+ MODEL

Journal of Bodywork & Movement Therapies (2013) xx, 1e8

Available online at www.sciencedirect.com

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CASE REPORT

Lower thoracic syndrome e A differential

screen for back pain following vertical
compression injury: A case report
Deepak Sebastian, DPT, ND, PhD, OCS, FAAOMPT

Institute of Therapeutic Sciences, Residency in Orthopaedic Physical Therapy, Fellowship in

Orthopaedic Manual Physical Therapy, 51008 Richard Drive, Plymouth, MI 48170, USA

Received 2 September 2013; received in revised form 8 December 2013; accepted 14 December 2013

KEYWORDS Summary A 36-year-old male experienced left sided back and radiating flank pain, following
Vertical compression; a fall on his buttock. A detailed medical evaluation ruled out the presence of red flags. Initial
Lower thoracic; examination revealed positive findings of comparable local tenderness over the left T11, T12
Flank pain and left paraspinal area, and a 2 cm shortening of the left leg. 8 treatment visits for a period of
4 weeks addressed mechanical dysfunction at the T11, T12, lumbar and pelvic region,
comprising manual therapy, therapeutic exercise and pain relieving modalities. Reduction of
local tenderness, back and radiating flank pain was observed. Additionally, resolution of the
persistent apparent shortening of his left leg was observed, following a high velocity thrust
(HVT) manipulation of the T11, T12 segments. The vertebral motion segment of T11, T12,
the thoracoabdominal nerves, the 12th rib, the quadratus lumborum and the serratus posterior
inferior are speculated to be potential symptom mediators. The findings in the case report sug-
gest the lower thoracic region to be included during the evaluation process of back pain, espe-
cially when the mechanism of injury is a vertical compression.
ª 2014 Elsevier Ltd. All rights reserved.

Introduction is considered to be primarily related to biomechanical

Back pain, being a universal experience among the adult
population, can have a spondylogenic, neurogenic, vis-
cerogenic or psychogenic source. The spondylogenic source
E-mail address: institutemanualpt@yahoo.com.
challenges in the lumbar vertebrae and the structures
supporting the intervertebral motion segment, namely the
disc, nerve root, facet joint, ligaments and muscles
(Jinkins, 2004). This model also includes the pelvic complex
and the hip joint as contributing factors (Simopoulos et al.,
2012). The junction formed between the twelfth thoracic
vertebrae and the first lumbar vertebrae, has also been

1360-8592/$ - see front matter ª 2014 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.jbmt.2013.12.009

Please cite this article in press as: Sebastian, D., Lower thoracic syndrome e A differential screen for back pain following vertical
compression injury: A case report, Journal of Bodywork & Movement Therapies (2013), http://dx.doi.org/10.1016/j.jbmt.2013.12.009
 + MODEL
2 D. Sebastian

described as a potential source (Maigne, 1980; Sebastian,

2006).
The lower thoracic region, unlike the upper and mid
thoracic region, is infrequently described as a source of
musculoskeletal pain and dysfunction. The clinical muscu-
loskeletal entities described to cause pain and dysfunction
in this region are thoracic disc herniations (Angevine and
McCormick, 2012), thoracolumbar junction syndrome
(Maigne, 1980; Sebastian, 2006) and the twelfth rib syn-
drome (Keoghane et al., 2009; Cranfield et al., 1997). The
T11, T12 vertebrae have been described to be vulnerable
for injury, the mechanisms which include vertical
compression and flexion compression (Weninger et al.,
2009). These, however, are described to cause stable or
unstable fractures of the vertebrae. Traumatic vertical
compression injuries that do not result in a fracture are
poorly documented as a source of pain. A single impact fall
on the buttock can transmit forces that are 6.4e9.0 times
body weight (Sran and Robinovitch, 2008) with the added
risk of burst fractures of the lower thoracic and upper
lumbar vertebrae (Wilcox et al., 2003). Researchers
describe the thoraco-lumbar junction to be vulnerable for
compression injuries even with a minor slip and fall on the
buttock (Weber et al., 2002). Hence, the inadequacy of
supporting literature, of this clinically relevant mechanism
of injury, directs clinicians to be aware of it. This is espe-
cially important when anecdotal patient histories suggest a Figure 1 Reported pain locations.
slip and fall on the buttock on slippery floors, icy sidewalks,
while skating or roller-blading, or a fall off a horse. We
speculate that when bony disruption does not occur in a did not seek immediate medical help as the pain had sub-
single or sustained traumatic event, the structures of the sided to a tolerable intensity. He works as a graphics en-
vertebral motion segment (the facet joint, exiting nerve gineer and reports spending long hours sitting in front of a
root, supporting muscles and ligaments) are subjected to computer at work. His discomfort would gradually progress
stress, consequently resulting in dysfunction (Quinn et al., in sitting and would surge if he attempted to slouch. Moving
2010; Cavanaugh et al., 1996; Solomonow, 2012; around would help relieve some of the symptoms but would
Alexander, 1985). While literature suggests vertical return in any one position sustained for too long. He re-
compression to cause lower thoracic fractures, the possi- ported occasional sharp and shooting pain into the left flank
bility of dysfunction in the absence of a fracture needs area. He rated this pain as 8 on a scale of 10 using the
consideration. This case report aims to offer an insight to Numerical Pain Rating Scale (NPRS) (Chapman et al., 2011).
this speculation. It suggests that several structures in the His pain was partially relieved by heat and resting. He re-
lower thoracic region are susceptible, when the mechanism ported of the pain disturbing his sleep, very occasionally.
of injury is a vertical compression. These structures are the The pain gradually progressed to the lower lumbar and
vertebral motion segments of the lower thoracic spine, the pelvic regions on the left, which he described as a nagging
12th rib, the quadratus lumborum (QL), the serratus pos- aching pain. Owing to the persistence of pain and discom-
terior inferior (SPI) and the thoracoabdominal nerves. fort he consulted his physician 6 months later and under-
went a detailed examination of his spine and kidneys,
which included X-rays and an MRI. He was ruled out for
Case description vertebral fracture and kidney disease and referred to
physical therapy with a diagnosis of ‘back pain’.
History and clinical findings
Testing
A 36-year-old male who experienced symptoms of left sided
lower thoracic and back pain with pain radiating into the Observation revealed the patient to be in minimal distress
left flank, is presented (Fig. 1). The pain was reported to on movement. In standing, a minor curvature with con-
have started following a direct vertical compression on the cavity on the left was observed in the lower thoracic and
buttocks, when the patient jumped into a mud pit with his thoraco-lumbar region. Lumbar flexion in sitting revealed
hips and knee flexed. This incident had occurred 8 months reversal of lordosis with terminal restriction at 60
. Addi-
ago. He reported that the mud pit was harder than ex- tionally, reproduction of local discomfort in the lower
pected in consistency and felt like he was landing on a semi thoracic and thoracolumbar area was observed. This was
hard surface. He experienced a sharp pain immediately further aggravated in a slump or slouch sitting position.
which lingered for a few minutes and subsided to a marked Lumbar flexion in standing measured 60
with minimal
soreness in the lower thoracic and thoracolumbar area. He discomfort in the lumbar region and a mild stretch in the

Please cite this article in press as: Sebastian, D., Lower thoracic syndrome e A differential screen for back pain following vertical
compression injury: A case report, Journal of Bodywork & Movement Therapies (2013), http://dx.doi.org/10.1016/j.jbmt.2013.12.009
 + MODEL
Lower thoracic syndrome: A differential screen for back pain
hamstring area. Repeated lumbar flexion revealed no
changes. Lumbar extension was full with minimal discom-
fort in the lower thoracic region and repeated lumbar
extension revealed no change. Side bending reproduced
discomfort bilaterally, right more than left with movement
restriction at 10
. Right rotation reproduced discomfort
with a range of 20
.
The transverse processes of T10, T11, T12 were palpated
in the prone lying position (Fig. 2). Firm palpation revealed
local tenderness in this area with comparable tenderness
over the left T11, T12 vertebral segment.
In prone lying, with the elbows flexed and the chin
resting on the palms on the hands, firm postero-anterior
pressure was applied over the left lateral aspect of T10,
T11, T12. This reproduced minimal symptoms at T10, T11,
and marked symptoms at T11, T12. The clinician then
placed all fingers except the thumb, under the lower costal
margin of the 12th rib, and pulled the hands in a superior
and anterior direction. This reproduced discomfort in the
twelfth rib area, but was not comparable to the original
pain. Additionally, a 2 cm shortening was observed in the
left lower extremity.
Neurological examination revealed intact lumbo-sacral
dermatomes, myotomes, deep tendon reflexes, and a
normal Babinski reflex. He denied bladder and bowel dis-
turbances. Manual muscle testing revealed core weakness.
Currently there is no validated method to assess core
lumbo-pelvic strength, hence the standard abdominal
muscle testing as described by Kendall, was used. With the
patient lying supine, the legs were raised to 60
passively.
The patient was asked to tuck in his abdomen to flatten his
lordosis. He was instructed to continue breathing. Now the
patient was asked to lower the legs actively without losing
the stomach tucked in position and the flattened lordosis.
The test suggests that if the stomach tucked in position and
the flattened lordosis was not maintained at about 60
it is
graded as ‘poor’. This patient was unable to maintain the
stomach tucked and flattened lordosis position, at 60
.
Subsequently, the patient tested negative for the clinical
prediction rule for lumbar instability (Hicks et al., 2005),
despite weakness of the core. However, this test cluster has
a sensitivity value of 0.55 and specificity value of 0.86,
Figure 2 Site of local tenderness.
Please cite this article in press as: Sebastian, D., Lower thoracic syndrome e A differential screen for back pain following vertical
compression injury: A case report, Journal of Bodywork & Movement Therapies (2013), http://dx.doi.org/10.1016/j.jbmt.2013.12.009
3
hence not the gold standard to identify the presence of
instability. Additionally, he exhibited signs of creep
(Sanchez-Zuriaga et al., 2010) as in the need to constantly
shift positions to be comfortable and difficulty coming up
from sit to stand without back pain. Hence, despite testing
negative for the prediction rule for instability, the presence
of weakness and signs of creep indicated the possibility of
core weakness. His Oswestry score on initial examination
was 11/50 (Maughan and Lewis, 2010), with most difficulty
reported in sitting 2, sleeping 2 and social life 1. Pain in-
tensity on the Oswestry was marked as 4, traveling 1 and
employment 1.
Evaluation, diagnosis, and prognosis
The differential screen with the current pain presentation
recommends ruling out the possibility of a vertebral
fracture, visceral pathology especially renal, hepato-
biliary and gastrointestinal, thoracolumbar junction syn-
drome and 12th rib syndrome. The patient had undergone
a detail medical evaluation prior to being referred to
physical therapy. This included a visceral screen, X-rays
and MRI to rule out the possibility of a fracture or
neurological pathology, including the presence of a
thoracic disc herniation. He was assured that the findings
were negative and suggested that the presentation was
musculoskeletal requiring the expertise of a physical
therapist.
Attention to the thoraco-lumbar junction may be
mandate, especially with a history of vertical compression
injury (Weninger et al., 2009). In the absence of fracture
and in the presence of a junction syndrome, the clinical
presentation includes gluteal, hip and groin pain with a
positive iliac crest sign. The iliac crest sign described pain
being reproduced over the lateral aspect of the iliac crest
when the skin and muscle layers over this area, is rolled
with the examiners fingers. However, the classic presen-
tation of thoraco-lumbar junction dysfunction (Maigne,
1980; Sebastian, 2006) was absent in this clinical
presentation.
The differential diagnosis for flank pain from a muscu-
loskeletal perspective, includes the previously described
‘12th rib syndrome’ (Keoghane et al., 2009). This has also
been described as a form of intercostal neuralgia and can
be missed since a thorough clinical examination for patients
with flank pain is usually not performed. Confirmation is
typically made by exactly reproducing the patient’s pain on
point compression over the tip of the involved rib, usually
the 12th or 11th or at the 10th costchondral junction. The
‘hooking maneuver’ is a simple clinical test (Keoghane
et al., 2009), in which the examining clinician can repro-
duce agonizing pain by placing his or her hand underneath
the lower costal margin and pulling anteriorly. This test was
however negative in this patient, with no reproducible
tenderness over the costochondral junctions in the lower
thoracic region.
Given the above findings it was concluded that the
patient presented with mechanical somatic dysfunction of
the T11, T12 vertebral segments with possible irritation of
the left lower thoracoabdominal nerve. This was
concluded by the restricted mobility of the lumbar spine
 + MODEL
4 D. Sebastian
in thoracolumbar flexion, right side bending and rotation,
with radiating pain to the left flank. Additionally, there
was protective guarding of the serratus posterior inferior
and left quadratus lumborum with a visible left leg
shortening. Suprapelvic pelvic hypertonocity especially
the quadratus lumborum has been described to cause
apparent leg shortening on the ipsilateral side (Knutson,
2005). Increased contraction of the quadratus lumborum
with increased vertical loading may have been the cause
for the hypertonicity (McGill et al., 1996) and resultant leg
length discrepancy. Protective guarding of the serratus
posterior inferior was confirmed by the active trigger point
causing pain reproduction on palpation at the level of the
lateral and lower 3e4 ribs (Travell et al., 1983) with
reproduction of pain on thoracolumbar flexion, lumbar
side bending and rotation to the opposite side (Travell
et al., 1983). Given the patient’s age, level of activity,
and general health status, it was anticipated that this
patient would respond well to treatment and regain
normal physiological function and return to pain free
participation in her work and leisure activities.
Evaluation, diagnosis and prognosis were determined
based on the practice management model and nomencla-
ture outlined in the guide to physical therapist practice
(APTA, 2001). The preferred practice pattern for this case
was based on pattern 4D (Impaired joint mobility, motor
function, muscle performance, and range of motion asso-
ciated with connective tissue dysfunction).
Intervention
Treatment addressed mechanical dysfunction at the lower
thoracic spine comprising manual therapy in the form of
soft tissue mobilization, non-thrust and thrust manipula-
tion, corrective exercise and pain modalities. The patient
was seen two times a week for four weeks. The first week
consisted of one treatment session as the first visit was
spent entirely on the evaluation and paperwork process and
the patient had to leave. The sequence of treatment was as
follows.
Week 1 (2 sessions)
Treatment consisted of soft tissue mobilization (Zheng
et al., 2012) of the lower thoracic region. The clinician
faced the patient from the side with the patient in a prone
lying position. The thenar eminence and the palmar surface
of the thumb was placed on the long axis of the erector
spinae just adjacent and lateral to the spinous process on
the opposite side of the clinician. Now the thumb was
reinforced by the palmar surface of the other hand for a
gentle laterally directed pressure over the erector spinae.
The applied pressure was gradually increased based on
patient tolerance. The pressure was held for about 5e10 s
and repeated along the length of the thoracic spine (Fig. 3).
Treatments were concluded with quadripolar interferential
current over the lower thoracic region, mainly as an
adjunct for it’s short term analgesic effect (Fuentes et al.,
2010). The patient was instructed in transversus abdominus
setting exercises to encourage core lumbar stabilization, 3
sets of 10 repetitions.
Please cite this article in press as: Sebastian, D., Lower thoracic syndrome e A differential screen for back pain following vertical
compression injury: A case report, Journal of Bodywork & Movement Therapies (2013), http://dx.doi.org/10.1016/j.jbmt.2013.12.009
Figure 3 Erector spinae soft tissue mobilization.
The patient left the clinic on the first day with soreness.
At the end of the first week, examination revealed a min-
imal decrease in the intensity of tenderness over the left
paraspinals of the lower thoracic region. No significant
changes were noted in pain and function (rated 6 on a scale
of10). Lumbar flexion revealed minimal improvement of
about 10
and continued to reproduce discomfort.
The patient was away for 7 days following his first week
of treatment for personal reasons and he also had a respi-
ratory tract illness for a couple of days. He continued with
his home exercises, and on returning back to treatment he
reported feeling about the same. He, however reported
decreased achiness in the lower lumbar and pelvic regions
as a possible result of the core exercises.
Week 2 (2 sessions)
A re-assessment did not reveal any major changes from his
initial evaluation. There was a minimal decrease in local
tenderness, which however, continued to persist. Soft tis-
sue mobilization was continued over the lower thoracic
region followed by core strengthening, focusing on the
transverses abdominus and gluteus medius. Activation of
the transverses abdominus was done in hook lying, asking
the patient to tuck in the stomach. In this position, while
breathing was maintained, he was asked to perform alter-
nate leg raises (Rackwitz et al., 2006).. Activation of the
gluteus medius was done in sidelying with the leg in
extension and raising the leg up toward the ceiling (Reiman
et al., 2012). During the second session of the second week,
treatment commenced with soft tissue mobilization, fol-
lowed by a supine thrust manipulation of T11, T12. The
patient was made to lay supine, arms crossed over the
chest and knees flexed. The clinician faced the patient
from the side. The head and neck of the patient was sup-
ported with one hand and the space between the thenar
and hypothenar eminence of the clinicians’ right hand was
placed on the lower thoracic segments. The mobilization
impulse was applied over the patients’ arms with the cli-
nicians’ chest (Fig. 4).
Audible release was heard from the manipulation as a
series of cavitation sounds, almost like ripping a piece of
 + MODEL
Lower thoracic syndrome: A differential screen for back pain
Figure 4 Preparing for high velocity manipulation of lower
thoracic spinal segments.
dry cloth. We assumed that this included multiple facet
articulations, including the costo-vertebral articulations.
Treatment concluded with quadripolar interferential
current over the lower thoracic region. Core strengthening
was enhanced with the side support exercise, where the
body was held horizontally almost parallel to the floor as
the patient supported himself with one elbow on the floor,
hips off the surface, with both feet on the floor (Gottschall
et al., 2013). The patient was instructed to hold this posi-
tion for 10 s and was repeated on both sides. This exercise
also enhances contraction of the quadratus lumborum
(McGill et al., 1996). He was instructed to continue the
exercises previously instructed along with this, as a home
program.
At the end of the second week, improved range of mo-
tion and decreased discomfort during slouching and flexion,
was observed. A complete resolution of the leg length
discrepancy was noted. Examination revealed a decrease in
left flank pain (pain rating 2 on a scale of 10) with
decreased symptom reproduction on local pressure. Lum-
bar mobility was almost full in all planes, without discom-
fort. He was functioning with almost no discomfort during
routine activities of daily living. He reported a minimal
recurrence of lower thoracic discomfort at the end of a
working day, or a long car ride.
Week 3 (2 sessions)
Soft tissue mobilization was continued. He was instructed
in proper back mechanics mainly for proper sitting and
position transitions during function. Lumbar stabilization
was progressed to supine sit ups with transverse abdomi-
nus contraction maintained, leg extension on prone fours
for the multifidus (Kumar, 2011) and hip abduction and
extension with elastic bands1 of a light resistance, for the
gluteus medius and maximus (Reiman et al., 2012). He
performed 3 sets of 10 repetitions for the prone fours and
hip abduction exercises. A 10 s hold, 5 repetitions (on
1
Theraband Inc.
Please cite this article in press as: Sebastian, D., Lower thoracic syndrome e A differential screen for back pain following vertical
compression injury: A case report, Journal of Bodywork & Movement Therapies (2013), http://dx.doi.org/10.1016/j.jbmt.2013.12.009
5
each side) regime was instructed for the side support
exercise.
At the end of the third week, improved range of motion
and decreased discomfort during slouching and flexion was
observed. The leg length discrepancy did not recur and
neutral position was maintained. The left flank pain was
0e1 on the NPRS scale, with near complete resolution of
pain on local pressure over the left lower thoracic region.
Lumbar mobility was almost full, without discomfort in
all planes. He was functioning with almost no discomfort
during routine activities of daily living, with negligible
lower thoracic discomfort at the end of a working day or a
long car ride. He mentioned it was more an achiness rather
than pain. He was contemplating playing soccer over the
weekend.
Week 4 (2 sessions)
Soft tissue mobilization and reinforcement of proper back
mechanics mainly for sitting and position transitions during
function, was continued. Lumbar stabilization was
continued as outlined in week three.
Outcomes
His Oswestry score was 3/50 (sitting 2, traveling 1) and his
Global Rating Of Change (GROCQ) score was 5þ (A good
deal better). The GROCQ is considered a reliable self report
measure for pain and function (Costa et al., 2008; Kamper
et al., 2009).
Discussion
The sensory supply of the anterior divisions of the seventh,
eighth, ninth, tenth, and eleventh thoracic intercostal
nerves is distributed to the skin of the abdomen and mid
back (Court et al., 2005). Their representation hence pre-
dominate in the flank area. Compression injuries of the
lower thoracic and upper lumbar area have been described
to cause myelopathy secondary to spinal canal stenosis or
radiculopathy secondary to foraminal stenosis (Boswell
et al., 2012). Since myelopathic signs were negative, the
radiating flank pain suggests the possibility of foraminal
stenosis secondary to compression of the thoracoabdominal
nerves (Sellman and Mayer, 1988).
Vertical compression injuries have been described to
cause injuries mostly in the lower thoracic region and
thoracolumbar junction. In a 7 year study of 324 patients
with spinal injuries 136 sustained compression type in-
juries. The T11, T12 and L1 segments were found to be the
most common (76.5%) (Weninger et al., 2009). The poste-
rior column is included in the compression trauma
(Kaltenecker et al., 1992), which include the facet articu-
lations. The supporting musculature hence cannot be
overlooked. Two muscles in this location that have been
described as being vulnerable to pain syndromes are
quadratus lumborum (McGill et al., 1996) and serratus
posterior inferior (Vilensky et al., 2001). The serratus pos-
terior inferior is directly attached to the lower thoracic
spine and rib articulations, and quadratus lumborum to T12
 + MODEL
6 D. Sebastian

via its rib articulation. The vulnerability of the quadratus
lumborum to vertical compression has been described
(McGill et al., 1996). Intramuscular fine-wire electrodes
monitored the electromyographic activity of quadratus
lumborum in four young adults. A wide variety of tasks were
performed. While the quadratus lumborum was active
during most activities it increased activation, in response to
increasing compression, in static upright standing postures.
This especially suggests the vulnerability of this muscle to
vertical compression forces. The quadratus lumborum is of
particular interest as there was a very obvious shortening of
the left leg secondary to a possible dysfunction of this
muscle. This was suspected based on the location of
discomfort and restriction of right side bending.
The effects on serratus posterior inferior, in response to
vertical compression injuries should not be under-
estimated. Researchers (Vilensky et al., 2001) suggest the
serratus posterior inferior to be primarily a proprioceptor
being in the location of the lower end of the thoracic spine.
They act as stretch receptors and are considered sensors of
strain at this level. This spinal motion segment (facet and
rib articulations and supporting musculature) is highly
vulnerable to the effects of vertical compression (Fig. 5).
The vulnerability of the thoracic spine to mechanical
dysfunction has been well established (Singh, 2004;
O’Connor et al., 2002), and as is the case with the lumbar
and cervical spine, degeneration with stiffness are inherent
sources of axial pain and radiculopathy. The thoracic zygo-
apophyseal joints are capable of local and referred pain
generation in the thoracic region. It is noted that on
injection, pain was referred one segment inferior and
lateral to the joint. Pain referral occurred up to 2.5 seg-
ments inferior to the facet joint injected within the axial
skeleton but never into the appendicular skeleton (Dreyfuss
et al., 1994). This potentially suggests pain in the thoracic
region radiating into the flank may be of a facet joint origin
as well.
The effect of spinal manipulation directed to the lower
thoracic spine requires explanation. The sudden stretch of
the capsule stimulates and effects muscle spindle afferents
and golgi tendon organ afferents resulting in a reflex
relaxation of the musculature (Bicalho, 2010; Pickar, 2002).
The principle joints effected in this clinical scenario are the
capsules of the facet, costovertebral and the costo-
transverse articulations. Additionally magnetic resonance
studies have shown HVT manipulation gaps facet joints and
increases the dimensions of the intervertebral foramen
(Cramer et al., 2000). This might explain the decrease in
pain caused by the thoracoabdominal nerves exiting from
the lower thoracic intervertebral foramen.
The favorable effects of core strengthening to support
normal alignment and thereby de-stress pain sensitive
structures of the spinal motion segment, have been docu-
mented in the literature (Hodges and Jull, 2000). This pa-
tient had mechanical restriction with core weakness and
signs of mild instability in the lumbo-pelvic region as envi-
sioned by the signs of creep. Soft tissues exposed to sus-
tained loading in a single direction without interruption
move further than their physiological range. This slight
movement, known as creep, results from rearrangement of

Figure 5 Vulnerable structures in non traumatic vertical compression.

Please cite this article in press as: Sebastian, D., Lower thoracic syndrome e A differential screen for back pain following vertical
compression injury: A case report, Journal of Bodywork & Movement Therapies (2013), http://dx.doi.org/10.1016/j.jbmt.2013.12.009
 + MODEL
Lower thoracic syndrome: A differential screen for back pain
collagen fibers and water being squeezed from the soft
tissue. Studies have shown that the resulting tissue laxity
alters afferent feedback from ligamentous receptors and
impairs reflex activation of the back muscles. If the sus-
tained loading is not excessive the soft tissues recover
reasonably quickly (Sanchez-Zuriaga et al., 2010) which
may explain the frequent adjustment of posture for a po-
sition of comfort. This patient tested negative for the
clinical prediction rule for lumbar instability for determi-
nation of response to a stabilization program. The point to
note, however, is that it is not the gold standard for
instability (sensitivity 0.56 and a specificity of 0.86)
(Bazrgari et al., 2011).
Conclusion
This case report supports decreased lower thoracic and left
flank pain and improved lumbar mobility and function
following treatment of mechanical dysfunction at the lower
thoracic region. There is anatomical evidence to support
the potential for left flank pain from mechanical dysfunc-
tion of the lower thoracic spine. The lower thoracic spine is
vulnerable for mechanical dysfunction secondary to verti-
cal compression forces. The vertebral motion segment of
T11, T12, has an anatomical relationship to the thor-
acoabdominal nerves, the 12th rib, the quadratus lumbo-
rum and the serratus posterior inferior. The structures are
speculated to be potential symptom mediators and collec-
tively identified as vulnerable structures in lower thoracic
syndrome. The findings in this case report suggest the lower
thoracic region to be included during the evaluation pro-
cess of back pain, further reinforced by two situations, a
history of vertical compression injury with associated lower
thoracic and flank pain.
References
Alexander, M.J., 1985 Mar. Biomechanical aspects of lumbar spine
injuries in athletes: a review. Can. J. Appl. Sport Sci. 10 (1),
1e20.
Angevine, P.D., McCormick, P.C., 2012 Mar. Thoracic disc. J. Neu-
rosurg. Spine 16 (3), 261e262.
APTA, 2001. Guide to physical therapist practice. In: Phys. Ther.,
second ed., vol. 81, pp. 9e744
Bazrgari, B., Hendershot, B., Muslim, K., Toosizadeh, N.,
Nussbaum, M.A., Madigan, M.L., 2011 Nov. Disturbance and
recovery of trunk mechanical and neuromuscular behaviors
following prolonged trunk flexion: influences of duration and
external load on creep-induced effects. Ergonomics 54 (11),
1043e1052.
Bicalho, Eduardo, Palma Setti, João Antônio, Macagnan, Jones,
Rivas Cano, José Luis, Manffra, Elisangela Ferretti, 2010. Im-
mediate effects of a high-velocity spine manipulation in para-
spinal muscles activity of nonspecific chronic low-back pain
subjects. Man. Ther. 15, 469e475.
Boswell, S., et al., 2012 Sep. Combined open decompressive
laminectomy and vertebroplasty for treatment of thor-
acolumbar fractures retrospective review of 41 cases. Clin.
Neurol. Neurosurg. 114 (7), 902e906.
Cavanaugh, J.M., Ozaktay, A.C., Yamashita, H.T., King, A.I., 1996
Sep. Lumbar facet pain: biomechanics, neuroanatomy and
neurophysiology. J. Biomech. 29 (9), 1117e1129.
Please cite this article in press as: Sebastian, D., Lower thoracic syndrome e A differential screen for back pain following vertical
compression injury: A case report, Journal of Bodywork & Movement Therapies (2013), http://dx.doi.org/10.1016/j.jbmt.2013.12.009
7
Chapman, J.R., Norvell, D.C., Hermsmeyer, J.T., Bransford, R.J.,
DeVine, J., McGirt, M.J., Lee, M.J., 2011 Oct 1. Evaluating
common outcomes for measuring treatment success for chronic
low back pain. Spine 36, 54e68.
Costa, L.O.P., Maher, C.G., Latimer, J., et al., 2008. Clinimetric
testing of three self-report outcome measures for low back pain
patients in Brazil: which one is the best? Spine 33, 2459e2463.
Court, C., Vialle, R., Lepeintre, J.F., Tadié, M., 2005 Mar. The
thoracoabdominal intercostal nerves: an anatomical study for
their use in neurotization. Surg. Radiol. Anat. 27 (1), 8e14.
Cramer, G.D., Tuck, N.R., Knudsen, J.T., Fonda, S.D.,
Schliesser, J.S., Fournier, J.T., et al., 2000. Effects of side-
posture positioning and side-posture adjusting on the lumbar
zygapophyseal joints as evaluated by magnetic resonance im-
aging: a before and after study with randomization. J. Manip.
Physiol. Ther. 23, 380e394.
Cranfield, K.A., Buist, R.J., Nandi, P.R., Baranowski, A.P., 1997.
The twelfth rib syndrome. J. Pain Symptom Manage. 13 (3),
172e175.
Dreyfuss, et al., 1994. Thoracic zygoapophyseal joint pain pat-
terns: a study in normal volunteers. Spine 19, 807e811.
Fuentes, J.P., Armijo Olivo, S., Magee, D.J., Gross, D.P., 2010 Sep.
Effectiveness of interferential current therapy in the manage-
ment of musculoskeletal pain: a systematic review and meta-
analysis. Phys. Ther. 90 (9), 1219e1238.
Gottschall, J.S., Mills, J., Hastings, B., 2013. Integration core ex-
ercises elicit greater muscle activation than isolation exercises.
J. Strength Cond. Res. 27 (3), 590e596.
Hicks, G.E., Fritz, J.M., Delitto, A., 2005. Preliminary development
of a clinical prediction rule for determining which patients with
low back pain will respond to a stabilization exercise program.
Arch. Phys. Med. Rehabil. 86, 1753e1762.
Hodges, P., Jull, G., 2000. Does strengthening the abdominal
muscles prevent low back pain? J. Rheumatol. 27 (9),
2286e2288.
Jinkins, J.R., 2004. Acquired degenerative changes of the interver-
tebral segments at and suprajacent to the lumbosacral junction.
A radioanatomic analysis of the nondiscal structures of the spinal
column and perispinal soft tissues. Eur. J. Radiol. 50 (2), 134e158.
Kaltenecker, G., Kwasny, O., Maier, R., Schurawitzki, H., Hertz, H.,
1992. Results after conservatively managed vertebral fractures
of the thoracolumbar level with special reference to bony ste-
nosis of the spinal canal. Unfallchirurg 95 (3), 118e123.
Kamper, Steven J., Maher, Christopher G., Mackay, Grant, 2009.
Global rating of change scales: a review of strengths and
weaknesses and considerations for design. J. Man. Manip. Ther.
17 (3), 163e170.
Keoghane, S.R., Douglas, J., Pounder, D., 2009. Twelfth rib syn-
drome: a forgotten cause of flank pain. BJU Int. 103 (5),
569e570.
Knutson, Gary A., 2005. Anatomic and functional leg-length
inequality: a review and recommendation for clinical decision-
making. Part II, the functional or unloaded leg-length asym-
metry. Chiropr. Osteopat. 13, 12.
Kumar, S.P., 2011 Oct. Efficacy of segmental stabilization exercise
for lumbar segmental instability in patients with mechanical
low back pain: a randomized placebo controlled crossover
study. N. Am. J. Med. Sci. 3 (10), 456e461.
Maigne, R., 1980. Low back pain of thoracolumbar origin. Arch.
Phys. Med. Rehabil. 61, 389e395.
Maughan, E.F., Lewis, J.S., 2010. Outcome measures in chronic low
back pain. Eur. Spine J. 19 (9), 1484e1494.
McGill, S., Juker, D., Kropf, P., 1996. Quantitative intramuscular
myoelectric activity of quadratus lumborum during a wide va-
riety of tasks. Clin. Biomech. 11 (3), 170e172.
O’Connor, R.C., Andary, M.T., Russo, R.B., DeLano, M., 2002.
Thoracic radiculopathy. Phys. Med. Rehabil. Clin. N. Am. 13 (3),
623e644.
 + MODEL
8 D. Sebastian
Pickar, Joel G., 2002. Neurophysiological effects of spinal manip-
ulation. Spine J. 2, 357e371.
Quinn, Kyle P., Dong, Ling, Golder, Francis J., Winkelstein, Beth A.,
2010 November. Neuronal hyperexcitability in the dorsal horn
after painful facet joint injury. Pain 151 (2), 414e421.
Rackwitz, B., de Bie, R., Limm, H., von Garnier, K., Ewert, T.,
Stucki, G., 2006. Segmental stabilizing exercises and low back
pain. What is the evidence? A systematic review of randomized
controlled trials. Clin. Rehabil. 20 (7), 553e567.
Reiman, M.P., Bolgla, L.A., Loudon, J.K., 2012. A literature review
of studies evaluating gluteus maximus and gluteus medius
activation during rehabilitation exercises. Physiother. Theory
Pract. 28 (4), 257e268.
Sanchez-Zuriaga, Adams, M.A., Dolan, P., 2010. Is activation of the
back muscles impaired by creep or muscle fatigue? Spine 35 (5),
517e525.
Sebastian, D., 2006. Thoraco lumbar junction syndrome: a case
report. Physiother. Theory Pract. 22 (1), 53e60.
Sellman, M.S., Mayer, R.F., 1988. Thoracoabdominal radiculopathy.
South Med. J. 81 (2), 199e201.
Simopoulos, T.T., Manchikanti, L., Singh, V., Gupta, S.,
Hameed, H., Diwan, S., Cohen, S.P., 2012. A systematic evalu-
ation of prevalence and diagnostic accuracy of sacroiliac joint
interventions. Pain Physician 15 (3), 305e344.
Singh, V., 2004. Thoracic discography. Pain Physician 7 (4),
451e458.
Please cite this article in press as: Sebastian, D., Lower thoracic syndrome e A differential screen for back pain following vertical
compression injury: A case report, Journal of Bodywork & Movement Therapies (2013), http://dx.doi.org/10.1016/j.jbmt.2013.12.009
Solomonow, M., 2012. Neuromuscular manifestations of visco-
elastic tissue degradation following high and low risk repetitive
lumbar flexion. J. Electromyogr. Kinesiol. 22 (2), 155e175.
Sran, M.M., Robinovitch, S.N., 2008. Preventing fall-related
vertebral fractures: effect of floor stiffness on peak impact
forces during backward falls. Spine 33 (17), 1856e1862.
Travell, J.G., Simons, D.G., Simons, L.S., Cummings, B.D., 1983.
Myofascial pain and dysfunction: the trigger point manual. In:
The Upper Half of Body, vol. 1. Williams and Wilkins, Baltimore.
Vilensky, J.A., Baltes, M., Weikel, L., Fortin, J.D., Fourie, L.J.,
2001. Serratus posterior muscles: anatomy, clinical relevance,
and function. Clin. Anat. 14 (4), 237e241.
Weber, M., Uehlinger, K., Gerber, H., 2002. Osteoporotic vertebral
compression fracture causing neurologic deficit. J. Clin. Rheu-
matol. 8 (3), 166e173.
Weninger, P., Schultz, A., Hertz, H., 2009. Conservative manage-
ment 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. 129 (2), 207e219.
Wilcox, R.K., et al., 2003 Nov. A dynamic study of thoracolumbar
burst fractures. J. Bone Joint Surg. Am. 85-A (11), 2184e2189.
Zheng, Z., Wang, J., Gao, Q., Hou, J., Ma, L., Jiang, C., Chen, G.,
2012. Therapeutic evaluation of lumbar tender point deep
massage for chronic non-specific low back pain. J. Tradit. Chin.
Med. 32 (4), 534e537.