UPPER BACK | RIB PAIN
a. Thoracic Spine
i. Costovertebral & Costotransverse Joint Pain
Costotransverse and costovertebral joint disorders are associated with localised tenderness and reduced joint mobility. These symptoms are pronounced on active movements of the thoracic spine in one or more direction, and may be aggravated with deep inspiration. Symptoms may present in either acute or chronic settings depending on the individual and the mechanism of injury. One or more thoracic vertebrae or ribs may be involved.
You can expect to feel restriction in your range of motion, pain on movement or deep inspiration, and associated muscle guarding.
We initially manage this condition with hands on manual therapy, including joint mobilisation to facilitate normal joint movement. Heat, activity modification and bakball may be recommend to manage symptoms.
Longer term we look to addressing any underling dysfunctions or technique correction to reduce future aggravation.
ii. T4 syndrome
T4 syndrome is an uncommon condition that presents with arm pain, headache, sensory changes in hands (paraesthesia) and mid-scapular tightness resulting from upper thoracic joint dysfunction. The combination of spread symptoms has been referred to as T4 syndrome, however is not currently verified clinically. The condition is thought to develop from the sympathetic nervous system.
On examination, a combination of thoracic hypomobility and shoulder protraction is present. Management is directed towards improving thoracic mobility and scapular positioning. Longer term we look to return to activity and sport pathways.
iii. Scheuermann’s disease
Scheuermann’s disease is a common cause of thoracic pain in adolescents. The condition is marked by multiple vertebral end-plate irregularities. The condition is characterised by a low thoracic kyphosis seen in adolescents. The severity of the condition may range from mild to severe depending on the deformity. In adolescents training in static positions for prolonged periods such as cycling, may need to be modified to avoid aggravation in long term management of symptoms. An inability to participate in physical activity may also be experienced, leading to increased sedentary behaviour.
You can expect to feel muscle tightness and fatigue, intermittent back pain, and reduced flexibility on assessment.
We initially look for this in the initial assessment: postural abnormalities, thoracic kyphosis, positive Adam’s test – structural or functional scoliosis, muscle length discrepancies, reduced range of motion, and muscular strength of trunk and gluteal.
Initially we manage the condition with bracing and exercise in mild cases. Moderate to severe cases may require surgical intervention to manage.
Thoracic disc pathologies are classified by the severity of the disc injury and subsequent symptoms. In general, thoracic disc will present with mid back pain around the site of the issue. In instances where the nerve root is compressed, pain and/ or altered sensation may be present at the rib cage from the back to the front of the chest. Often a patient will report pain with cough, sneeze or deep inspiration.
We initially look at the thoracic range of motion, strength, sensation, neural mobility and joint mobility. We may refer for imaging depending on the severity of the symptoms.
Initially we manage the condition with education, hands on manual therapy, taping, heat and NSAIDs if required. Longer term we look to include exercises to improve strength and movement, before commencing return to activity and sport.