What is thoracic joint dysfunction and how does it happen?
Thoracic mechanical intersegmental joint dysfunction is a area of the thoracic spine that demonstrates improper movement. This improper movement most commonly results in local discomfort. Research suggests two basic origins of ISJD, mechanical and reflexive. Mechanical dysfunction arises from an outside force acting on a segment for either; a brief trauma or an extended period of overuse. Some experts believe the cause of altered joint mechanics may begin from an imbalance between the associated muscle groups (3). Psychological and emotional factors may contribute. Hypomobility of these joints in the back is thought to produce concurrent increased local nociceptive (pain) activity and (4,5,6,7).
ISJD may give rise to a self-perpetuating cycle of discomfort in which the negative effects of hypomobility are perpetuated by inflammation, muscular hypertonicity (via Hilton's Law) and imbalance. Joint dysfunction is rarely an isolated event as dysfunction in one segment often leads to involvement of other segments and the spine as a whole (3). Longstanding joint dysfunction is thought to result in premature degenerative change (8).
How common is thoracic joint dysfunction?
While the specific incidence of thoracic intersegmental joint dysfunction is difficult to estimate, complaints involving the thoracic region compromise of approximately 15% of all spinal problems. (9) The one-year prevalence of thoracic spine pain is estimated at 17%, much lower than the frequency of cervical and lumbar complaints. (10) Thoracic spine pain has received considerably less attention than its cervical and lumbar counterparts, yet can be equally disabling (11-13).
Who is affected by thoracic joint dysfunction and pain?
Thoracic spine complaints affect all age groups. (14) Up to 10% of adolescents have experienced thoracic spine pain that has interfered with school or leisure activities (15). The use of backpacks seems to correlate with adolescent thoracic spine pain (15-16). Adolescent females are affected slightly more frequently than males (16).
What are the symptoms of thoracic joint dysfunction?
Clinically, thoracic intersegmental joint dysfunction presents as one sided/midline back pain. Thoracic ijoint dysfunction has the potential to disrupt the biomechanics in associated areas of the spine, costovertebral joints, and shoulder, thereby producing distant secondary complaints. (11,17,18). Thoracic dysfunction has been related to problems in the neck, shoulder, arms, and anterior chest (22,56,57). Thoracic ISJD may alter normal respiration and contribute to breathing difficulties (11).
Global and intersegmental motion deficits are the hallmarks of thoracic joint dysfunction (19). Doctors routinely use motion palpation to determine an areas excess or decrease in movement (24-26). Clinicians must also assess costovertebral (rib) joints, as movement of the thoracic spine is intimately coupled with rib function (27-31).
Are x-rays or other imaging necessary?
Plain film radiography (x-ray) is of limited value except in cases of trauma (44). Radiographs are appropriate for patients with “red flags”. Radiographs may be needed to rule out suspicion of vertebral compression fractures.
Advanced imaging may be appropriate for patients with a history of major trauma, severe neurologic compromise, or suspicion of vertebral infection (45). However, MRI demonstrates the presence of thoracic disc herniation in 37% of asymptomatic patients, and disc bulge in 53%. (58)
What are the best conservative treatment options for thoracic joint dysfunction?
Treatment should focus on restoring joint mobility, stretching hypertonic tissues, and correcting postural faults. Manipulation has proven benefit in the treatment of thoracic spine complaints (32,47,48). Improvement is noted after an average of three to six treatments (32,48). Thoracic spine manipulation has been shown to immediately increase muscle strength (51). Home self-mobilization on a foam roller, ball, or other apparatus may improve outcomes (54,55).
Motion limitations often involve contractile elements as well as joints. Myofascial release and stretching may be necessary to address the paraspinal, intercostal, and shoulder girdle musculature. Postural abnormalities, including an increased kyphosis or rounded shoulders are associated with thoracic spine pain (52).
Therapy modalities, including ice, heat, ultrasound, or e-stim may provide temporary benefit. (53)
1. Leach RA. The chiropractic Theories: A textbook of scientific research. Lippincott Williams, and Wilkins 2004:8
2. Peterson DH, Bergmann TF. Chiropractic technique: principles and practice. 2nd ed. St. Louis: Mosby; 2002
3. Lewit K. Manipulative Therapy: Musculoskeletal Medicine. Churchill Livingstone / Eselvier, 2010
4. Schaible H, Grubb B. Afferent and spinal mechanisms of joint pain. Pain 1993; 55:5-54.
5. Jozsa L, Balint J, Kannus P, Jarvinen M, Lehto M. Mechanoreceptors in human myotendinous junction. Muscle Nerve 1993; 16:453-7
6. Peterson D. Principles of adjustive technique. In: Bergmann T, Peterson D, Lawrence D, editors. Chiropractic technique. New York: Churchill-Livingstone; 1993. p. 123-95.
7. Peterson D, Bergmann T. Joint assessment principles and procedures. In: Bergmann T, Peterson D, Lawrence D, editors. Chiropractic technique. New York: Churchill Livingstone; 1993. p. 51-121.
8. DJD = C/S 30
9. Linton SJ, Hellsing AL, Hallden K. A population-based study of spinal pain among 35-45-year-old individuals. Prevalence, sick leave, and health care use. Spine (Phila Pa 1976) 1998 Jul 1;23(13):1457-1463.
10. Niemelainen R, Videman T, Battie M. Prevalence and characteristics of upper or mid-back pain in Finnish men. Spine 2006;31(16):1846-9.
11. Edmondston SJ, Singer KP: Thoracic spine: anatomical and biomechanical considerations for manual therapy. Man Ther 1997, 2:132-143.
12. Briggs AM, Bragge P, Smith AJ, Govil D, Straker LM: Prevalence and associated factors for thoracic spine pain in the adult working population. A literature review.J Occup Health 2009, 51:177-192.
13. Cesar Fernandez-de-las-Penas et al. Changes in Neck Pain and Active Range of Motion After a Single Thoracic Spine Manipulation in Subjects Presenting with Mechanical Neck Pain: A Case Series Journal of Manipulative and Physiological Therapeutics, Volume 30, Issue 4, May 2007, Pages 312-320
14. Andrew M Briggs, Anne J Smith, Leon M Straker and Peter Braggs Thoracic spine pain in the general population: Prevalence, incidence and associated factors in children, adolescents and adults. A systematic review BMC Musculoskeletal Disorders 2009, 10:77
15. Kujala UM, Taimela S, Viljanen T: Leisure physical activity and various pain symptoms among adolescents. Brit J of Sports Med 1999, 33:325-328.
16. Andrew M Briggs, Anne J Smith, Leon M Straker and Peter Bragge Thoracic spine pain in the general population: Prevalence, incidence and associated factors in children, adolescents and adults. A systematic review BMC Musculoskeletal Disorders 2009, 10:77
17. Gregory PL, Biswas AC, Batt ME. Musculoskeletal problems of the chest wall in athletes. Sports Med. 2002;32(4):235–250.
18. Karlson KA. Thoracic region pain in athletes. Curr Sports Med Rep. 2004;3(1):53–57.
19. Humphreys BK, Delahaye M, Peterson CK. An investigation into the validity of cervical spine motion palpation using subjects with congenital block vertebrae as a 'gold standard'. BMC Musculoskelet Disord. 2004 Jun 15;5:19
20. Weber M, Uehlinger K, Gerber H. Osteoporotic vertebral compression fracture causing neurologic deficit. J Clin Rheumatol. 2002;8(3):166-73.
21. Weninger P, Schultz A, Hertz H. Conservative management of thoracolumbar and lumbar spine compression and burst fractures: functional and radiographic outcomes in 136 cases treated by closed reduction and casting. Arch Orthop Trauma Surg. 2009;129(2):207-19.
22. Gregory PL, Biswas AC, Batt ME. Musculoskeletal problems of the chest wall in athletes. Sports Med. 2002;32:235–250.
23. Fruth SJ. Differential diagnosis and treatment in a patient with posterior upper thoracic pain. Phys Ther. 2006 Feb;86(2):254-68.
24. Potter L, McCarthy C, Oldham J. Intraexaminer reliability of identifying a dysfunctional segment in the thoracic and lumbar spine. J Manipulative Physiol Ther. 2006;29:203–207.
25. Cleland JA, Childs JD, Fritz JM, Whitman JM. Interrater Reliability of the History and Physical Examination in Patients With Mechanical Neck Pain. Arch Phys Med Rehabil 2006 10;87(10):1388-1395.
26. Heiderscheit B, Boissonnault W. Reliability of Joint Mobility and Pain Assessment of the Thoracic Spine and Rib Cage in Asymptomatic Individuals. Journal of Manual and Manipulative Therapy 2008 12;16(4):210-216.
27. Lee D. Biomechanics of the thorax: A clinical model of in vivo function. J Man Manip Ther. 1993;1(1):13–21.
28. Scaringe JG, Ketner C. Manual methods for the treatment of rib dysfunctions and associated functional lesions. Topics in Clinical Chiropractic 1999;6 :20– 38.
29. Bland JH. Diagnosis of thoracic pain syndromes. In: Giles LGF, Singer KP, eds. The Clinical Anatomy and Management of Thoracic Spine Pain. Boston, Mass: Butterworth-Heinemann; 2000:145–156.
30. Bookhout MR. Evaluation of the thoracic spine and rib cage. In: Flynn TW. The Thoracic Spine and Rib Cage: Musculoskeletal Evaluation and Treatment Boston, Mass: Butterworth-Heinemann; 1996:147–167.
31. Triano JJ, Erwin M, Hansen DT. Costovertebral and costotransverse joint pain: a commonly overlooked pain generator. Topics in Clinical Chiropractic 1999;6 :79-92
32. Linda Schiller, Effectiveness of Spinal Manipulative Therapy in the Treatment of Mechanical Thoracic Spine Pain: A Pilot Randomized Clinical Trial J Manipulative Physiol Ther 2001;24:394-401
33. Hicks GE, Fritz JM, Delitto A, Mishock J. Interrater reliability of clinical examination measures for identification of lumbar segmental instability. Arch Phys Med Rehabil 2003;84 :1858– 1864.
34. Maher C, Adams R. Reliability of pain and stiffness assessments in clinical manual lumbar spine examination. Phys Ther 1994;74 :801– 811.
35. Boline PD, Haas M, Meyer JJ, et al. Interexaminer reliability of eight evaluative dimensions of lumbar segmental abnormality: part II. J Manipulative Physiol Ther 1993;16 :363– 374.
36. Riddle DL. Measurement of accessory motion: critical issues and related concepts. Phys Ther 1992;72 :865– 874.
37. Lee M, Steven GP, Crosbie J, Higgs RJ. Variations in posteroanterior stiffness in the thoracolumbar spine: Preliminary observations and proposed mechanisms. Phys Ther. 1998;78:1277–1287.
39. Giamberardino MA, Affaitati G, Lerza R, Laurentis SD. Neurophysiological basis of visceral pain. Journal of Musculoskeletal Pain 2002;10 :151-163
40. Melton LJ 3rd, Kan SH, Frye MA, et al. Epidemiology of vertebral fractures in women. Am J Epidemiol 1989;129:1000–11
41. Ridenour TR, Haddad SF, Hictchon PW, Piper J, Traynelis VC, Van Gilder JC. Herniated thoracic disks: treatment and outcome. J Spinal Disord 1993;6:218-24
42. Carson J, Gumpert J, Jefferson A. Diagnosis and treatment of thoracic intervertebral disk protrusions. J Neurol Neurosurg Psychiatry 1971;34:68-77.
44. Cates JR et al. Chiropractic Clinical Compass Chiropractic Management of Thoracic Spine Conditions: A Literature Synthesis. CCGPP
45. Chou R, Fu R, Carrino JA, Deyo RA. Imaging strategies for low-back pain: systematic review and meta-analysis. Lancet. 2009;373:463.-72
47. Giles LGF, Muller R. Chronic Spinal Pain: A Randomized Clinical Trial Comparing Medication, Acupuncture, and Spinal Manipulation. Spine 2003 (Jul 15); 28 (14): 1490–1502
48. Triano JJ, Hondras MA, McGregor M. Differences in treatment history with manipulation for acute, subacute, chronic and recurrent spine pain. J Manipulative Physiol Ther. 1992;15:24–30
50. George SZ, Bishop MD, Bialosky JE, Zeppieri G, Jr., Robinson ME. Immediate effects of spinal manipulation on thermal pain sensitivity: An experimental study. BMC Musculoskelet Disord. 2006;7:68.
51. Cleland JA, Selleck B, Stowell T, et al. Shortterm effects of thoracic manipulation on lower trapezius strength. J Man Manip Ther. 2004;12:82–90.
52. Griegel-Morris P, Larson K, Mueller-Klaus K, Oatis C. Incidence of common postural abnormalities in the cervical, shoulder, and thoracic regions and their association with pain in two age groups of healthy subjects. Phys Ther 1992;72(6):425-31.
53. Fuentes JP, Armijo Olivo S, Magee DJ, Gross DP. Effectiveness of interferential current therapy in the management of musculoskeletal pain: a systematic review and meta-analysis. Phys Ther. 2010 Sep;90(9):1219-38
54. Johnson KD, Grindstaff TL. Thoracic Region Self-Mobilization: A Clinical Suggestion. Int J Sports Phys Ther. 2012 April; 7(2): 252–256.
55. Johnson KD, Kim KM, Yu BK, Saliba SA, Grindstaff TL. Reliability of thoracic spine rotation range-of-motion measurements in healthy adults. J Ath Train. 2012;47(1):52–60
56. Menck JY, Requejo SM, Kulig K. Thoracic spine dysfunction in upper extremity complex regional pain syndrome type I. J Orthop Sports Phys Ther. 2000;30:401–409.
57. Arroyo JF, Jolliet P, Junod AF. Costovertebral joint dysfunction: Another misdiagnosed cause of atypical chest pain. Postgrad Med J. 1992;68:655–659.
58. Wood KB, Garvey TA, Gundry C, Heithoff KB, Magnetic resonance imaging of the thoracic spine. Evaluation of asymptomatic individuals, J Bone Joint Surg Am. 1995 Nov;77(11):1631-8.
59. Bogduk, N.; Marsland, A. "The Cervical Zygapophysial Joints as a Source of Neck Pain," Spine 13:610, 1988