This document lists potential serious medical conditions that can present with thoracic spine or rib problems, along with associated red flags from patient history and physical exam. It identifies red flags for conditions like myocardial infarction, angina, pericarditis, spinal fracture, pneumothorax, pneumonia, pleurisy, pulmonary embolism, and chest pain without cardiac causes. Red flags include things like certain types of chest pain, dyspnea, risk factors, fever, cough, and physical exam findings related to each condition. Differentiating these conditions is important for guiding appropriate medical management.

1. Red Flags for Potential Serious Conditions in Patients with Thoracic Spine/Rib Problems
Red Flags for the Thoracic Spine and Ribcage Region
Red Flag Red Flag
Condition Data obtained during Data obtained during
Interview/History Physical Exam
Myocardial Chest Pain Pallor, sweating, dyspnea, nausea, palpitations
Infarction1-3 Presence of risk factors: Previous history of: Symptoms lasting greater than 30 minutes and not
coronary artery disease, hypertension, relieved with sublingual nitroglycerin
smoking, diabetes, elevated blood serum
cholesterol (>240 mg/dl)
Men over age 40, women over age 50
Stable Angina Chest pain/pressure that occurs with predictable
Pectoris4 levels of exertion
Symptoms are also predictably alleviated with rest
or sublingual nitroglycerine
Unstable Angina Chest pain that occurs outside of a predictable Not responsive to nitroglycerine
Pectoris4 pattern
Pericarditis5 Sharp/stabbing chest pain that may be referred to Increased pain with left side lying
the lateral neck or either shoulder Relieved with forward lean while sitting (supporting
arms on knees or a table)
Spinal Fracture6 History of fall or motor vehicle crashHistory of Midline tenderness at level of fracture
osteoporosisProlonged steroid useAge over Brusing
70Loss of function or mobility Lower extremity neurological deficitsEvidence of
increased thoracic kyphosis
Pneumothorax7 Recent bout of coughing or strenuous exercise or Chest pain - intensified with inspiration
trauma Difficult to ventilate/expand ribcage
Hyperresonance upon percussion
Decreased breath sounds
Pneumonia5 Pleuritic pain - may be referred to shoulder Fever, chills, headaches, malaise, nausea
Productive cough
Pleurisy5 Severe, sharp “knife-like” pain with inspiration Dyspnea - deceased chest wall excursion
History of a recent/co-existing respiratory
disorder (e.g., infection, pneumonia, tumor,
tuberculosis)
Pulmonary Embolus5 Chest, shoulder, or upper abdominal pain Dyspnea
Dyspnea Tachynea
History of, or risk factors for developing a deep Tachycardia
vein thrombosis
Chest Pain without Age under 40
cardiac disease8 Type “A” male or “neurotic” female
High perceived level of vital exhaustion
Recent uncontrollable and undesirable life events
References:
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with myocardial infarction presenting without chest pain. JAMA. 2000;283:3223-3229.
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factors. Am Heart J. 2002;144:1012-7.
4. Henderson JM. Ruling out danger: differential diagnosis of thoracic spine. Physician and Sportsmedicine. 1992;20:124-31.
5. Wiener SL. Differential Diagnosis of Acute Pain by Body Region. New York, McGraw-Hill, 1993
6. Hsu JM, Joseph T, Ellis AM. Thoracolumbar fracture in blunt trauma patients: guidelines for diagnosis and imaging. Injury.
2003;34:426-33.
7. Misthos P, Kakaris S, Sepsas E, et al.A prospective analysis of occult pneumothorax, delayed pneumothorax and delayed
hemothorax after minor blunt thoracic trauma. Eur J of Cardio-thoracic Surg. 2004;25:859-864.
8. Roll M, Theorell T. Acute chest pain without obvious organic cause before age 40: personality and recent life events.
Journal of Psychosomatic Research. 1987;31:215-221.
Joe Godges DPT, MA, OCS KP So Cal Ortho PT Residency