THORACIC SPINE REHABILITATION
miD BACK CONDITIONS
The following glossary provides a brief description of a variety of causes of mid back pain. In reading these descriptions try not to focus on the condition itself, but rather understanding how this may relate to your injury mechanism, symptoms and positive management of your individual case of mid back pain.
Inter-vertebral joint injury: This type of injury involves the connections between the thoracic vertebrae (the discs and facet joints). It is the most common cause of pain in this body region, and may be of sudden or gradual onset. Usually the injury mechanism involves twisting or extension, and pain may be felt centrally, on one side or both sides of the spine. There is usually localised tenderness over a certain segment of the spine, and symptoms may be worse with twisting movements or sitting, and eased by laying down or placing pressure through the back such as leaning on a wall.
Rib articulation injury – costovertebral/costotransverse joints: This involves injury or irritation to the joints that connect our ribs to the spine (costo-transverse and costo-vertebral joints). These joints can be sprained and/or become inflamed, and may also display arthritic changes that can cause pain. Typically, a localised area of pain to the side of the spine is felt. Movement of the ribs with breathing and coughing usually aggravates symptoms.
Postural Kyphosis: An accentuated forwards curvature of the middle back. This often occurs due to a repetitive training activity or posture that involves repetitive or prolonged bending of the middle back. This is often seen in individuals performing cycling, weights training or prolonged sitting at desks. The middle back is usually very stiff, being hard to straighten and rotate. Dominant chest muscles and weak shoulder blade muscles can also contribute. PLEASE NOTE – postural kyphosis is different to structural kyphosis, where the shape of vertebrae changes due to a disease such as Scheurmann’s disease or osteoporosis.
Kyphosis refers to an increased curvature (hump) in the thoracic region. This can be postural, from prolonged sitting or activities involving repetitive bending. In some cases it can be a structural change from a disease e.g. Schuermann's Kyphosis, or from fractured vertebrae causing the spine to wedge forwards. Image credit: Mayo Clinic, 2017 (1).
Disc herniation: Disc herniation is rare in the thoracic spine due to the stability and protection offered by the ribs. However, it can still occur. Usually it happens in the lower part of the middle back (T10,11,12). Symptoms usually involve local back pain with pain also referring into the chest wall or flanks in band type patterns from back to front. There may be sensory changes such as pins and needles or numbness.
Referred pain from the thoracic spine: It is quite common for a problem in the thoracic spine to cause chest wall pain, especially in younger athletes. Usually this referred pain is accompanied by stiffness and tenderness in the middle back, centrally or on one side of the back over the facet or rib joints (usually this pain is felt on the same side of the thorax as the referred chest pain). However, because referred chest pain can be unpredictable and lack a clear pattern, it is important to rule out other possible causes such as chest pain of cardiac origin (from a problem in the heart). This may require medical review (See – atypical causes of thoracic pain).
‘T4 syndrome’: Injury or dysfunction in the intervertebral joints in the upper thoracic spine region can sometimes cause diffuse arm pain, pins and needles or numbness in the upper arm. This collection of symptoms has been called T4 syndrome. It is thought that these symptoms occur because of irritation of the sympathetic nerves that lie close to this part of the spine. There is usually stiffness/restriction in the middle and upper back and a poked forward head posture in addition to arm symptoms.
Costochondritis: This condition involves the joints between the ribs and the sternum. Symptoms involve chest pain and tenderness where the ribs link up to the sternum. Pain is usually flared up with activity that involves pushing/pulling with the arms (e.g. push ups). Costochondritis can be hard to settle, and a combined approach using physiotherapy and medical intervention such as anti-inflammatory medication/injection is more successful.
Sternoclavicular joint injury: The sternoclavicular joint is where the collarbone connects to the sternum and attaches the shoulder blade (scapula) to the thorax. This joint is very strong, with several ligaments. Injury to this joint involves significant trauma such as a direct blow to the chest or shoulder. There is usually localised pain and swelling at the joint, and if a bad enough injury the collarbone may dislocate. This can require medical review to re-position the bones and immobilisation in a sling or bandage, especially if the collarbone slips backwards where it can press onto the trachea (airway), oesophagus and blood vessels.
Scheurmann’s Kyphosis (‘Schmorl’s Nodes’): A common cause of thoracic pain in adolescents. Characterised by an exaggerated rounding (kyphosis) of the middle back. It occurs due to abnormal development and growth of the thoracic vertebrae which causes them to become wedge shaped in the front, causing the increased curvature. This condition requires medical review to determine appropriate management.
Vertebral End Plate Fracture: An end plate fracture is a unique disc related injury caused by excessive compression of the spine. This may occur with a fall from height to land on feet or tail bone, heavy weight lifting or in an accident. They occur more easily in people with weak bones (see osteoporosis). The excessive compression fractures the bone underneath the intervertebral disc, allowing the disc to protrude into the top of the vertebrae. Symptoms are usually worse with impact, weight bearing and coughing/straining. The back is usually very tense and sore
Arthritis: With lots of physical work and ageing the joints and connections in the thoracic spine can display arthritic changes like other joints of the body. Typically, discs lose height as we get older, ligaments thicken and the facet and rib joints become stiffer or arthritic. Thickened bony growths or spurs (osteophytes) may develop on vertebrae and facet joints as part of this process, leading to further stiffness and/or pain. With significant arthritis, there may also be nerve root compression/irritation or stenosis. Arthritic middle backs are typically very stiff and achy, especially first thing in the morning. They feel better with gentle exercise and movement.
Arthritis can affect the joints and discs in the spine. Discs can narrow and bone spurs grow, potentially causing loss of mobility and compression of spinal nerve roots. Image credit: EMed, 2017 (3).
'Soft tissue Injury' - Muscle and Ligament Injury: Any muscle or ligament that supports or controls the spine can be strained or sprained. Muscular strains usually occur when the spine is being loaded, for example when lifting or during sport/exercise. Pain is usually sharp and well localised, reproduced by contraction of the affected muscle. Trigger points (focal areas of tension) in the muscles around the thoracic spine (especially the erector spinae and scapular muscles) can also cause middle back pain, and this may be related to an underlying injury to another spinal structure. Ligament sprains can occur under similar circumstances to muscle strains, or as part of larger injuries such as intervertebral disc injury and fractures of the spine. Where a specific or localised ligament has been injured there is usually focal tenderness and pain when the ligament is stretched in certain directions.
Rib trauma/fracture: injury of any of the ribs may occur due to trauma such as in a car accident, in a sporting incident or a fall. Injured ribs are very sore to touch and sharp pain may be felt on movement, deep breathing and coughing/bracing. Pain usually persists for 3-4 weeks after injury. Bruising may be visible around the injury site. If fractured, painful clicking may be felt. Most rib fractures respond well to conservative management and will heel within 6-12 weeks. In some cases where multiple ribs are broken or the fractures are displaced, surgical intervention may be needed and medical review is important to ensure there is no damage to internal organs, especially the lungs. Where symptoms of shortness of breath are involved urgent medical review should be sought.
Rib stress fracture: A stress fracture (small, un-displaced fracture – like a crack in concrete) can occur where muscles pull on the ribs where they attach. This can be seen in throwing athletes around the first rib where the scalene muscle attach, and in rowers and weightlifters around the 4th and 5th rib where the serratus muscle attaches. Management usually involves identification and correction of sporting technique or training factors.
Rib dislocation: In certain cases of trauma in an accident or sporting injury, a rib can be dislocated from its connections to the spine. It may dislocate either forwards (anterior) or backwards (posterior). Typically, there is painful and restricted movement, and deep breathing or coughing is very difficult. Sensation of or palpable changed location of the rib may be felt, sometimes as a prominence or hollow on the back/flank. Re-positioning manoeuvres and massage can help to restore rib position.
Spinal Fractures: Any vertebrae of the thoracic spine can be fractured where the injury mechanism involves strong enough forces, such as in a car accident, fall or sporting incident. If a person’s bone density is poor (such as with osteoporosis) a more minor incident could lead to a fracture. Fractures can occur in variety of locations, including the body of the vertebrae, the vertebral arch or the points of bone on the back of the vertebrae (spinous and transverse processes). Fractures are usually intensely painful and there is a clear injury mechanism. Immediate review with scans is needed, often requiring medical review and sometimes surgery to ensure healing. At the time of fracture there is also significant soft tissue damage (related to the forces involved at the time of injury), and there is potential for damage to the spinal cord and nerve structures.
Referred pain from the shoulders/neck: In some cases, pain in the middle back may be produced by musculoskeletal structures in the shoulder (glenohumeral joint) or neck (cervical spine). Typically, these body areas cause referred pain in between or around the shoulder blades. Symptoms are usually aggravated by factors relating to the movement of loading of the shoulder/neck. Assessment of your shoulders and neck will help to identify if they are causing your middle back pain and require treatment.
Scoliosis: Scoliosis refers to a lateral curvature of the spine, especially seen in the thoracic region. Whilst it is normal for the spine to have some curvature towards the dominant arm, in some individuals this curvature becomes excessive, resulting in asymmetrical posture, abnormal patterns of muscle development/tightness and pain. Scoliosis is more common in young females and is an acquired condition. In extreme cases, it may even make breathing difficult and there can be significant discomfort with day to day activities. Sometimes there may also be an increased forwards curvature and hump in the thoracic spine, termed a 'kyphoscoliosis'. Conservative management involving stretching and strengthening programs can help in managing acquired scoliosis, but when scoliosis is severe, bracing or surgical review may be required to correct the abnormality.
Atypical causes of thoracic pain: As a final note, it is important to remember that mid back pain can be related to a variety of non-musculoskeletal (non-mechanical) causes. Of particular note are osteoporosis, malignancy (cancer), fibromyalgia, rheumatoid conditions and pain referred from internal organs such as the kidneys. Where chest pain is felt it is important to determine that this is not cardiac (coming from a problem in the heart). Another common presentation is thoracic pain from the shingles (chickenpox) virus, which may have an accompanying skin rash. Typically, pain from these conditions does not have a clear mechanical pattern, and there may be strange aggravating and relieving factors. Associated factors in an individual’s medical history may mean that non-mechanical causes of middle back pain need to be ruled out and reviewed with further medical investigation
1. Mayo Clinic (2017). Disease Conditions – Kyphosis. Retrieved from http://www.mayoclinic.org/diseases-conditions/kyphosis/multimedia/kyphosis/img-20007874
2. Mayfield Brain & Spine (2016). Degenerative Disc Disease (DDD). Retrieved from https://www.mayfieldclinic.com/PE-DDD.htm
3. EMed (2017). Herniated Disc in the Cervical, Lumbar & Thoracic Spine. Retrieved from https://webcontent.temed.com/spine/disorders/disk-hernia
4. Denneroll Spinal Orthotics (2017). Thoracic ScoliRoll. Retrieved from https://www.denneroll.com/portfolio/thoracic-scoliroll/