Thoracic spine

The unique feature of the vertebrae in the thoracic region is the presence of facets, both on the sides of the vertebral bodies and the transverse processes. These are for articulation with the ribs, forming the costovertebral and costotransverse joints (Fig. 14.1). Most of the ribs articulate with two adjacent vertebral bodies and one transverse process. The facets on the head of the ribs articulate in turn with demi-facets on the upper and lower borders of the vertebrae, and the crest on the rib head butts onto the intervertebral disc. The joint capsule is loose and strengthened anteriorly to form the three portions of the radiate ligament. The costovertebral joint cavity is divided into two by the intra-articular ligament, except for ribs one, ten, eleven and twelve which articulate with a single vertebra and have a single joint cavity.

Figure 14.1 Joints between the ribs and thoracic spine.

The costotransverse joints are formed only with the upper ten ribs. The joint is made between the articular facet of the transverse process and the oval facet on the rib tubercle. The thin joint capsule is strengthened by the costotransverse ligaments.

Sternal articulations

The sternocostal joints are formed between the medial end of the costal cartilages of ribs one to seven. The joint between the first rib and the sternum is cartilaginous, but all the others are synovial. Each is surrounded by a capsule and supported by radiate ligaments. The fibres of these ligaments fan out and intertwine with those of the ligaments above and below, and also with those of the opposite sternocostal joints. In addition, the radiate ligament fibres fuse with the tendinous fibres of the pectoralis major. The eighth, ninth, and tenth ribs form interchondral joints between their costal cartilages.

The costochondral joints are formed between the end of the rib and the lateral edge of the costal cartilage. The joint formed is cartilaginous, its perichondrium being continuous with the periosteum of the rib itself. Only slight bending and twisting actions are possible at this joint. The manubriosternal articulation is that between the upper part of the sternum and the manubrium. The joint is cartilaginous, with a hollow disc in its centre, and is strengthened by the sternocostal ligaments and longitudinal fibrous bands. About 7° of movement occurs at the joint in association with breathing.

Rib movements

Movement of the diaphragm, ribs and sternum increases the volume within the thorax with inspiration. Each rib acts as a lever, with one axis travelling through the costovertebral and sternocostal joints, and another through the costovertebral and costotransverse joints. The two axes permit two types of motion, known as ‘pump handle’ and ‘bucket handle’. In the pump handle action the upper ribs and sternum are raised, increasing the anteroposterior diameter of the thorax. With bucket handle motion the lower ribs move both up and out, widening the infrasternal angle and increasing the transverse diameter of the thorax. In the lower ribs (8−12) a third motion called ‘caliper action’ may also occur where the lateral diameter of the chest is increased, without significant joint motion.

The variation in movement between the upper and lower ribs is due, in part, to the differing structure of their respective costotransverse joints. The upper joints are cup-shaped permitting mainly rotation (pump handle), while those lower down are flat permitting both rotation and gliding movements (bucket handle).

In addition to respiratory motion, the ribs also move in association with the thoracic spine. With flexion of the spine the ribs move closer together and with extension they are pulled further apart, flattening the ribcage. This latter action in the upper ribs is important for the correct movement of the scapulothoracic joint. Lateral flexion causes the ribs on the concave side to move together and those on the convex side to move apart. Rotation gives horizontal gliding of one rib relative to another.

Ribcage shape at rest

The general shape of the ribcage will change as a result of thoracic mobility, with an increased thoracic kyphosis causing a general flattening of the ribcage. In addition, congenital abnormalities occur, including pigeon chest, funnel chest and barrel chest.

• Pigeon chest is seen when the sternum is orientated downwards and the ribcage becomes pointed because the anteroposterior (AP) diameter is increased.

• Funnel chest occurs when the sternum is pushed backwards in relation to the ribcage, often due to an overgrowth of the ribs (Magee, 2002). On inspiration the depression of the sternum may become more noticeable.

• Barrel chest deformity occurs when the sternum is orientated forwards and upwards, increasing the AP diameter. This deformity is seen in some pathological lung conditions.

The ribcage will also alter shape in cases of scoliosis. The vertebral bodies rotate towards the convexity of the curve, dragging the ribs with them. The ribs on the convex side of the curve are pushed backwards creating a ‘hump’ and those on the concave side of the curve move anteriorly causing a ‘hollow’ (Fig. 14.2). Rotation of the vertebral body causes the spinous processes to move away from the mid-line, in the opposite direction to the scoliosis. Right rotation of the vertebra therefore sees the spinous process deviating to the left.

Figure 14.2 Ribcage shape in scoliosis.

Definition

Scoliosis is a deformity of the spine where a single or multiple lateral curvature is seen. The scoliosis is named according to the convexity (sharp point) of the curve.

Movement of the thoracic spine

The relative thinness of the discs in the thoracic region, coupled with the presence of the ribs, makes movement here more limited than in other spinal areas. Extension is limited to about 30° with slightly more flexion being possible – roughly 40°. Flexion is freer in the lower thoracic region but still restricted by the ribs. Extension is limited by approximation of the facets and spinous processes as well as tissue tension, and causes the thoracic cage to become flatter. Lateral flexion is limited to roughly 25° to each side, a greater range being available in the lower region. Lateral flexion is accompanied by the same amount of rotation, which occurs contralaterally. For example, right lateral flexion is accompanied by right axial rotation, causing the tip of the spinous process to rest to the left of the mid-line. Rib movements accompany lateral flexion, with the ribs on the concave side compressing and those on the side of the convexity being pulled apart.

The range of rotation is larger than other movements, with 35° being possible to either side. However, when the spine is extended, both lateral flexion and rotation are dramatically reduced. As rotation occurs, the inferior facets of the upper vertebra slide laterally with respect to the lower vertebra, towards the direction of the rotation. Movement of the vertebra is accompanied by distortion of the ribs. The ribcage becomes more rounded on the side to which the rotation is occurring, and flattens on the opposite side.

Rotation of the thoracic spine is an important constituent of locomotion. In walking, when the right leg swings forward, the lower trunk and the pelvis rotate to the left about the fixed left leg. To keep the head facing forwards the upper spine must rotate to the right, pulling the shoulders back into a forward facing direction. As the upper and lower parts of the spine are rotating in opposite directions, there is a point at which the two movements cancel each other out. This point is the intervertebral disc between T7 and T8 which is not subjected to any rotation, while those vertebra immediately above and below rotate maximally, but in opposite directions.

Examination

The screening examination is essentially similar to that of the lumbar spine, except that rotation is the movement most likely to be revealing as this normally has the greatest range. Rotation is performed in a sitting position, with overpressure being given through the shoulders. Resisted flexion and extension may be performed in a lying or a sitting position. Resisted lateral flexion is tested in a standing position with the therapist initially at the patient’s side. The patient’s near wrist of the straight arm is gripped, as is the far shoulder. Stability is improved if the therapist widens his or her base of support by placing the near foot between those of the patient.

As rotation and lateral flexion accompany each other in the thoracic spine, it is often revealing to combine these movements at examination. Thoracic rotation is performed, and is followed by lateral flexion, first in one direction and then the other.

Palpation takes in the vertebrae, rib joints and ribs themselves, and is carried out with the patient in a prone position with the arms over the couch side to move the scapulae apart. Alternatively, posteroanterior (PA) pressures may be used with the thoracic spine extended using the elbow support prone-lying starting position. In a prone-lying position the spinous processes of the thoracic vertebrae are angled downwards like the scales of a fish. The thoracic vertebrae may be considered in threes, with the transverse processes being found relative to the spinous processes as shown in Table 14.1.

Table 14.1 Palpation of the thoracic vertebrae

As an approximate guide to levels, the AC joint is normally aligned with the C7–T1 interspace, the spine of the scapula at T3 and the inferior scapular angle at T7.

The rib angles gradually spread out from the spine with the eighth rib being furthest (about 6 cm) from the mid-line. The rib angles can be palpated at the same levels as the transverse processes down to the T8/T9, by pushing the soft tissue to one side. The facet joints lie in the paravertebral sulci, and the transverse processes, which overlie the costotransverse joints, are found 3–4 cm from the mid-line. Guidelines for rib palpation are shown in Table 14.2.

Table 14.2 Rib palpation

Modifications to the slump test for the thoracic spine

A variation of this test for the cervical and thoracic spine is to perform it in the long sitting position (Fig. 14.3A). From this position thoracic and lumbar flexion are added followed by cervical flexion (Fig. 14.3B). Altering the order of movement will change the neurodynamic demands (Butler and Slater, 1994), enabling the practitioner to refine the test. For example, performing cervical flexion before lumbar and thoracic flexion will challenge the cervical neural tissues more. The test can be further refined to place emphasis on the sympathetic trunk (Slater, Butler and Shacklock, 1994). This is especially relevant in the presence of sympathetic signs in conditions such as T4 syndrome, thoracic outlet syndrome and Raynaud’s syndrome, and in cases where cervicothoracic conditions mimic cardiac disease. Sympathetic testing is achieved by adding components of lateral flexion and rotation of the thoracic spine and lateral flexion of the cervical spine. Additional stress may be imposed by adding a minimal straight leg raise (SLR).

Figure 14.3 The slump test (long sitting). (A) Start. (B) Finish.

From Butler (1991) with permission.

Keypoint

Where sympathetic signs (skin changes, sweating, swelling) are present in conditions such as thoracic outlet syndrome (TOS) and Raynaud’s syndrome, modify the slump test to emphasize the sympathetic trunk. Add thoracic lateral flexion and rotation, and cervical lateral flexion to the standard slump test.

Injury to the ribcage

Direct trauma to the ribcage can result in damage to the ribs, intercostal muscles or, indirectly, to the rib joints. Deep breathing will usually reproduce the pain of rib or intercostal injury, and palpation can be used to reveal the exact site of injury as these structures are superficial. Trunk extension will open the ribcage and cause pain, and intercostal muscle tearing will generally give pain to resisted trunk flexion. Rib springing at a distance from the point of injury usually produces pain from a rib fracture.

Rib displacement

Respiratory movements of the ribs may be used to assess anteroposterior position, by comparing one side of the body to the other. If a rib on one side stops moving before the rib on the other side during inhalation, the rib is said to be depressed. Inhalation involves an upward movement of the rib, so if the rib stops moving, it has been held down. Similarly, if the rib stops moving during exhalation (downward movement) it is said to be elevated, because it is being held in an upward position.

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Movement may also be forward or backward. An anterior displacement may occur with a subluxation of the costovertebral joint, and the rib is sheared forwards. The rib will appear more prominent than its neighbour. This can occur in sport due to a blow to the back, typically when a knee hits the player on the back of the chest in rugby. A posterior displacement is more common and presents as a prominence of the rib angle. This is normally due to a blow to the chest, again from a tackle or through seatbelt or steering-wheel trauma in a road traffic accident (RTA). Management of rib displacement is by the use of muscle energy techniques (MET) and rib joint mobilization (see Treatment note 14.1).

Treatment note 14.1 Manual therapy techniques for rib displacement

Manual therapy techniques encourage correct rib movement during respiration. Essentially they force the rib into the opposite direction to the one in which they are being held. The rib may be bound down by scar tissue, requiring continuous stretching, or through muscle tightness/shortness, requiring PNF stretching. The intercostal muscles (forced expiration), oblique abdominals (trunk rotation), serratus anterior (scapular protraction), latissimus dorsi (arm adduction), scalenes (1st rib, neck side flexion) and quadratus lumborum (12th rib, trunk side flexion) should all be considered.

Elevation

An elevated rib does not move down far enough during expiration. The aim is to encourage this movement and draw the rib down as the patient breathes out. For the 1st rib pressure is placed over the rib with the knuckle (key grip) (Fig. 14.4). The head is side flexed to relax the anterior scalene and the rib is pressed downwards with expiration. The 2nd rib is gripped within the axilla and pulled downwards as the patient exhales powerfully (Fig. 14.5). The remaining ribs may be gripped with the fingertips or pushed downwards using the knife edge of the hand (Fig. 14.6).

Figure 14.4 Mobilization of an elevated first rib.

Figure 14.5 Mobilization of an elevated second rib.

Figure 14.6 General rib mobilization for elevation.

Depresssion

The depressed rib is bound down and stops moving upwards during inspiration. The aim is therefore to encourage further upward movement as the patient breathes in. For the 1st rib, stretch of the anterior scalenes is used (side flex the neck to the opposite side) to pull the rib upwards (Fig. 14.7). For the 2nd rib the finger or thumb pads press on the rib within the axilla (Fig. 14.8), and for the remaining ribs the thumb pad or pisiform presses on the rib undersurface within the intercostal space (Fig. 14.9).

Figure 14.7 Treatment for a depressed first rib using anterior scalene stretch.

Figure 14.8 Treatment of a depressed second rib using thumb pressure.

Figure 14.9 Treatment for general rib depression using pisiform grip.

Anterior displacement

Where the rib lies further forward than the rib on the other side of the body, the aim is to open the ribcage and pull the rib backwards. For an anterior rib on the right, the patient sits at the end of the couch with the therapist to the left. The patient folds the arms across the chest. The therapist hooks his or her fingers over the anterior rib and sidebends the patient to the left to open the ribcage, and rotates to the right to encourage the rib to move back (Fig. 14.10).

Figure 14.10 Treatment of anterior rib displacement using sidebending.

Posterior displacement

For a posterior rib, the contact area is with the heel of the hand over the rib angle. For a right posterior displacement the action is to sidebend to the left to open the ribcage and rotate to the left to draw the rib forwards (Fig. 14.11). An alternative approach is to perform a posteroanterior mobilization on the rib angle while the patient is prone. The pisiform of one hand performs the action while the pisiform of the other presses over the transverse process of the vertebra on the opposite side to prevent the vertebra from rotating as the rib is mobilized (Fig. 14.12).

Figure 14.11 Treatment of posterior rib displacement using side flexion.

Figure 14.12 Treatment of a posterior rib in prone lying.

Manual therapy

Joint mobilization

A variety of procedures may be used for the thoracic spine (Fig. 14.13).

• Posteroanterior central vertebral pressure (PAVP) is the technique normally used first, in the presence of both unilateral and bilateral symptoms (Maitland, 1986). In the thoracic spine the spinous processes are larger than those of the cervical spine, and so the therapist may use the thumbs either side by side or one in front of the other. For the upper thoracic spine the therapist stands at the patient’s head, and for the lower regions at the patient’s side. An oscillatory motion is given with the range of movement being particularly great in the middle and lower thoracic areas, but somewhat limited between T1 and T2.

• The costovertebral and costotransverse joints are mobilized by springing the rib. The therapist places his or her thumbs, or the ulnar border of the hand and little finger, along the line of the rib to be mobilized to give a broad (and more comfortable) area of contact. The mobilization must take the patient’s respiratory movements into account, pressure for higher grade movements coinciding with expiration.

• Anteroposterior movements (AP) may be performed on any of the costal joints (costochondral, interchondral, sternocostal). The therapist’s thumbs are placed over the joint to be mobilized with the fingers fanning out over the patient’s chest. The movement may be directed towards the patient’s head or feet to reproduce the symptoms, and then continued in this direction at a lesser grade.

• Intervertebral rotations may be applied both locally and generally. Local rotation may be carried out using pressure over the transverse processes. The thenar eminence of one hand is placed on the transverse process of one vertebra with the fingers pointing towards the patient’s head. The hypothenar eminence of the other hand is placed on the transverse process on the opposing side of the spine either of the same vertebra or that of the vertebra below, with the fingers towards the patient’s feet. A number of techniques are used. Rotation may be applied by using alternating pressure from one hand and then the other with the hands over the same spinal level (McKenzie, 1990), or a high velocity low amplitude thrust may be applied as the patient breathes out, with the hands over the transverse processes of two levels (Bourdillon, 1982).

• General rotation may be performed with the patient seated over the couch end, with the arms folded and the hands gripping the shoulders. The therapist stands to the side of the patient. The patient rotates as far as is possible away from the therapist, who reaches across the patient’s chest and grasps the patient’s far shoulder. Overpressure is applied as the therapist pulls the far shoulder towards him- or herself and presses the far scapula away with the flat of the hand. Slight traction may be applied by gripping the far elbow rather than the shoulder. The therapist bends his or her knees before applying the grip and then straightens them as he or she pulls up and round. This technique may be used for mobilization or contract-relax stretching.

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• Longitudinal mobilization or traction may be applied to the thoracic spine with the patient sitting and the therapist standing behind them. The patient interlocks their fingers and places their hands behind their neck, elbows pointing forwards rather than outwards. The patient’s neck should be comfortably flexed with the ligamentum nuchae not fully stretched. The therapist winds their arms through the triangular space created by the patient’s arms and draws the patient against their chest, adducting their arms to grip the patient’s chest slightly. The therapist flexes their knees and rocks the patient forwards and backwards gently. As the patient is drawn backwards, they contact the therapist’s chest and are pressed into thoracic extension. The traction force is generated by the therapist straightening their legs. No distraction force should be created by the therapist’s arms—an attempt should not be made to lift the patient.

Figure 14.13 Thoracic mobilisation (A) Using thumbs, (B) Using pisiform pressure, (C) rotatory mobilisaiton using heel of hand, (D) extension using leverage.

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As a general note, the close proximity of structures in the thoracic region makes it difficult to assess precisely whether a patient’s symptoms are coming from the intervertebral joint, the costotransverse joint, the costovertebral joints or a combination of all three. For this reason many of the mobilizations affect all of these joints.

Keypoint

Mobilization techniques for the thoracic spine affect several joints simultaneously.

Trunk muscles

The trunk muscles are open to injury in the same way as any other muscle in the body, but muscle conditions are often overlooked in the search for signs of more complex injuries involving the intervertebral joints. Injury to the intercostal muscles has already been mentioned, but the abdominal muscles and erector spinae may also give pain from injury or muscle soreness.

Injury to the rectus abdominis has been described in tennis players especially. During the cocking phase of serving the arm is reached overhead and the spine hyperextended stretching the rectus and imposing high leverage forces upon the muscle (Maquirriain et al., 2002). This action requires highly coordinated sequential muscle activity which may break down in the presence of fatigue. Injury to the internal oblique can occur as part of a side strain syndrome during activities such as cricket, hurdling and javelin throwing, for example. Injury to the lateral abdominals is shown as a positive resisted side flexion test. MRI scan has shown separate involvement of the internal oblique, external oblique and transversus abdominis (Humphries and Jamison, 2004), and in each case the non-dominant side was affected. Isolated injury to the internal oblique has also been described in tennis (Maquirriain and Ghisi, 2006) although it is less common. Differential diagnosis must be made from rib fracture and iliac crest avulsion injury, both of which are revealed radiographically.

The abdominal muscles are tested isometrically to eliminate involvement of the spine. A crook-lying position is preferred, as this partially relaxes the iliopsoas. Straight flexion taxes the rectus abdominis while flexion–rotation works the oblique abdominals. Pure rotation is tested in a sitting position, while lateral flexion is tested either in a sitting or standing position.

The upper (supra-umbilical) portion of the rectus abdominis is assessed from a sit-up position, while the lower (infra-umbilical) portion is assessed by lowering the straight legs from 90° hip flexion to work the muscle in a reverse origin to insertion fashion. Comparison is made between the right and left sides of the rectus by palpation, and watching the displacement of the umbilicus which will be pulled to the side of the stronger muscle (Lacote et al., 1987).

The oblique abdominals are worked by performing rotation and lateral flexion, Rotation may be gauged using a twisting trunk curl action, for example reaching the right arm towards the left knee or isometric trunk rotation in sitting. Rotation to the left works the right external oblique and left internal oblique and vice versa. Resisted side flexion is performed grasping the patient’s hand and asking them to reach the other hand down to the side of their knee. The transversus abdominis acts to support the viscera and is active in forced expiration. It may be tested with the patient in a prone-kneeling position. From this position the subject breathes out against a resistance (balloon or spirometer) and pulls the abdominal wall in.

The erector spinae are tested in a prone-lying position, the subject being asked to extend the trunk and lift the chest from the couch. Isometric contraction is assessed by having the patient (in a prone-lying position) maintain a horizontal position of the trunk with only the legs supported. Alternatively, the patient should rest the chest over the couch end and attempt to straighten the legs to a horizontal position. The quadratus lumborum is tested with the subject prone, leg extended and slightly abducted, to elevate the pelvis laterally. Traction is placed through the elevated leg to oppose the pull of the quadratus lumborum (Kendall and McCreary, 1983).

Hernia

A hernia is a protrusion of the contents of a cavity through the cavity wall. Most usually an organ or peritoneum is forced through the muscular layer of the abdominal wall at sites of natural weakness where nerves and blood vessels leave the abdomen. The most common types are femoral, inguinal and incisional. Less common types include umbilical, epigastric and hiatus herniae.

Initial management of hernias is conservative, and involves instruction on actions to avoid increasing intra-abdominal pressure. When symptoms persist, surgery is required.

Sportsman’s hernia

Sportsman’s hernia or groin disruption is a condition which may mimic inguinal hernia in many ways (Gilmore, 1995). To understand the condition we need to look at the structure of the region.

The inguinal canal (Fig. 14.14) is approximately 4 cm long, and transports the spermatic cord in the male, the round ligament in the female, and in both sexes the ilioinguinal nerve. Its anterior wall is formed from the aponeurosis (tendon sheet) of the external oblique supported by the internal oblique muscle at its lateral third. The posterior wall is from the transversalis fascia reinforced by the conjoint tendon at its medial third. The roof of the canal is formed by the internal oblique and transversus abdominis as they merge to form the conjoint tendon running from the pubic crest to the pectineal line of the pelvis. The deep inguinal ring is about 1.5 cm above the mid-point of the inguinal ligament and is an opening in the transversalis fascia. The superficial inguinal ring is a hole in the external oblique aponeurosis and lies at the medial end of the tendon above the pubic tubercle.

Figure 14.14 Formation of the inguinal canal.

From Palastanga, Field and Soames (1994), with permission.

Definition

The transversalis fascia is part of a membranous bag lining the abdomen; (i) it lies on the deep surface of the transversus abdominis muscle, (ii) its thick lower portion is attached to the inguinal ligament, (iii) the femoral vessels drag the fascia with them as they travel into the leg forming the femoral sheath.

Sportsman’s hernia (athletic pubalgia) is an injury of the muscular and fascial attachments to the anterior pubis (Kachingwe and Grech, 2008). Several structures may be involved (Table 14.3). The condition can include a tearing of the external oblique aponeurosis and the conjoint tendon, causing the superficial inguinal ring to dilate (Fig. 14.15). There may be a dehiscence (separation) between the conjoint tendon and the inguinal ligament but no hernial sac (Gilmore, 1995). The transversalis fascia may weaken and separate from the conjoint tendon (Hackney, 1993) and the external oblique has been said to tear at the site of emergence of the anterior ramus of the iliohypogastric nerve (Williams and Foster, 1995).

Table 14.3 Sportsman’s hernia: tissue pathology and history

Tissues affected	Typical signs and symptoms	Differential diagnosis
Transversalis fascia Posterior inguinal wall Insertion of distal rectus abdominis Conjoined tendon at its attachment to the anterosuperior pubis External oblique aponeurosis	Deep pain to groin/lower abdomen Pain exacerbated by sport-specific activities Palpable tenderness over rectus insertion Pain with resisted hip abduction Pain with resisted trunk curl	Hip structures Bone injury Neurological involvement Inguinal hernia Osteitis pubis Adductor strain Iliopsoas teninosis Rectus abdominis strain

Unverzagt, Schuemann and Mathisen (2008); Kachingwe and Grech (2008).

Figure 14.15 Hernia repair incisions within the inguinal region.

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The condition was originally described in soccer players but may occur in other sports. As many as 28% of soccer players may experience the condition (Kemp and Batt, 1998), and 50% of male athletes presenting with groin pain lasting longer than 8 weeks have been found during surgery to have sports herniae (Lovell, 1995).

There is a gradual onset of pain with one-third of the patients reporting a specific injury which may have resulted in tearing. Pain (in the inguinal, adductor or perineal region) is exacerbated by sports specific kicking actions and sudden changes in movement direction. The superficial inguinal ring is often dilated to palpation. Tenderness to palpation over the conjoint tendon and inguinal canal is increased by a resisted sit-up action. It is usual for several pathologies to coexist, with sportsman’s hernia occurring alongside adductor tendinitis. In a study of athletes with groin pain for more than 3 months, 19 out of 21 were found to have two or more separate pathologies (Ekberg, Persson and Abrahamson, 1988), and in general 25–30% of athletes with this condition can be expected to have a secondary diagnosis (Lovell, 1995).

Keypoint

A sportsman’s hernia is a separation of the external oblique aponeurosis from the inguinal ligament. It is a muscle attachment injury rather than a true hernia and no protrusion (hernial sac) is present.

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Imaging may not identify the tissue affected, but is important to rule out alternative diagnoses (Kachingwe and Grech, 2008). Endoscopic examination may be used and followed by immediate repair where a defect is found. Ultrasonography may be used to identify the tissue changes at the exact point of tenderness. Coupled with a Valsalva manoeuvre ultrasound can differentiate true herniation from simple tissue overstretch. The use of colour Doppler permits the visualization of the epigastric vessels, and can assist in the differentiation of sports hernia from inguinal hernia. Direct inguinal hernia is said to lie medial to the inferior epigastric vessels, while the indirect hernia lies laterally to this vessel (Hagan et al., 2007).

Treatment is surgical (open or laparoscopic) where conservative management has failed. Repair of the torn conjoint tendon may be performed using polypropylene mesh and the tendon is approximated to the inguinal ligament. The external oblique is repaired and the inguinal ring reconstituted. Surgical success rates have been reported between 63 and 93% (Kemp and Batt, 1998), possibly reflecting the presence of additional pathologies.

Both prevention (Gilmore, 1995; Norris, 1995) and successful rehabilitation of this condition rely heavily on correct abdominal training. One of the factors in the development of this condition may be a muscle imbalance which is created in the athlete by sit-up exercises. Tightness in the hip flexors, combined with preferential recruitment of the rectus abdominis and poor recruitment of the deep abdominals, leaves the lower abdominal area open to injury. Increasing the training emphasis on abdominal hollowing actions and reducing the emphasis on lumbar flexion actions is a key factor which should be combined with stretching of the tight hip flexors.

In addition, dominance of the adductor muscles in certain sports such as soccer should be considered. Stretching the tight adductors and working the abductors proportionally should be considered. It has been suggested that repeated adductor actions create a shearing force across the pubic symphysis that places stress on the posterior inguinal wall (Simonet, Saylor and Sim, 1995). In support of this hypothesis, it is common clinically to find athletes who have coexisting osteitis pubis and/or adductor tendinitis. Muscle balance exercises relevant to the prevention and rehabilitation of this condition are shown in Table 14.4.

Table 14.4 Muscle balance exercises for sports hernia

Keypoint

Muscle balance assessment is essential in the management of sports hernia. Tight hip flexors and hip adductors, together with dominance of the superficial abdominals over the core stabilizers, is often found.

Thoracic outlet syndrome

Thoracic outlet syndrome (TOS) affects the superior thoracic aperture, a region bordered by the T1 vertebra posteriorly, the medial edge of the 1st rib and the manubrium of the sternum. TOS is a compression of the neurovascular structures travelling to the axilla from the cervical region and typically involves the brachial plexus rather than the nerve roots (Fig. 14.16). Symptoms appear in the arm rather than the neck, with the lower cervical and upper thoracic area (C8/T1) most commonly affected. Bilateral tingling appears over the median or ulnar nerve distributions into the forearm and hand. The anatomy of the region favours compression. The nervous structures travel through the costoclavicular space, formed by the inner clavicle, first rib and insertions of the scalene muscles. The lower trunk of the brachial plexus and the subclavian artery travel through the outlet formed between the scalenus anterior and scalenus medius to rest on the first rib. Symptoms from vascular compression are less common than those from neurological involvement, but alteration in blood flow may be used as a test for the condition (see below).

Figure 14.16 Thoracic outlet syndrome.

Provocative tests for TOS

Various provocative tests are available which aim to reproduce the patient’s symptoms. Sustained scapular elevation, or simply holding the arms overhead may increase the signs. The Adson test examines the radial pulse while the patient breathes in deeply and holds the breath, at the same time extending the neck and rotating it either towards or away from the affected side. Abduction of the shoulder to 90° with full external rotation, combined with vigorous hand movements, may give rise to symptoms if compression is significant. This is sometimes called the elevated arm stress test (EAST) or abduction−external rotation (AER) position test (Fig. 14.17). In addition, exaggerating the military posture and at the same time placing longitudinal traction through the arms may limit the costoclavicular space and reproduce symptoms (Grieve, 1986).

Figure 14.17 Provocative tests for thoracic outlet syndrome. (A) EAST test. (B) Modified Adson’s test.

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Examination of the thoracic spine should also be made to differentiate the condition from T4 syndrome (see below), and the long-sitting slump test and upper limb tension tests should be performed.

Vascular involvement

Vascular conditions which affect the upper limb in sport, although rare, are important, and are described in this chapter rather than Chapter 18. If missed, these conditions can lead to vascular insufficiency with serious long term effects. Early retirement from sport may be one result, but the worst case scenario is death as a result of a thromboembolus (Taylor and Kerry, 2003). Five more common vascular conditions are described below.

T4 syndrome

The T4 syndrome (Maitland, 1986; McGuckin, 1986) produces vague widespread symptoms of pain and paraesthesia in the upper limbs and head, possibly with autonomic involvement. Any region between T2 and T7 may be affected, but the focus is normally around T4. The distribution of symptoms in the hand is glove-like in contrast to that of thoracic outlet syndrome, but many subjects have sensations extending from the wrist and forearm. Head symptoms appear in a ‘skull cap’ distribution, and the patient is commonly woken with pain. Onset may be due to unaccustomed activities or trauma (road traffic accident), but in many cases there is no specific history of injury. As with thoracic outlet syndrome, a predisposing factor is postural. Head protraction, shoulder girdle protraction and accentuated thoracic kyphosis are common, and place a stretch on the thoracic tissues.

On examination, movements can be localized by performing rotations and flexion/extension from a slumped sitting starting position. Palpation is carried out with the patient prone, head in mid-position, with the therapist standing at the patient’s head. The patient’s forearms hang over the couch side and the upper arms are abducted to 90° to widen the interscapular space. Signs of joint localization include pain, resistance to passive movement and guarding muscle spasm. Common findings include alteration of the alignment of one spinous process in comparison with its neighbours, with local pain to palpation. Examination must take in the cervical spine and first rib. The first rib is palpated above the centre of the clavicle, with the direction of pressure aimed towards the patient’s lower scapula.

Mobilization is used for any joints which exhibited signs at examination, and may be carried out with the patient in a supine position, arms folded across the chest and hands placed over the anterior aspect of the shoulders. The therapist places one hand beneath the patient’s thoracic spine with the side of his or her thumb or hand in contact with the area to be mobilized. Downward pressure is exerted through the patient’s arms onto the therapist’s hand. Postural correction may be carried out as with thoracic outlet syndrome.

Scheuermann’s disease

Scheuermann’s disease (juvenile osteochondrosis of the spine) is a condition predominantly affecting the thoracic spine around T9, although the lumbar levels may be involved (Greene, Hensinger and Hunter, 1985). The condition is more common in males, and occurs in about 6% of the adolescent population in the 12–18 age group (Corrigan and Maitland, 1983). There is a disturbance of the normal ossification of the vertebrae. The vertebrae ossify from three centres, one at the centre of the vertebral body and two secondary centres (the ring epiphyses) in the cartilage end plates. In Scheuermanns’s disease there is an alteration of the normal development of the ring epiphyses, but avascular necrosis does not occur (Gartland, 1987) in contrast to true osteochondrosis. Penetration of discal material is often seen through the cartilage end plate of the disc and into the vertebral body (Schmorl’s nodes). The changes are largely developmental, but trauma may play a part in exacerbating the condition. In contrast, when the central bony nucleus is affected Calve’s vertebral osteochondritis is present, a much less common condition affecting a single vertebra.

The changes in Scheuermann’s disease are primarily to the anterior margins of the thoracic vertebra as these bear greater weight. The disc narrows anteriorly, and deficient growth of the vertebral body occurs as a result of epiphyseal malformation. The vertebra gradually takes on a wedged formation. Normally, several vertebrae are affected in the thoracic spine. The athlete is usually a skeletally immature adolescent, with a ‘rounded back’ posture. In the active stage of the condition there may be localized pain, often provoked by repeated thoracic flexion as occurs in certain swimming strokes (butterflier’s back) and aerobic dance classes. Deep notches are visible over the anterior corners of the vertebrae on x-ray, and these appear sclerotic rather than rarefied (Fig. 14.18). The ring epiphyses are irregular, but the erythrocyte sedimentation rate (ESR) is normal.

Figure 14.18 Radiographic appearance of Scheuermann’s disease.

From Read (2000) with permission.

The condition is self-limiting, with pain generally ceasing at the end of skeletal growth. In the active stage rest is required, and thoracic taping may reduce pain through deload. In more severe cases, especially those affecting a number of thoracic segments where kyphosis exceeds 30°, a spinal brace (Milwaukee brace) may be required to prevent gross deformity. An exercise programme to prevent further deformity is essential. This normally involves strengthening in extension and patient education to avoid repeated flexion during activities and prolonged flexion in sitting and lying. In addition, increasing the lumbar lordosis and stretching the hamstrings has been recommended (Corrigan and Maitland, 1983).

A 4−6 week rehabilitation programme consisting of postural re-education, physiotherapy pain modalities (including acupuncture) and psychological support has been shown to reduce pain by 16−32% in a study of 351 patients with Scheuermann’s disease (Weiss, Dieckmann and Gerner, 2002). The maximum kyphotic angle was reduced from an average of 60.7° prior to treatment to 54.9° following physiotherapy treatment (Weiss, Dieckmann and Gerner, 2003).

Exercise therapy for the thoracic spine

As well as restoring fitness components to this body area (such as mobility and strength) following injury, posture is a prime consideration. One of the common postural faults in this region is an increase in kyphosis. The increased thoracic curve often begins with scapular abduction which moves the centre of gravity of the upper body forwards. In time, the thoracic spine flexes further as a result of the change in equilibrium. The increased curvature has a direct effect on scapulohumeral rhythm by limiting scapulothoracic motion and preventing the final degrees of abduction and extension of the glenohumeral joint. Reversing this trend requires a reduction in thoracic curvature to move the centre of gravity posteriorly, shortening of the shoulder retractors, and often restoration of correct shoulder depressor action. In the following section, examples are given of exercises to correct thoracic curvature by increasing extension. General examples of mobility exercises are also given for use in the restoration phase of injury.

Thoracic extension can be performed in a lying position. The pelvis is posteriorly tilted to flatten and block the lumbar spine, and the arms are lifted to the side and eventually overhead (Fig. 14.19A). Lifting the sternum to extend the thoracic spine without expanding the ribcage (Fig. 14.19B) is also a useful exercise and may be practised in a sitting, high kneeling or standing position. In elbow support prone kneeling (Fig. 14.19C) thoracic extension is performed by pressing (thrusting) the chest towards the floor. Passive extension may be performed by lying over a rolled towel, with the towel positioned at the apex of the thoracic curve (Fig. 14.19D). If the head does not rest on the mat, a thin pillow is used to prevent a protracted head position.

Figure 14.19 Exercise therapy for thoracic extension. (A) Thoracic extension, (B) Thoracic extension using towel as pivot, (C) Sternal lift.

Thoracic mobility to rotation and lateral flexion may be localized to various segmental levels (Fig. 14.20). Mobility to rotation is performed in a sitting position, and may be localized by changing the position of the arms. Leaving the arms at the sides and leading the movement with the head (looking around to the direction of movement) will focus movement to the upper thoracic spine. Holding the elbows horizontally stresses the mid-thoracic spine, which when reaching overhead pulls through the thoracolumbar fascia to stress the lower thoracic spine. Side (lateral) flexion may be mobilized by side-bending against a wall to prevent flexion/extension. With the hands by the sides (reach for the side of the knee) the lower thoracic region is stressed. Placing the hands behind the head and reaching up with the elbow transfers the centre of rotation higher up. Side-lying over a cushion or roll with the upper arm reaching overhead will stretch the muscles of side flexion as well as mobilizing the thoracic spine.

Figure 14.20 (A) Thoracic mobility exercises: (i) upper, (ii) mid, (iii) lower. (B) Thoracic side flexion: (i) lower region, (ii) upper region, (iii) side flexor stretch.

Examples of strength exercises for the thoracic spine musculature include single- or double-handed rowing actions, pull-downs and modified dips (Fig. 14.21).

Figure 14.21 Resistance exercises for the thorax. (A) Lateral pull down. (B) Seated rowing. (C) One arm dumb-bell row. (D) Modified dip.