Osteopathy Practical Technique Bridging Course

Session 8: Thoracic Spine

Part A:

Introduction to the surface anatomy of the thoracic

spine

References:
Moore KL, Dalley AF, Agur AMR. Clinically Oriented Anatomy. 6th Ed. Philadelphia:Wolters
Kluwer/Lippincott Williams & Wilkins. 2010. Ch 1, p 71
Lumley JSP. Surface Anatomy. The anatomical basis of clinical examination. 4th Ed.
Edinburgh:Churchill Livingstone. 2008 Ch 6 and Ch 4
Chila AG. Editor. Foundations of Osteopathic Medicine. 3rd Ed. Philadelphia:Lippincott
Williams & Wilkins. 2011. Ch 39
Greenman PE. Principles of Manual Medicine. 2nd Ed. Philadelphia:Lippincott Williams &
Wilkins. 1996. Ch 14
Nordin M and Frankel VH. Basic Biomechanics of the Musculoskeletal System. Philadelphia:
Lippicott Williams & Wilkins. 2012. p 261
Structures of the Thoracic Region that need to be known
The following list contains the structures to be covered in this lecture and associated
practical class. You will need to use the above references, or other suitable texts, to outline
the details required. For muscles and ligaments you will need to know their origin*, insertion*
and action.
*Note the origin and insertion may be known as proximal, distal, superior or inferior
attachment in some texts.
Bones:
Landmarks:

Muscles:

Thoracic vertebrae, scapula

Vertebrae: spinous processes, transverse processes
T1 medial and superior angle of the scapula,
T3 medial aspect of spine of scapula
T4 manubriosternal angle
T7 inferior angle of scapula
T9 sternoxiphoid junction
C7 and T1 spinous processes
Posterior: erector spinae (spinalis thoracis, rotatores), latissimus dorsi,
trapezius, rhomboids, intercostal muscles

Thoracic Rule of Three1

The spinous processes of T1-3 are palpable at the same level as the vertebral body to which
they are attached
The spinous processes of T4-6 are located one-half of a vertebra below that to which they
are attached.

The spinous processes of T7-9 are located a full vertebra lower than the vertebra to which
they are attached.
The spinous processes of T10-12, like T1-3, are palpated at the level of the vertebra to
which they are attached.
Reference
1. Greenman PE. Principles of Manual Medicine. 2nd Ed. Philadelphia: Lippincott Williams
& Wilkins. 1996. Pg 55
Thoracic Spinous Processes
Patient position: Sitting.
Practitioner position: standing behind the patient, or slightly to one side.
Applicator:
pad of the finger(s)
Procedure:
a. Ask the patient to move their chin towards their chest and sit in a slumped
position
b. Place the pad of the middle finger on the most prominent spinous process*
at the top of the thoracic spine or the base of the cervical spine. This will be
most likely be in line with the shoulders
c. place the index (or ring) finger pad on the spinous process above your
middle finger and the ring (or index) finger pad on the spinous process below
your middle finger
c. Ask the patient to extend their neck, or bring their head back.
d. The spinous process of C6 will move noticeably posteriorly over the
spinous process of C7. The practitioners finger that is more superior, or
closer to the head, should feel the spinous process of C6 move.
e. With the patients head in a neutral position, ask the patient to turn their
head and look over one shoulder and then over the other shoulder. The
spinous process of C7 will move more than the spinous process of T1. The
middle finger should be able to palpate this movement of C7.
f. This confirms the location of T1 as being that of the inferior finger if the
fingers have been placed appropriately. If the fingers have been placed too
high or too low adjust their location and confirm the spinous processes of C6,
7 and T1.
g. Once T1 spinous process has been located, palpate down the spine,
counting each spinous process until T12 is located. This can be done by
palpating along the length of the spinous process until you reach its tip. Then
let the finger pad slip off the tip onto the spinous process of vertebra below
and let it move along the length to the tip. Because of the anatomical variation
of the thoracic vertebrae (see rule of three notes above) the length of each
spinous process will vary. The length may be experienced as a dip between
the tip of one spinous process and another.
*Note: the most prominent spinous process that is observed when the neck is flexed is
usually C7s spinous process.
Alternative procedure:
a. Locate the spinous process of T12 as previously described and move the
fingers up the spine and count all twelve spinous processes.

A guide to aid in the location of thoracic spinous processes is:

The tip of the spinous process of T3 is approximately level with the medial aspect of the
spine of the scapula
The tip of the spinous process of T7 is at the level of the inferior angle of the scapula.
Please note that these levels may vary depending on the tension of the muscles and fascia
attached to the scapula. Therefore it is important to be able to locate specific spinous
processes in different ways, rather than relying on one method by itself.
Thoracic Transverse Processes
Patient position: Prone or seated in the slumped position.
Practitioner position: standing at the side of the table, level with the patients thorax and
facing toward the patients head or torso. Or standing behind the patient or slightly to one
side.
Applicator:
pad of the finger(s)
Procedure:
a. locate the spinous processes of the thoracic vertebrae
b. move the finger laterally over the erector spinae muscles until the lateral
border is reached
c. allow the pads of the fingers to sink through the muscle with a slight
anteromedial pressure until the transverse process is felt
d. the transverse processes are located at the level of the ribs. The ribs can
be used as a guide to where you would expect to locate the transverse
processes
NOTE: The transverse processes are located approximately 3 cm lateral to the spinous
processes. They may be difficult to palpate due to the muscles covering them. The tip of the
spinous process is located 1 cm below the transverse process of the inferior vertebra.
Trapezius
Patient position: Prone.
Practitioner position: standing at the side of the table, level with the patients thorax and
facing toward the patient
Applicator:
pad of the finger(s)
Procedure:
a. locate the tip of the shoulder and move the flat of the fingers along the
superior ridge of the muscle toward the neck. The fibres can be traced up to
the base of the skull.
b. curl your fingers around the edge of the superior border (you will need to
be medial of the acromion process of the scapula)
c. find the spine of the scapula and trace it medially
d. let the fingers slide off the scapula onto the muscles middle fibres.
e. to enhance these fibres ask your patient to bring their shoulder up off the
table. Note: these fibres are quite superficial and thin
f. follow these fibres down the back to the lower fibres.
g. to enhance these fibres and locate the border ask the patient to place their
arms alongside their head and lift the arms slightly off the table.
Note: to enhance the visual location of the muscle, draw a line from the inferior angle of the
scapular to the spinous process of T12.

Rhomboids
Patient position: Prone.
Practitioner position: standing at the side of the table, level with the patients thorax and
facing toward the patient
Applicator:
pad of the finger(s)
Procedure:
a. locate the medial aspect of the scapula and the spinous processes of C7
to T5
b. slide your fingers off the medial border of the scapula
c. let them sink through the trapezius muscle until the rhomboids can be felt
d. palpate the inferior and superior border of the muscle
e. to enhance its outline ask the patient to place their forearm on their lower
back
Note: to enhance the visual location of the muscle you can draw a line between the spinous
process of C7 to the superior aspect of the medial border of the scapula and another
between the spinous process of T5 to the inferior aspect of the medial border of the scapula.

Part B: Range of Motion of the Thoracic Spine

The assessment of the thoracic spine is conducted in a similar manner as the lumbar spine.
In most clinical examinations the thoracic and lumbar spine would be examined at the same
time because of the continuity of the spine. For learning purposes the regions are split up.
The other structures that would be examined at the same time include the ribs and the
sternum; these structures will be covered in the next lecture notes.

Thoracic region standing examination - landmarks

Patient:
standing and seated
Practitioner: standing behind patient, facing their back. Change your posture to ensure that
your eyes are level with the structure being examined
Applicator:
hands or fingers, radial side of hand
Procedure:
a. place your middle finger on the spinous process of T1 and your index
thoracic
finger and ring finger on either side of the spinous process
spine
b. run your hand down the thoracic spine, paying attention to where the
spinous processes are located, the tension of the tissues under your finger
pads, the bulk of the erector spinae muscles, the colour and texture of the
skin
waist
c. place the index and middle fingers of each hand in the space between the
creases
patients arms and the side of their body at waist height. Note whether the
distance between the arms is symmetrical. If it is not, you may observe that
there is a skin fold on the side that has the biggest distance between the side
of the body and the elbow crease. NOTE: this is also included in the lumbar
examination. It is included as part of the thoracic spine as an inferior point of
reference.
shoulder
d. place your fingers on the superior aspect of the lateral shoulder and note
height
the height in relation to the right and left side. Are they equal or is one higher
than the other?

scapular

e. observe the scapular, noting the medial borders for their distance from the
spinous processes, the inferior angles to assess if they are at the same height

Other observations would be associated with muscle tone and bulk, comparing right side
with the left.
Thoracic Region Active Range of Motion (standing)
Flexion
Patient:
Practitioner:
Applicator:
Procedure:

standing (ensure that they are standing in a comfortable, upright posture)

standing behind patient, facing their back.
hands
a. place your hands on the patients iliac crest and lateral hip region*
b. ask the patient to bring their chin down toward their chest
c. ask the patient to slowly curl their spine forward and down toward the floor,
leading with their head, and keeping their knees from bending.
d. if they have commented that they have back pain ensure you instruct them
to only curl down as far down as they can without causing pain and to stop at
the point that pain begins to occur.
e. ask them to slowly curl up, keeping their head close to the body and the
last structure to uncurl. Observe the thoracic region during this motion.
f. instruct the patient to stop when you can see and feel the movement start
to include the lumbar vertebra
g. note any findings in your patient records

Note: You are observing how each spinous process of the spine moves and how the sides
of the back and their muscles move. By asking the patient to curl down you can watch how
each spinous process moves. Is each spinous process able to move superiorly and
anteriorly or is it held so that no flexion occurs. Does one side of the back rise higher than
the other; this is particularly relevant for the thoracic region as the ribs will often highlight
disturbances in normal function of the thoracic spine? Does the patient deviate to one side?
If you ask your patient to bend forward you may not be able to note each spinous processs
motion as the patient may bend from the hips, or move in different ways. Therefore, getting
used to using an instruction that provides you with the ability to note as much about the
regions motion as possible you will be able to fine tune your ability to become more specific
in the where somatic dysfunctions are that need to be treated.
*By placing your hands on the iliac crest you can monitor the tension in the body for
symmetry, asymmetry and direction of pull if asymmetry is present. This is as relevant for
thoracic motion as it is for lumbar motion. As stated above, it is usual to examine both
thoracic and lumbar motion at the same time, so placing the hands on the iliac crests would
be normal practice.
Extension
Patient:
standing (ensure that they are standing in a comfortable, upright posture)
Practitioner: standing behind patient, facing their back. You may need to stand a little bit
further back so that you can observe the thoracic spine and avoid the patients head coming
toward you
Applicator:
hands
Procedure:
a. place your hands on the patients iliac crest and lateral hip region

Caution

b. ask the patient to lean backwards, as far as is comfortable, while keeping

their spine elongated or elevated. Dont let the patient collapse backwards or
you will not be able to observe the motion of the lumbar region
c. keep your hands on the patients iliac crest/lateral hip to ensure that they
do not fall over. It also gives you information on how the tissues are coping
with the movement.
d. instruct the patient to stop when you can see motion being to occur in the
upper lumbars. The amount of motion is likely to be small
e. ask the patient to straighten up and note the motion of the thoracic region
f. note any findings in your patient records

Lateral flexion or side bending

Patient:
Practitioner:
Applicator:
Procedure:

Caution

standing (ensure that they are standing in a comfortable, upright posture)

standing behind patient, facing their back.
hands may be needed to guide patients arm
a. ask the patient to move their hand down the side of their leg so that they
laterally flex the spine
b. you may need to guide their hand with yours, or show them what you want
them to do
c. observe the way the spinous processes move is there an even curve or
is there a flattened section. Watch how the muscles are contracting. Note
whether the patient moves anteriorly or posteriorly when they bend to the
side.
d. instruct the patient to stop when you can see movement begin at the
upper lumbars
e. ask them to straighten up and when at rest in an upright posture ask them
to repeat a and bend to the other side
e. note whether the second lateral flexion has a similar quality to it as the
first side examined, ie compare one side with the other.
g. for elderly people, or patients with balance problems, you may need to be
alert to the possibility of them falling over. You should be ready to support
these patients if they should need this assistance.
h. note any findings in your patient records

Rotation
Patient:
standing (ensure that they are standing in a comfortable, upright posture)
Practitioner: standing behind patient, facing their back. You may need to crouch to ensure
that your eyes are level with the structure being examined
Applicator:
hands
Procedure:
a. place your hands on the patients iliac crest and lateral hip region.
b. hold the pelvis steady so that when the patient rotates the spine the pelvis
does not move
c. ask your patient to cross their arms over their chest this gets the arms
out of the way as they rotate from side to side
d. ask the patient to turn their body to one side, leading with the shoulders
rather than the head. This helps reduce the strain that can occur in the neck if
they move too forcefully
e. ask the patient to stop when you see movement begin in the upper
lumbars
f. ask the patient to go back into a neutral position

g. observe the spinous processes and the muscles for their ability to move in
a symmetrical fashion as the rotate and return to neutral
h. ask the patient to rotate to the other side repeating steps a e.
i. compare the rotation to one side with the other.
j. note any findings in your patient records

Thoracic Region Active Range of Motion (seated)

seated, in a neutral position, arms crossed to keep them out of the way of the
Patient:
motion being performed
Practitioner: standing behind patient, facing their back. You may need to crouch to ensure
that your eyes are level with the structure being examined. Note: it is often easier to assess
the thoracics in the seated position as you can more easily identify the motion. However, this
does take out the influence of the lower extremity of the movement performed
Applicator:
hands
Procedure:
a. ask the patient to put chin to chest and curl forward
Flexion
b. observe how the spinous processes move as an indication of the thoracic
vertebral motion. Also observe for muscle asymmetry and the rib angles for
symmetry
c. ask the patient to return to neutral position, leading with the back and with
head returning to neutral last
Extension
d. ask the patient to elevate up through the spine and then lean backwards
e. ensure you are standing directly behind the patient and that you can
support their body if they over extend
f. ask the patient to return to neutral
Lateral
g. ask the patient to bend to one side, leading with the tip of the shoulder. Be
Flexion
careful that the movement is started at the upper thoracic vertebrae and that
the movement does not automatically come from the lumbars. You may wish
to place a hand at their waist to ensure that they maintain the motion within
the thoracic region
h. ask the patient to return to neutral and then sidebend to the other side
Rotation
i. ask the patient to turn toward one side, starting with the shoulders. You
may need to instruct the patient to not lead with the head as this may place a
strain through the cervical region
j. again, a hand placed at the patients waist may help ensure that the
movement is confined to the thoracic region
k. ask the patient to return to neutral and then turn to the other side
l. ask the patient to return to neutral
Note: With lateral flexion and rotation ensure that the patient does not bring in secondary
planes of motion (rotation, lateral flexion, flexion, extension). You want to observe what the
patient is capable of doing in the one plane of motion. If motion is limited a patient will often
bring in a secondary plane of motion in order to move as far as possible.
Remember: We are assessing their ability to perform the movement. The amount of motion
possible is one of the ways we assess the patients ability to perform the motion and to help
us determine if a dysfunction is present. Bringing in other planes of motion clouds the
assessment because it can appear that the patient is more capable than they truly are and
may mask the presence of a dysfunction.
Also remember to ensure they stay in the neutral position throughout all the movements.

Passive Thoracic Region Range of Motion (seated)

Patient:
seated, in a neutral position, fingers interlaced behind the neck (especially for
upper thoracic region)
Practitioner: standing behind and toward the side of the patient.
Applicator:
hands and arm, finger pads of fingers
Procedure:
a. ask the patient to interlace their fingers behind their neck and bring their
elbows together. Be careful that patient does not drag down through the neck
with their arms and hands
b. hold the patients elbows with your hand
c. place your palpating finger pads on the spinous process of T1,
interspinous space, and T2. Alternatively, use the pad of the thumb and
contact the lateral aspect of the T1 to T2 spinous processes. You may need
to have the patients shoulder tucked under your axilla and your forearm
along the patients forearm.
d. gently press down on the patients elbows to introduce flexion. Remember
that the range of motion is quite small, therefore for T1 you will only need to
introduce a very small range of motion, otherwise you will miss the T1 motion.
e. bring the patient back to neutral. You may need to place your hand or
fingers under the elbow to do this motion.
f. to introduce extension, bring the elbows superiorly. Again, for the upper
thoracic level this range of motion will be quite small.
g. return the patient to neutral
h. change the patients arm position to one where the forearms cross over
the chest. Hold the patients forearm or just above the patients opposite
elbow. The position of your hand will depend on your ability to control the
lateral flexion that is to be introduced.
i. to introduce lateral flexion, gently press down on the patients shoulder
with your axilla. You can also use your hand to gently bring the patients arms
in a cephalad direction to assist in the lateral flexion motion
k. return the patient to neutral
l. to introduce rotation gently bring the patient toward you with your hand
and torso.
m. return the patient to neutral
Note: For the upper thoracic range of motion, having the patients fingers behind their neck
allows you to more easily target the specific range of motion you are looking for. One reason
for this is because the lever and fulcrum can be more accurately placed to assess the upper
thoracic motion and allows for easier patient handling.
However, this hold is only appropriate for patients who can do this with ease. For patients
who cannot comfortably place their hands behind their necks, use similar arm positions and
holds as you would for the thoracic region.
For the lower thoracic vertebraes range of motion you may wish to use similar patient arm
positions and patient holds as you would for the lumbar vertebrae.
Passive Thoracic Region Range of Motion (sidelying)
Patient:
Practitioner:
Applicator:
Procedure:

sidelying, in a neutral position

standing in front of the patient, at a level with the patients neck and shoulder.
hands and arm, finger pads of fingers
a. place your cephalad hand beneath the patients neck so that your little
finger covers C7s spinous process. This helps to splint the neck and allow
the neck to move as a single unit.

b. support the patients head with your forearm.

c. if the patients lower upper extremity (side they are lying on) is in the way
you can ask them to place the arm alongside their head. This would mean
that your forearm is between the patients head and upper arm.
d. with your caudad hand, palpate the spinous processes of T1 and 2, and
the interspinous space.
e. to introduce flexion, gently bring the patients head and neck toward you.
Be careful to ensure that you keep the motion in the correct plane and that
you do not introduce sidebending into the neck as you move it.
f. return the thoracic spine to neutral
g. to introduce extension, gently move the head and neck away from you.
Note: it is likely that you will not be able to use this position for the entire
thoracic vertebrae; only the superior thoracic vertebrae are easily palpated in
this position.
h. return the thoracic spine to neutral
i. to introduce lateral flexion, gently bring their head and neck toward the
ceiling. It is important to ensure that the neck is splinted so that you do not
strain the structures of the neck and you allow the side bending to occur only
within the thoracic region.
j. return the thoracic spine to neutral
k. to introduce rotation, turn the patients head and neck toward the ceiling.
Be sure you maintain control of the cervical vertebrae and that the neck is
well splinted while performing this manoeuvre.
l. return the thoracic spine to neutral
Alternative:

a. an alternative application for assessing the thoracic spine is to have the

patients fingers interlaced behind their neck in such a way that the caudad
fingers cover the C7 spinous process. You may need the patient to come
closer to the edge of the table so that their elbows are not resting on the table
b. hold the patients elbows together with your cephalad hand or patients
elbows against your abdomen this will free up both hands for palpation
c. to encourage flexion bring the patients elbows toward their feet, or
abdomen with your hand. You can also place the patients elbows against
your abdomen and move the elbows in a caudad direction by moving your
body toward the patients feet. If you use this approach you can leave your
cephalad hand holding the elbows or you can use the cephalad hand to
palpate the thoracic spinous processes as well.
d. to introduce extension, move the patients elbows in a cephalad direction.
You may need to push anteriorly with your palpating fingers to facilitate
extension
e. to introduce lateral flexion place your cephalad arm under the patients
arm (that is lying against the table) and have your hand over their hand.
Gently lift the patients neck and head off the table ensuring that the neck is
well splinted and that the movement occurs in the thoracic spine and that no
strain is put through the neck.
f. to introduce rotation, keep the same contact as per lateral flexion and
bring the patients arms up toward the ceiling. This should allow for rotation to
occur in the thoracic spine.

Note: it may be that you will not be able to assess the lower thoracic vertebrae by
introducing the movement from a cephalad direction. The lower thoracics may be more
easily assessed by using a similar approach to that used in assessing the lumbar spine in
the sidelying position.

Passive Range of Motion of the Thoracic Spine (prone)

Patient:
Practitioner:
Applicator:
Procedure:

prone,
standing at the side of the patient, at a level with the patients upper torso
hands and arm, finger pads of fingers
a. ask the patient to bring their arms up alongside their ears and flex their
elbows so that the forearms are crossed so that their forehead rests on their
forearms.
b. with your cephalad hand hold the patients forearms, mid-way.
c. with your caudad hand palpate the thoracic spinous processes
d. to introduce extension, lift the patients forearms up toward the ceiling.
Keep your arm straight and move your body toward the patients feet and
allow this motion to lift the patients forearms. You can bend your caudad
knee to assist in this motion.
e. palpate the extension with your caudad hand
f. return the patient to neutral
g. to introduce lateral flexion, lift the patients forearms up slightly and then
bring them toward you. Be careful not to introduce any significant amount of
extension into the thoracic region at the same time
h. return the patient to neutral
i. to introduce rotation, hold the patients elbow furthest from you and lift
toward the ceiling
j. return the patient to neutral

Passive Range of Motion of the Thoracic Region (supine)

Patient:
Practitioner:
Applicator:
Procedure:

supine
standing beside the patient, at a level with the patients upper torso.
hands and arm, finger pads of fingers
a. ask the patient to interlace their fingers behind their neck so that their
caudad fingers cross over C7
b. gently lift the patients shoulder on the opposite side to you with your
cephalad hand so that you can slide your caudad hand beneath the patients
back and can palpate the spinous processes. Let the shoulder move back
against the table
c. place your cephalad hand on the patients elbows
d. to introduce flexion, gently press the patients elbows towards their
abdomen
e. palpate the spinous processes and feel them move apart as flexion is
introduced
f. gently return the patient to neutral
Alternate Procedure
a. ask the patient to cross their arms over their chest so that their elbows
are together. For female patients you may wish to place a small rolled up
towel over their sternum so that when the forearms have pressure placed on
them, the breast tissue is not compressed. This makes it more comfortable for
the patient. You may also do this for male patients, however, they generally
require less cushioning height (the towel is not rolled up as much). Be sure
that you place the towel so that it does not press against the anterior throat;
keep it below the line of the clavicle.
b. place your hand under the patients opposite shoulder and lift it up so that
you can slip your palpating hand underneath the spinous processes

c. to introduce flexion place your free hand on the patients elbows and/or
place your sternum/chest over their elbows (you may wish to put a pillow
between the elbows and your chest)
d. introduce a posteroinferior motion through the elbows to induce flexion of
the thoracic spine
e. to assess extension you can either bring the elbows in a posterosuperior
direction with your hand or use your chest to assist in the motion. In some
patients you may need to provide a slight anterior pressure with your
palpating hand.
f. to introduce rotation, lift the patients opposite shoulder and let it move
back toward the table. You will need to go to the other side of the patient to
assist rotation in the opposite direction
g. to introduce lateral flexion ask the patient to lift their head off the table.
Slide your hand and forearm underneath their head and neck. The fingers of
your hand should be pointing toward the patients feet and the patients head
should be resting along your forearm. When you have the patients head and
neck secure bring the patient toward you. Return the patient to neutral and
repeat the motion down through the spine. Be careful not to introduce too
much flexion in the position. NOTE: you can use this hold to introduce
flexion into the spine. By introducing a rocking motion in a cephalad/caudad
direction (patient) you can easily assess flexion and this may provide a better
assessment of the motion.
NOTE: when leaning on the patients elbow, only apply sufficient force to place tension
through the posterior aspect of the patients back.