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I recently had a patient come in with reports of R-side lower thoracic pain that radiated down the flank. The patient denied any mechanism of injury but the pain began sometime within the last 3 days. The lower thoracic pain was increased with bending forward and with oblique cervical flexion to the opposite side. When the patient was asked to touch his toes, his preferential movement was to go into a sumo squat. When asked to perform normal lumbar flexion, he tried and immediately stopped due to pain. The primary thing that should stand out about this is potentially a neural component. Flexion of the spine lengthens the vertebral canal, tensioning the spinal cord. Both of the pain provoking motions increase tension in the spinal cord. The patient denied any real pain relieving positions or motions but it was eased with avoiding the provoking positions. Another thing to consider with the R-side flank pain is potentially kidney involvement, however, the patient denied any bowel or bladder problems. Objective Cervical Flexion: DN Cervical Extension: DN Cervical Rotation: DP bilat L<R Shoulder Pattern 1 (ext/add/IR): DN bilat R>L Shoulder Pattern 2 (flex/abd/ER): FN bilat Thoracic Rotation: DN to R Multisegmental Flexion: DP Multisegmental Extension: DN Multisegmental Rotation: DN bilat Side Glides in Standing: Dysfunctional loading R side R iliac crest/PSIS/ischial tuberosity all depressed compared to L 12 rib anterior on R PA of 12th rib on R recreates patient's pain  Due to my suspicion of rib involvement, I had the patient perform repeated thoracic whips for 20 repetitions to the R side. I then had the patient perform the oblique cervical flexion, which was no longer painful. If we are to put a pathoanatomical name to the patient's pain, I would say there was a combination of 12th rib dysfunction and downslip of inominate on the R side that was straining the Quadratus Lumborum (flank pain). As far as manual treatment goes, I did some IASTM along the thoracolumbar paraspinals and a superior mobilization to the R inominate. The patient's HEP was only thoracic whips to the R side. I thought this was an interesting case due to the involvement of the entire spine for a very small pain location (relatively speaking). While the patient's pain may respond to repeated thoracic whips, it is essential to address any remaining mobility restrictions in the objective findings as well as abnormal movement patterns and postures the patient regularly displays that contributes to the dysfunction. -Chris
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