• increased emphasis on education (activity limitations, proper resting positions, and appropriate use of ice)
• if hypermobility is present use of soft or hard collar is appropriate to reduce stress on healing tissues
• exercises are limited to relaxation breathing, gentle AROM for proprioception, and static postural cuing with a mirror

• intro of mobilizations and specific HEP for stretching
• postural awareness training in dynamic situations

• stabilization training for neuro-muscular re-education
• dynamic posutral training incorporated with UE

what type of injuries are associated with pain being worse in the Am with or without referred/radicular symptoms

• may be associated with degenerative changes of adjacent structures (stenotic features)

• spinal stenosis
• localized infection
• peripheral neurovascular entrapment
• localized inection, peripheral neurovascular entrapment, and localized tumor

• bracin indicated if segment is hypermobile
• manual traction and I-II mobilization helps to decompress the involved segment and control symptoms
• gentle small amplitude AROM is indicated
• breathing exercises

• postural correction; intitally static
• address hypomobility with mobilization and exercise

• incorporation of stretches/STM of neurovascular structural interfaces when necessary
• dynamic stabilization training and postural awareness educaiton/adaptations for entire trunk

• may associate with emotional tension, chronic postural changes or secondary to direct trauma to the cervical musculature
• most common finding is forward head posutre
• associated with irritation of the greater occipital nerve or the trigeminal nerves

• intracranial sources such as HTN, head injury, intracranial tumor, cerebral hypoxia

• education regarding the use of relaxation breathing, warm/cool compresses at the base of the neck, ergonomic/ADL modifications that may be directly affecting the problem
• progression:
• specific soft tissue/myofascial techniques; particularly suboccipitals and levator scapule
• joint mobs at O-A and A-A joints for flexion and rotation if restricted
• neuromuscular training for deep flexors and extensors
• postural training in static and dynamic sitations
• consider use of pressure points at the occular orbits, at the zygomatic arch, or just lateral to nostrils in the case of sinus congestion

1. manubriosternal

2. SC

3. interchondral

4. costotransverse

5. costovertebral

1. upper ribs run close to horizontal

2. as you descend down the rib cage the ribs run more oblique

describe the rib movement with inspiration and expiration with the pump handle action (5-6)

• inspiration-ribs pull up and forward, increasing AP diameter of the thoracic cavity
• first 6 ribs increase teh AP diameter of the thoracic cavity by rotating around their long axes
• rotation upward of the rib nexk is associated with elevation of the rib cage
• rotation downward of the rib neck is associated with depression of the rib cage
• movements are accompanied by elevation and depression of the manubrium and sternum respectively
• motions as if water pump

• ribs 7-10 are incolved in increasing the lateral dimensions of the thoracic cavity
• to increase the infrasternal angle the ribs move upward, backward, and laterally
• to decrease the infrasternal angle the ribs move downward, forward, and medially
• bucket handle motions do occur in ribs 2-6, but lesser extent

• ribs 8-12 move laterally to increase the lateral dimension of the thoracic cavity

• decreased intercostal space, no expansion of intercostals space with deep breath

• palpation for position will ID a rib subluxation

• diaphragm
• scalenes
• intercostals

• serratus anterior
• serratus posterior superior
• serratus posterior inferior
• levator costae (longus and brevis)
• SCM
• latissimus dorsi
• iliocostalis thoracis and cervicis
• pec major
• pec minor
• quadratus lumborum

1. core musculature
2. extensive ligamentous support
3. sterno-costo-vertebral ring

• localized, sharp, posterior angulation
• kyphotic deformity, usually structural, and oten a result of anterior wedging of the vertebral body

results from postmenopausal osteoprosis

• usually occurs in the upper to middle thoarcic spine

• pigeon chest
• sternum projects forward and downward

• funnel chest
• sternum pushed posteriorly secondary to overgrowth of ribs

• sternum projects forward and upward
• increasing the AP dimension

• decreased osteokinematic motion of either the thoracic vertebrae or the ribs
• tissues involved: articular, myosfascia, or both
• often result of excessive bending or rotational force
• onset: insidious or sudden depending on degree of trauma
• iriitability of tissue dictates: intensity of pain, amount of pain radiation, degree of physical activity which aggrevates it, amount of rest needed to calm down
• location of pain may be same or oposite side of hypomobility
• pain may radiate around or through anterior aspect of chest
• truely hypomobile joint will consistently present itself on habitual movement testing to display a restricted arthrokinematic glide

• increased osteokinematics motion of either the thoracic vertebrae or the ribs
• result of acute major trauma, preitive minor trauma over prolonged period
• onset: insidious or sudden depending on degree of trauma
• iritability of the tissue dictates: intensity of pain, amount of pain radiation, degree of physical activity which aggravates it, amount of rest needed to calm it down
• must determine stage and nature of pathology so treatment can be appropriately be applied
• acute sublexation of a rib or a ring will produce localized pain of involved joint
• lonstanding cases of thoracic hypermobility pain is poorly localized to specific segment and tends to radiate over region of thorax
• hypermobile joints present variably with habitual movement testing
• referral of pain is variable and can be around the chest or through it
• hypermobile joints present variably with habitual movement testing

• pts with thoracic pain, but no positive objective mechanical findings are difficult to treat
• number of non-mechanical factors can reger pain to thorax, therefore, non-mechanical causes of thoracic pain must be ruled out
• if all non-mechanical causes of pain have been ruled out and you can detect no mechanical dysfuncitions a postural approach to treatment can be taken emphasizing stabilization training

• intrathoracic and intraabdominal disorders can refer to the thorax
• pain tends to be dull and deep and not influenced by physical activity, rest may offer some releif