3 Ways to Make Your Thoracic Assessment More Specific

Many physios will have their own ‘thoracic assessment routine’ down pat and ready to wheel out whenever someone mentions upper back pain.

And no wonder, thoracic symptoms can often be vague, which can lend to a fairly generic assessment by default. The challenge is that important pathology, inflammatory conditions and even contributing movement impairments can easily be missed if we aren’t specific enough with our questioning and examination.

In her Thoracic Assessment Practical, Dr Alicia Rayner shared several tips to help physios perform a more targeted thoracic assessment. This blog highlights three areas to be more specific that can improve your approach to thoracic assessment.

If you’d like to see exactly how expert physio Dr Alicia Rayner assesses the thoracic spine, watch her full Practical here. With Practicals, you can be a fly on the wall and see exactly how top experts assess and treat specific conditions – so you can become a better clinician, faster. Learn more here.

1 – The subjective assessment

The thoracic spine is an area where a thorough subjective examination can really matter.

Before exploring mechanical factors, make sure you’re screening for important pathology. One condition that can be easily overlooked is a vertebral compression fracture.While we should always keep fractures on our radar, it’s important to be particularly vigilant in people over 50, and especially those over 70 years of age. A key question is whether the patient has a history of long-term corticosteroid use, which significantly increases fracture risk.

Similarly, thoracic symptoms should prompt consideration of non-musculoskeletal causes. For example, a patient reporting left-sided thoracic burning pain during exercise warrants consideration of cardiac referral rather than automatically assuming a musculoskeletal source. Always be sure to ask about shortness of breath to help screen for pulmonary embolism.

When screening for inflammatory conditions such as ankylosing spondylitis, specific questions become important. Ask about:

• Morning pain and stiffness lasting longer than 30 minutes
• Symptoms that improve with movement and worsen with rest
• Waking during the second half of the night because of pain
• Family history of inflammatory conditions
• Psoriasis or other inflammatory skin conditions

One particularly useful tip is that ankylosing spondylitis does not always present the same way across sexes. While males may commonly present with thoracic symptoms early, females are more likely to report bilateral shoulder or bilateral hip pain, which can delay recognition if we’re not considering inflammatory pathology.

The quality of questioning also matters. Rather than jumping straight into a checklist, start broadly. Questions such as: “Tell me about your pain.” allow patients to tell their story and often reveal important information that structured questioning can miss. From there, become more specific and measurable. Watch Alicia explain in this clip from her Practical:

Finally, make sure to get a detailed body chart. Pain in the thoracic spine can be vague, but try to be as precise about symptom location and quality as possible, as this can help guide your clinical reasoning.

Remember too that arm pain is not always cervical in origin. Upper thoracic structures, particularly around T1 and T2, can refer symptoms into the arm. Patients may describe burning, electric shocks or dysaesthesia extending down the limb, making it important not to immediately assume a cervical source.

2 – Thoracic Range of Movement (ROM) assessment

We’re all guilty of performing a quick assessment of thoracic flexion, extension, rotation and lateral flexion simply to identify pain provocation.

However, taking the time to complete a more thorough assessment can provide valuable information. Particularly, a more thorough rotation assessment can provide far more useful information when you separate upper and lower thoracic movement. Understanding this can help direct both your treatment and exercise prescription rather than treating the thoracic spine as one homogenous segment. Watch Alicia demonstrate her assessment in this video from her Practical:

3 – Scapular muscle assessment

Scapular muscle assessment is another area where clinicians often miss important information. One common mistake is testing both sides simultaneously; the problem is that patients can compensate or brace, masking deficits that become much more obvious when assessed unilaterally.

Instead, assess each side independently and progressively challenge scapular control through different positions. Observe how well the patient can control the scapula during movement rather than simply assessing whether they can achieve a position.

Alicia also recommends making assessment tasks more objective where possible. For example, incorporating a defined task such as repeated taps allows you to observe control, endurance and movement quality rather than relying solely on subjective impressions. See Alicia demonstrate in this clip from her Practical:

After prone assessment, progressing assessment into more demanding positions, such as four-point kneeling, can further expose deficits that may not be obvious in lower-level testing positions.

Wrapping up

The difference between a generic and an expert thoracic assessment isn’t the number of tests performed, but the specificity of the assessment, which comes from a deeper understanding of the anatomy and physiology of the region.

Asking targeted questions around red flags and inflammatory presentations, being more deliberate with thoracic ROM assessment, and challenging scapular control in a meaningful way can all provide information that directly influences management.

These are only a few insights from Alicia’s thorough Practical. If you want to see exactly how an expert assesses the thoracic spine, watch her full Practical here.