Mid-Thoracic Pain After Lifting in a Woman on Long-Term Steroids
Mrs. Halvorsen is a 71-year-old woman referred to your outpatient clinic with a three-week history of mid-thoracic pain that began suddenly while she lifted a 10 kg bag of compost. The pain is 6/10 at worst, sharp when she rises from a chair or coughs, and she now wakes twice most nights when she rolls over. She has taken prednisolone 10 mg daily for three years for polymyalgia rheumatica, along with calcium and vitamin D. She mentions that her height has decreased by about 4 cm since 2019 and that her mother had a 'dowager's hump'. She has no history of cancer, no fever, no unexplained weight loss, and no bladder or bowel change. There is focal tenderness over T7 with a mild thoracic kyphosis; thoracic flexion is restricted and painful, straight-leg raise and lower-limb neurology are normal. The referral reads 'thoracic hypomobility - mobilise and discharge in four visits'.
1. Which features raise your suspicion of a vertebral compression fracture, and how does that suspicion change what you do in the first session?
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Features that raise suspicion
- Mechanism and load: sudden pain lifting only 10 kg - far below what normal bone tolerates.
- Bone quality: three years of prednisolone at 10 mg daily is a well-recognised cause of glucocorticoid-induced osteoporosis; polymyalgia rheumatica itself is associated with reduced bone density and with vertebral fracture.
- Structural clues: 4 cm of self-reported height loss and maternal kyphosis both suggest prior vertebral deformity and elevated bone risk.
- Pain behaviour: focal T7 tenderness, pain on coughing and on rolling in bed - trunk loading and rotation through the fractured segment - plus night pain that wakes her.
- Weighing against fracture: no cancer history, fever, weight loss or neurological symptoms makes infection and malignancy less likely, but none of these excludes a fracture.
What changes today The referral's plan is unsafe until imaging has been considered. I would not apply end-range thoracic mobilisation or manipulation, and I would not prescribe loaded trunk flexion or rotation, to an undiagnosed fracture. Instead: record full observations, complete a neurological screen (dermatomes, myotomes, reflexes, gait, bladder and bowel), assess balance and falls risk, teach pain-relieving positions and a way to get out of bed and off the toilet without trunk loading, and contact the referrer the same day to request thoracic imaging and a bone health review. Document the reasoning, the advice given, and the referral made.
2. Which findings during your assessment would change this from a routine referral to an urgent one, and what would you say?
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Urgent escalation triggers
- Any new neurological deficit: leg weakness, a sensory level, brisk reflexes or clonus, gait ataxia, or new bladder or bowel dysfunction - possible cord or conus compression, which is time-critical.
- Band-like chest or abdominal pain, or pain that is severe and unrelenting at rest and at night, particularly with a cancer history, fever or weight loss - possible malignancy or infection.
- New or rapidly progressing kyphosis, inability to weight-bear because of pain, or pain after a further fall.
- Systemic features: fever, new confusion, hypotension, or anticoagulation with a new severe pain.
What I would say (SBAR) 'Situation: Mrs. Halvorsen, 71, three weeks of mid-thoracic pain after lifting 10 kg, now with new right-leg weakness and numbness below the ribs. Background: three years of prednisolone 10 mg, 4 cm height loss, focal T7 tenderness, referred for mobilisation. Assessment: neurological findings are new today; I have not treated her. Recommendation: please review her urgently today for imaging and neurological assessment; I have advised her not to drive and to return immediately if bladder or bowel function changes.'
Record the findings, the time, who was contacted, and the advice given. Do not treat, and do not simply send her home with an exercise sheet.
3. Imaging confirms an acute, stable T7 wedge fracture with no retropulsion. Outline your priorities for the first four weeks and who else must be involved.
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Clinical priorities
- Pain control sufficient to move: liaise with the physician about analgesia so she can breathe deeply and walk, because bed rest accelerates bone loss, deconditioning and chest infection.
- Early, controlled upright activity with a walking aid and coaching in log-rolling, sit-to-stand and safe lifting; load through the trunk in neutral rather than in flexion.
- Postural and extension-biased exercise for thoracic erector spinae and scapular control, graded, within a pain limit she can tolerate; no high-velocity thoracic manipulation and no loaded trunk rotation.
- Breathing exercises and cough support if pain limits inspiration.
- Falls and home assessment: she fell? No - but her bone fragility makes any fall a fracture risk; check vision, rugs, medication, and provide a raised toilet seat and a grab rail if needed.
- Set expectations: pain usually improves substantially over 6-12 weeks; the aim is function and future fracture prevention, not 'fixing the kyphosis'.
Who else must be involved The referring physician for analgesia and imaging review; a fracture liaison or osteoporosis service for DXA, calcium and vitamin D optimisation, and anti-resorptive or anabolic therapy; the rheumatology team that manages her prednisolone, since the lowest effective dose matters; and a dietitian and falls-prevention service as needed. Physiotherapy alone manages symptoms - it does not treat the underlying bone disease, and saying so in the note is part of the job.