Assessing The Thoracic Spine & Shoulder Girdle

COMMON DEVIATIONS

• There are four main deviations that can cause pain, injury, and movement dysfunction in the thoracic spine and shoulder girdle.

1. Excessive Thoracic Kyphosis
2. Protracted Shoulder Girdle
3. Internally Rotated Arms
4. Elevate Scapula 

• Our thoracic spine naturally has a mild forward-shaped curve called a kyphotic curve. A greater than normal curvature of the thoracic spine is known to as excessive Thoracic kyphosis. Excessive thoracic kyphosis disturb the function of the entire shoulder girdle.

• A protracted shoulder girdle occurs when the scapula (shoulder blades) move forward on the rib cage, causing their vertebral borders (the edges closest to the spine) to move away from the spine. Protraction of the shoulder blades also protracts the entire shoulder girdle, moving the acromion's and collarbones forward and out of alignment. When the shoulder girdle protracts, it affects the position of the glenohumeral joint, causing the upper arm to rotate inward toward the midline of the body. This position of the upper arms in the shoulder joints is known as internally rotated arms.

• An elevated scapula refers to an atypical,  upward position of the shoulder blade as it sits upon the rib cage. Elevated scapula (shoulder blades), a protracted shoulder girdle, internally rotated arms, and excessive thoracic kyphosis are inherently linked, and they limit shoulder function and range of motion in the arms, in the upper torso, and throughout the body.

ASSESSMENT PROCESS

1.  ask for the specific location of the pain. Where on the shoulder does it occur? Is it under the scapula (shoulder blade) or armpit? On the back or side of the neck? In the middle of one side of the chest? (For example, if a Patient describes pain on the top of scapula (shoulder blade) (or on the side or back of her neck), this may indicate that scapula (shoulder blade) is elevated on that side, resulting in muscle tightness and tension. Obtaining such detailed information will prompt you to check further during the visual and hands-on assessments.)
2.  Ask about the patient’s past injuries or surgeries. For example, a torn rotator cuff muscle or a fusion of vertebrae in the thoracic spine may limit movements and functions.
3. Ask about the patient's level of physical activity. Ask whether he plays sports often and, if so, what kind? For example, Bowlers experience excessive movement in their throwing arms that can affect shoulder functions.
4.  Ask about the Patient’s occupation. Does your client work at a computer desk or at a manual labor job? People who work at a computer all day long tend to round their upper backs, protract their shoulder girdles, and internally rotate their arms as they type. Spending lots of time in this posture will affect the alignment of the thoracic spine, the shoulder girdle, and the rest of the body.
5.  Ask the Patient if shoulder and arm or mid-to-upper back pain ever prevents him from engaging in an activity or limits what he can do. This will highlight the activities he feels he is missing out on, and why he is motivated to seek your help. And also help you to make personalize rehab protocol according to patient's need.
6.  Ask the patient what aggravates the pain and what makes it feel better. If a patient indicates, for instance, that driving makes her neck pain worse, you can coach her on improving her sitting and driving posture.
7.  Ask the patient if the pain ever wakes him up at night or makes sleep difficult. For example, if a patient tells you that sleeping on his side makes his shoulder or neck pain worse, you can coach him on how to improve his sleeping posture.
8.  Ask the patient if his pain increases with stress or if he is currently under a lot of stress. Chronic stress responses, such as shrugging the shoulders and rounding the upper back, can have a dramatic effect on the alignment of the thoracic spine and shoulder girdle.
   

Your emotion has great influence on your Posture. So, you need to take care of that. With this information we are good to go with Visual Assessment.

Visual Assessment.

• Tell patient to stand side ways and observe thoracic curve and shoulders for kyphosis and protracted Shoulder Girdles. And from behind observe for any change in both shoulders levels.

Hands on Assessment

ASSESSMENT FOR EXCESSIVE THORACIC KYPHOSIS

• ask Patient  to stand in front of you facing sideways. Place your fingers on the back of the patient’s neck and locate the vertebrae of  cervical spine. Follow the curvature of the spine from the top of the neck to the bottom, and feel each vertebra like the keys of a piano. You will notice that the last vertebra of the neck (C7) protrudes out slightly more than the vertebrae directly above it, perhaps noticeably so in the form of a dowager’s hump.

Note - If you are having difficulty locating C7, place your fingers on the base of the patient’s neck and instruct him to look down towards feet and then back up above his head. As he looks down and up, you will feel that C7 does not move much compared to the vertebrae above it (C6). 

• Once you have located C7 place the tip of your index finger on this vertebra. Extend your index finger so that it is straight and parallel to the ground (see figure below).

• Now position the index finger of your other hand with your finger straight and parallel to the ground between the middle of the clavicles (collarbones) on the top of the sternum (i.e., the jugular notch; see figure below ). 

• When both fingers are in place, evaluate the difference in height between your two fingers.When a person is in good alignment, your index finger on the front of the client’s chest should be about 1-1/2 inches (3.8 cm) lower than your finger positioned on the client’s neck because the anatomical position of the spinous process (bony projection off the back) of C7 is about 1-1/2 inches (3.8 cm) higher than the top of the sternum in proper alignment . If your index finger on the front of the client’s chest is more than 1-1/2 inches (3.8 cm) lower than your index finger on the neck, it is indicative that the Patient has excessive thoracic kyphosis. This is because the back of the rib cage attaches to the thoracic spine, and when the thoracic spine rounds forward, the sternum (where the front of the rib cage attaches) drops down and forward. The greater difference in height (of more than 1-1/2 inches) (3.8 cm) between your two fingers, the greater the amount of excessive thoracic kyphosis.

EVALUATE THE POSITION OF THE SHOULDER BLADES

• In Normal Alignment the shoulder blades (scapula) should rest relatively flat and down on the back of the rib cage.

• Palpate medial border of scapula and feel it  the medial border must lie flat on rib cage if not that indicated protraction of Scapula.

• Palpate superior angle of scapula on both side and see if one of them is higher as compare to other side, if it's higher that means Scapula is elevated.

• You can also check elevated scapula by checking Muscles. Feel both side of trapezius Muscles if you feel Excessive Tightness or Obvious knots. If one or both sides have excessive tension, you can safely assume that one or both shoulder blades are elevated because the tight muscles attach to the scapula.

EVALUATE THE POSITION OF THE ACROMION

• To further evaluate the position of the shoulder girdle, ask the client to turn to the side. Note the position of the acromion, the bony protuberance on the top of the shoulder. Ideally, that bony landmark should be in line with the tragus, (the fleshy piece of skin that covers up part of the opening at the front of the ear). If the acromion is farther forward than the tragus, it is an indication that the client has a protracted shoulder girdle.

EVALUATE THE POSITION OF THE ARMS

• You can determine whether a client’s arms are rotated too far internally by looking at the position of the fingers, hands, and wrists.

• Observe from sideways for position of hands. When a person is in proper alignment, the hands and arms should have a slight internal rotation—they should turn in toward the midline of the body about 15 degrees. If only the thumbs, forefingers, and some of the middle fingers are visible, then the arms are in correct alignment (see figure below). However, if you can see all of the client’s fingers and the backs of her hands, then arms are considered to be excessively internally rotated (see figure below)

HOW THE THORACIC SPINE AND SHOULDER GIRDLE RELATE TO ALL OTHER AREAS OF THE BODY

• As the thoracic spine rounds forward and the kyphotic curve increases, the lordotic curve in the lumbar spine also tends to increase to help maintain balance. This causes the pelvis to rotate forward and the leg to rotate internally, producing a valgus knee displacement and overpronation of the foot and ankle complex.

• When the thoracic spine and shoulders collapse, the head and neck follow and fall forward also. As the head collapses down and forward, the neck arches backward and upward to maintain balance and to enable the eyes to focus on the horizon. Over time, this collapsing forward of the head and overarching of the cervical spine can place undue stress and strain on the structures of the neck and upper back.