- T4 syndrome
- Periscapular Muscle Pain
- Lumbar Disc Bulge
- Facet joint pain
- Foraminal stenosis
The spine is divided into 5 sections with varying amounts of vertebrae in each section. The sections are:
- Cervical spine – more commonly referred to as the neck, this has 7 vertebrae
- Thoracic spine – this is essentially the upper and mid back and the largest section of the spine with 12 vertebrae
- Lumbar spine – below the thoracic spine, these 5 vertebrae can be the area a of lower back pain (and even leg pain) originates
- Sacrum: below the lumbar spine, these 5 vertebrae are fused together in humans
- Coccyx: below the sacrum, these small 5 vertebrae are also fused in humans but would be the tailbone in other animals, hence why it is commonly referred to as this
For the purpose of this page, we will focus on the thoracic and lumbar regions, where as the cervical spine can be found on our neck pain page.
(i) T4 syndrome
T4 syndrome, as with most syndromes, is a relatively vague diagnosis that can be applied to symptoms related to issues in the mid-thoracic spine such as stiffness. As mentioned above, there are 12 thoracic vertebrae in the spine, and it is not uncommon for these to stiffen up in the upper to mid regions, particularly between the shoulder blades. T4 refers to the 4th thoracic vertebrae, but whilst this level is commonly a bit stiff, this also applies to the adjacent vertebrae and can be quite a range.
Stiffness here and/or poor postural muscle conditioning can essentially overload certain structures in the region such as facet joints, intervertebral discs and muscles. It can also cause inflammation of the adjacent nerves which then then lead to referred pain.
Signs and symptoms include pain in the back as well as pain, tingling and numbness into the arm and hand. Headaches and neck pain can also come secondary to this and it can even refer pain into the chest and may feel like a bubble is trapped in your chest.
Once diagnosed, treatment focuses on mobilising any stiff segments in the spine. This will be accompanied by strengthening work, such as Pilates, alongside a few simple exercises prescribed by your physio. Postural work is a key focus, but this tends to be in the form of exercises rather than just being told to “stand up straight.” Essentially the aim is to improve the position and posture of the spine, ensuring the right muscles are working at the right time so that the joints, discs and muscles don’t get overloaded.
This complicated-looking word can be broken into its parts to make a lot more sense. ‘Costo-‘ refers to the ribs, ‘chond-‘ refers to cartilage and ‘-itis’ means inflammation. So costochondritis means inflammation of the cartilage of the ribs, in particular the cartilage that joins the breast bone and the upper 8 ribs at the sternocostal joints.
The reason it happens is unclear although may be related to one or more factors including heavy and repeated coughing, physical trauma to the chest, physical strain and chest infections. Importantly from a physiotherapy point of view it may also be secondary to general hypomobility (stiffness) in the upper back.
It is sometimes described as a pressure ont the chest, like wearing a particularly tight seatbelt. Deep breathing, coughing and sneezing can be uncomfortable or in some cases quite sharply painful, and it can also be brought on by physical activity due to the increased volume and rate of breathing increasing the movement in the thorax.
So how is it treated? Well it can settle spontaneously but this can range anywhere from a few days to many months. However, it is a good idea to address the underlying issues that may have brought this on in the first place. This will likely focus on addressing any postural issues that may leading to an excessively flexed (or ‘kyphosed’) thoracic spine. Strengthening of the upper back may also be beneficial, as well as strengthening the pectoral muscles through a good range of movement, as this will also help to stretch them out.
As with everything, though, appropriate treatment will depend on an accurate diagnosis so it is important this is clear before starting treatment.
(iii) Periscapular Muscle Pain
Periscapular muscle pain refers to pain experienced over and around the shoulder blades, or scapulae. This may be more across the tops of your shoulders or in the middle of your shoulder blades. It most commonly happens if these muscles are overworked e.g. holding you in a ‘working posture’ if you sit at a computer all day.
It tends to present as a tightness that “feels like it needs to be stretched,” the exact location depending on the muscles affected. The most common places are across the tops of the shoulders or between the shoulder blades. If the location feels very localised over the spine itself, it may be more of a joint stiffness than purely muscular, although they can often be present together.
Sports massage or deep tissue massage can be very effective at improving the symptoms, and acupuncture can also be effective. However, once the symptoms have settled it’s also important to identify the exact underlying cause(s) of the pain, such as muscle weakness or overuse and it may also be related to postures such as when driving, carrying a young child or when sitting at your desk. Pilates can help to improve the strength, endurance and action of these postural muscles and you will often find significant gains from as little as one session per week.
Using a cable machine in the gym or resistance bands, the exercise below is a very effective exercise to strengthen these periscapular muscles, and as you get better you can start to vary the height of your arms to challenge different muscles in different ways leading to much greater all round strength.
(i) Disc bulge
Also referred to as a disc protrusion, these are the dreaded words many don’t want to hear about our back pain, but hopefully this section will reduce some of those fears and ensure you that there is actually a lot that can be done for this problem.
Intervertebral discs are like water balloons in between the bones in your back. They are present in the neck, upper back and lower back and their primary function is weight-bearing. However, like other tissues in the body there are various ways that discs can be injured including degenerative changes (or “wear and tear”), bulges and hernations to name a few. Now the first thing to say is that degenerative changes are normal and small bulges are also not uncommon, but both these can happen with no pain whatsoever. If you have already had an MRI scan that shows a disc bulge, just be aware that this won’t necessarily be the cause of your pain and there is somewhere between a 60-80% false positive rate on MRI. For the purpose of this article, however, we will look at how disc bulges can cause pain.
Think how a water balloon bulges if you squeeze the opposite end; this is essentially what happens when a disc bulges. The reasons why this happens can be numerous, and the classic description is when lifting a weight incorrectly in the gym, although they can also happen over time related to postural or strength issues in the lower back – sometimes referred to as problems with the “core.” This images below show a healthy disc (left) and a left-sided disc bulge (right). In fact this shows a herniation, the difference being a herniation is more of an extreme version of a bulge where the back of the disc will partially tear.
It should be said that with this sort of injury it is not uncommon to experience pain in the leg. This is where the nerve roots (dark blue on the pictures above) become irritated and since these nerve roots supply the leg it can lead to pain referral in the distribution of this nerve, such as the sciatic nerve where it is referred to as sciatica.
So what can be done about it? Well once a diagnosis has been made, treatment initially focuses on symptom relief which may involve a combination of mobilisations, such as traction, and soft tissue work to help settle down any associated muscle spasm which may exacerbate the problem. This will be accompanied by some gentle mobilisation exercises to return movement to normal such as these two below – remember to just go within your pain-free range.
As any leg pain goes away and symptoms improve, strengthening will be commenced. Quality of spinal movement is particularly important, not just brute strength, so there will be a big focus on perfecting the exercise technique and this is something Pilates can be particularly good for.
In severe cases, surgery may be required but this is really very rare and will be avoided if at all possible.
In most cases, a good recovery can be reached although recovery times will vary significantly depending on the severity of the problem. As always, do get in touch if you have any queries on this and we will be more than happy to answer any questions you may have.
(ii) Facet joint pain
Facet joints are present all the way from the neck down to the lower back, with a left and right one at each level. They help with taking some of the weight off the spine but have a very key role in movement. As you can see from the video below, there are small gliding movements at each level which, when put together, can add up to a lot of movement overall. So when you bend forwards (flexion) the joints open up, and when you bend backwards(extension) they close down.
If there is inflammation in the joints, it will commonly be sore to bend backwards as you are essentially compressing an inflamed joint.
So how do we treat it?
Well initially the aim is to reduce the inflammation and settle the pain, and we do this by offloading the joint i.e. stop putting pressure on it. A combination of mobilisations to open up these joints and get them moving can help a lot – your physio will be able to do this in clinic. This will be accompanied by some simple exercises such as the rotation exercise shown in the section above as well as these knee hugs.
From here we will progress to strengthening exercises with the aim being to both strengthen the muscles as well as ensure they are working at the right time to both move the joints correctly as well as ensure the joints are not excessively loaded. The following two exercises are a good place to start.
(iii) Foraminal Stenosis
What is it?
Spinal stenosis refers to the narrowing of a foramen or tunnel which then presses on a nerve and causes pain. In the spine this can refer to canal stenosis or foraminal stenosis. For the purpose of this article we will focus on foarminal stenosis.
The picture above represents 3 vertebrae, or bones, in the lumbar spine. The nerve roots exit the intervertebral forarmen and then run down the legs.
What are the common signs and symptoms?
Quite simply pain in the lower back and frequently in one or both legs, possibly accompanied by some tingling and/or numbness. If there is a foraminal narrowing on one side, the pain will be more one-sided but if there is narrowing of both foramen, there may well be pain across the lower back and into both legs (although it could also be canal stenosis).
These symptoms are not uncommon for some other back problems so what is key here is how these symptoms come on. If the symptoms in the legs onset within a few minutes when you are in an extended position, such as standing or walking, and then relieve within a few minutes when you sit back down there is a good chance stenosis is present in the lumbar spine.
So what can be done about it?
Physiotherapy is your first port of call. In the earlier stages some simple mobilisations can open up the joints and improve the movement in the lumbar spine – your physio will be able to do this. This may well be accompanied by these knee hugs which open up the foramen.
However, while these are all well and good for settling the symptoms, our ultimate aim is to prevent them coming back. What’s important here to think about is the anatomy.
If you imagine in one of the foramen there is bit of extra bone that has been created down at the top of the foramen. As we stand up the weight is taken by the paraspinal muscles and, particularly as these start to fatigue, the facet joints (see article above). Therefore as the muscles fatigue the spine will compress vertically which will mean that bit of bone may start to impinge a little on the nerve below, setting off the symptoms. The answer in this case is strengthening work. Now this doesn’t mean you suddenly need to turn into a ‘gym bunny’ and start hitting the weights a few times a week, and actually this may not necessarily be the best thing for it. One of the most effective types of exercises for activating these paraspinal postural muscles is Pilates and you should be able to see within within 4-6 sessions a notable improvement which will then continue from there.
What if physio and/or Pilates doesn’t work?
Surgery is an option and can be very effective in the right case. The surgery is called a foraminotomy and is explained nicely in the animation below.
Post-operatively it is recommended that adequate rehabilitation takes place in order to address the reasons why it happened in the first place. Again, this will likely involve a combination of physio and Pilates in order to build up the strength in the supporting muscles of the spine and ensure good movement.