few patients have symptoms just
from being in flexed posture .if symptoms r present in individual
with a marked kyphosis ,it is primarily from an attempt to
correct the alignment too rapidly ,which may cause muscles to
cramp or cause symptoms associated with vertebral compression
.the symptoms may also be from strain of thoracoscapular
muscles that are often abducted because of kyposis.
Contributing activity
Poor sitting postures ,trunk curl exercises, swimming(butterfly and
breaststrokes), cycling on a racing bikes,older individual who have
osteoporosis.

101. Movement impairment
Limited ability to correct flexion alignment of thoracic
spine.
Acquired impairments
Increase thoracic curve
Muscle impairment
In younger adults shortness of rectus abdominis ,in
young man who have done great deal of weight
training the shortness of back extensors combined
shortness of RA is another contributing factor and
back extensor treatment,excessive length of paraspinal
muscle is yet another factor.
Treatment
Decrease thoracic kyphosis