With the vast amount of locations that non-musculoskeletal conditions can present with pain in the thorax, one red flag that often stands out is pain in the middle of the back. A patient that presents with a case of simple neck or shoulder pain resulting from forward head posture may appear to have red flags with night pain of the mid thoracic spine. However, with further questioning you will often discover that the patient prefers to sleep with multiple pillows, reproducing the forward head posture and potentially disc irritation. A pain presentation that is fairly common that we should be aware of is Cloward Areas. Cervical disc irritation has the tendency to refer to the mid thoracic spine and the scapular border. Think about how lumbar disc irritation can essentially refer down to the knees (and sometimes below). The cervical spine has the same feature. With careful questioning of when the thoracic pain comes about, you may notice that it occurs with sustained positioning of forward head posture and disappears with correction, thus lowering the likelihood of non-musculoskeletal involvement. This article contains a good summary of the abstracts related to Cloward Areas. Some of the studies discuss the usefulness of various imaging methods in diagnosing symptomatic discs. This is interesting because it recognizes the difference between symptomatic and asymptomatic radiological findings - something many overlook. What we must remember however, is that we do not treat the pathology based on imaging. We treat the impairments.
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