New-Onset Thoracic Pain After a Fall in an Older Adult
A 74-year-old woman presents 3 days after tripping on a curb and landing on her buttocks. She reports midline midthoracic pain (T6-T8) that worsens with flexion and with lying supine, and she has been sleeping in a recliner. She is on prednisone 10 mg daily for polymyalgia rheumatica. On exam: point tenderness at T7, no focal neurologic deficits, lower extremity strength 5/5, reflexes symmetric, no saddle anesthesia. Deep tendon reflexes are 2+ and symmetric; Babinski negative. She is afebrile. She asks whether you can "adjust her back to put the rib back in place" today, and she drove herself to the appointment.
1. What is the most important diagnostic consideration before any manual treatment in this patient, and how does it change your plan?
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Red flag: osteoporotic compression fracture (and, less likely, pathologic fracture).
Reasoning:
- Age >70, chronic glucocorticoid use, and a low-energy fall onto the buttocks are a classic triad for vertebral compression fracture.
- Midline tenderness at a single spinous level, pain worse with flexion and with supine positioning (she has adapted by sleeping reclined), is consistent with an anterior wedge fracture.
- Absence of neurologic deficits and negative Babinski do not exclude fracture.
Plan change:
- Defer high-velocity/low-amplitude thrust and any flexion-biased thoracic manipulation until imaging is obtained. Plain radiographs of the thoracic spine (or MRI if symptoms suggest acuity or if radiographs are equivocal) are the next step.
- If fracture is confirmed, management is conservative: analgesia, bracing consideration, activity modification, DEXA, and review of glucocorticoid dose with her rheumatologist. OMT, if used at all, shifts to gentle myofascial release, rib raising, and lymphatic techniques rather than thrust.
- If imaging is negative and pain is clearly myofascial/rib somatic dysfunction, then indirect or low-velocity techniques are reasonable.
Key teaching point: The presence of a plausible mechanism plus a risk factor (steroids, age, low-energy trauma) makes imaging the decision, not the physical exam alone.
2. The patient insists on treatment today and says she cannot return for two weeks. How do you handle this clinically and ethically?
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Approach:
- Do not perform a thrust technique in the setting of suspected fracture, regardless of patient insistence. This is a safety and informed-consent issue, not a customer-service issue.
- Explain the reasoning in plain language: "A fall in someone your age on steroids can crack a vertebra; a manipulation before we know that could make it worse."
- Offer an alternative today: gentle soft-tissue/myo-fascial work, positional release, breathing/rib techniques that avoid axial loading, and reassurance. This respects her request for care without crossing the safety line.
- Arrange imaging urgently (same-day or next-day radiographs if available) rather than waiting two weeks.
- Document the discussion, the red flags, the deferred thrust, and the plan.
Ethical frame: Patient autonomy supports informed refusal and shared decision-making, but it does not obligate the physician to provide a treatment that is contraindicated. The physician's duty is to offer a safe alternative and to make the diagnostic pathway accessible.