back pain

T4 / Rib 4 Problems

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I have recently been thinking about the connections between the ribcage and shoulder pain. From this, I have noticed a couple of connections.
The main one is dysfunction around rib 4 either side leading to pain in the same side shoulder and arm. This has typically presented as pain next to the scapula, tension in trapezius and radiating pain down the triceps into the forearm. The patient typically has a history of desk based work or driving, with the pain often coming on waking or after coughing / sneezing. Examination shows restricted thoracic spine and tenderness on the ribs, both sternally and on the spine. Having tried to research this, I struggled to uncover much that enlightened me, other than a chiropractic diagnosis of T4 syndrome, which doesn’t really match and often seems rather vague.
My view is that the symptoms are actually caused by fascial tension and pain related muscular spasm, so fascial release, gentle manipulation and soft tissue treatment can have an apparently miraculous effects on some people. I also do some cranial / functional work anteriorly to re-centre and balance the ribs / fascia.
From this, it has been useful to be able to rapidly assess the motion of the spine. Although a detailed examination is always important, it is useful to be able to have a rough guide as to where you should be looking.

Supine, where the patient lies passively and you use their bent knee to create rotation in the spine, blocking at the pelvis, ribs and shoulder to isolate the main sectors. This is following a simple standing active examination, where the patient attempts the main spinal movements of flexion, rotation and sidebending.As an extension of that, I started getting patients to attempt “monkey”. This is an Alexander technique standing posture, which is meant to demonstrate balance within the spine (my perspective). The most important thing to know about Alexander technique (other than it is really rather good and a couple of lessons from a good teacher is worthwhile, I recommend a number of patients to my local teacher) is that it is all about intention and the mind being in charge of the body, so speed is always controlled.To move into a version of monkey posture ask the patient to do the following:

1) Get them to stand comfortably, feet parallel (check, lots externally rotate to minimise loading in the glutes)
2) Bend the knees slightly
3) Bend forward at the waist, spine straight
4) Let the arms hang loose
This is a german video of a man sitting down, but if you stop half way, its monkey.
What I noticed is that most cannot bend solely at the hips without looking down and treating any thoracic restrictions allows them to move much better.
The reason for all of this is to demonstrate treatment further away from the area of complaint and to look for other areas of compromise in their movement patterns. They may also find cervical and lower limb problems start to surface. Once this has been physically demonstrated, it is easier to achieve compliance in terms of future treatments, exercise pescription and general understanding of their body.
And for a positive patient outcome, this can be used as part of their ongoing exercise plan.

A brief thought on running mechanics and gait

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It is generally thought that there are 4 main phases to the gait cycle when running:

Inital strike, stance, take off and forward swing.

Breaking this down into 2 separate sections, we can firstly look at the strike and stance phases. As the foot makes contact with the ground and rectus femoris (one of the quadriceps group of thigh muscles) proactively fires. As the foot touches the ground, the subtalar joint inverts or everts, the midfoot abducts or adducts and the forefoot plantarflexes or dorsiflexes. All these subtle movements combine to allow a small amount of pronation to occur, maximising the foots ability to dissipate shock.From this, we can see that a tight foot that underpronates limits this ability, which may lead to achillies problems, calf strains, lateral knee pain and illiotibial band issues. Conversely, overpronation can lead to tibial strain, anterior calf injuries and medial knee pain, due to the medial rotation occurring in the tibia. 

Swing phase happens at the same time on the opposite leg. The pelvis rotates forwards, with hip flexion initiated by the iliospoas. The Hamstrings start to lengthen, limiting the extension in the lower leg, caused by the quadriceps.The lower leg decends, hitting the surface as the body accelerates, ideally creating a vertical line between head and toe on impact.

During both phases, the core provides stability for the upper body, allowing the forces to be shared and transferred correctly. As the spine can be considered by some researchers a store and transfer for the energy contained within the running motion, core integration is important and if not present, an indicator and predisposition of other issues that need to be addressed.