There is a distinct lack of specific literature related to mechanical thoracic pain and this is all of a poor quality. Non-specific or mechanical thoracic pain can be defined as pain, tension, soreness and/or stiffness in the mid back or thoracic region. It is evoked by noxious stimulation of structures in the thoracic spine (Bogduk, 2009).

The mid back or thoracic region extends from the prominence of the C7 spinous process to the bottom of the rib cage. Some individuals may also feel pain around their chest wall, or isolated patches of pain, but spinal pain usually predominates (Appendix 2).

Cause

In approximately 90% of patients with low back pain (LBP) no specific patho-anatomic cause can be found (CSAG, 1994). It is likely to be the same for the thoracic spine.

Several structures in the thoracic spine including the joints, discs, muscles, nerves, vascular and connective tissues may be responsible for the pain symptoms but it is often not possible to identify a specific cause (Bogduk, 2009). Other structural causes may also be relevant e.g. Scheuermann's disease, osteoporotic collapse, thoracolumbar or cervicothoracic scoliosis, ankylosing spondylitis, chronic pain.

Mechanical thoracic pain can often be mistaken for visceral-originating symptoms (Appendix 3) (McKenzie and May, 2006). Pain around the scapular region and upper thoracic spine may also be from cervical origin (Cloward, 1959) and therefore any combination of neck and scapular or shoulder pain is probably referred from the cervical spine (McKenzie and May, 2006).

Prevalence

It has been estimated that there is a 3% population prevalence for thoracic pain (Linton et al, 1998). In a population study of 35 – 45 year olds, 66% had reported spinal pain in the previous year. Of this, 15% was in the thoracic area, 56% reported LBP and 44% reported cervical pain (Linton et al, 1998). It has also been reported that patients with thoracic pain represent 2.6% of the musculoskeletal physiotherapy caseload within the UK (McKenzie and May, 2006).

Presentation

Pain presentation is usually in a local area but symptoms are variable within the thoracic spine with or without referred symptoms or isolated patches to anterior chest or trunk (Appendix 2)

• Upper thoracic refers around the scapulae and upper chest wall
• Mid thoracic refers below the scapulae and around chest wall
• Lower thoracic refers into lumbar and pelvic area below the ribs (McKenzie and May, 2006)
• Postural changes due to accommodation of the pain may be present
• Larger breast size
• Restricted and painful back movements
• Mechanical thoracic pain may be associated with kyphotic or scoliotic deformity

Imaging and investigations are not routinely required to diagnose or assess mechanical thoracic pain (NICE, 2015).

First, consider supported self management (SSM) and conservative treatment options

Link to exit/redirection and health improvement

Anatomical/Biomechanical considerations

Stability from rib cage

variability of anatomy

Upper T/S approach as C/S

Lower T/S approach as L/S

Maintenance of extension as needed.

Timeframes/natural history

The natural history of mechanical thoracic pain has not been specifically described in the literature. Clinical experience would suggest its natural course will be similar to the lumbar and cervical spines with a recurrent episodic presentation.

Progressing as expected (up to 3 Rxs) before discharge or onward referral.

Consider general progression/escalation advice.

Onward referral is not usually considered necessary for thoracic pain unless red flags or non-mechanical pathologies are suspected or in the presence of undiagnosed structural deformity.

/B/gduk, N. (2009). On the definitions and physiology of back pain, referred pain, and radicular pain. Pain. 147. 17 – 19 Link Here (link correct as of 19/06/2019). NHS Scotland Athens username and password may be required.

Clinical Standards Advisory Group (CSAG) on low back pain. 1994. Report of a CSAG Committee on Back Pain. HMSO.

Cloward, R., 1959. Cervical Diskography: A Contribution to the Etiology and Mechanism of Neck, Shoulder and Arm Pain. Annals of Surgery, 150:1052 – 1064. Link Here (link correct as of 19/06/2019). NHS Scotland Athens username and password may be required.

Conroy, J.L/ and Schneiders, A.G. 2005. The T4 Syndrome, Case Report. Manual Therapy, 10 (4): 292-296 Link Here (link correct as of 19/06/2019). NHS Scotland Athens username and password may be required.

Defranca, G.D. and Levine,LJ, 1995. The T4 Syndrome. Journal of Manipulative and Physiological Therapeutics, 18 (1): 34-37 Link Here for abstract (link correct as of 19/06/2019). NHS Scotland Athens username and password may be required.

Evans, P. 1997. The T4 Syndrome, some basis Science Aspects. Physiotherapy, 83(4): 86-189 Link Here (link correct as of 19/06/2019). NHS Scotland Athens username and password may be required.

Jowsey, P. and Perry, J. 2010. Sympathetic nervous system effects in the hands following a grade 111 posterior-anterior rotatory mobilisation technique applied to T4: A randomised, placebo-controlled trial. Manual Therapy 15(3): 248-253 Link Here (link correct as of 08/11/2019). NHS Scotland Athens username and password may be required.

McKenzie, R., May, S., 2006. The Cervical and Thoracic Spine: Mechanical Diagnosis and Therapy. Spinal Publications.

Mellick,G.A. and Mellick, L.B. 2006. Clinical presentation; Quantitative Sensory testing and therapy of 2 patients with Fourth Thoracic Syndrome. Journal of Manipulative and physiological therapeutics, 29 (5): 403-407 Link Here (link correct as of 19/06/2019). NHS Scotland Athens username and password may be required.

Nice – Non Specific Neck Pain: https://cks.nice.org.uk/neck-pain-non-specific (link correct as of 08/11/2019