Bringing Relief for a Broken Back

“Our next client has a fractured thoracic vertebra,” my colleague said. That got my full and complete attention.

This client was being seen in our team environment, where I am joined by two of my staff when we see new clients. Reading her intake form, the fracture was at the level of T6 and occurred more than a year ago. Since we, in this environment, are seeing people in pain, one primary question precedes beginning treatment: What role, if any, is soft tissue playing in this client’s pain? 

Since soft tissue is my expertise, it may also be my blind spot. It’s an important question that has guided my approach for decades, helping me consider other possible reasons and whether I need to defer to other disciplines. 

Asking Good Questions

Our client was a delightful, energetic woman in her 60s with a warm and engaging smile. After taking a seat in our treatment room, she described the circumstances surrounding the fracture. She was active and had tackled a big landscaping project, which involved lifting and moving so many 60-pound bags of material that she was embarrassed to admit the number. 

Thoracic pain soon developed, and other providers assumed this was a strain. When symptoms didn’t improve, imaging revealed a vertebral fracture. Six months of physical therapy were only marginally helpful. Presently, she experienced a dull constant ache, made worse when she tried to stand up straight. At times, the pain was intense, and these episodic bouts were disabling. 

“The doctor said that surgical repair of the vertebra isn’t viable or appropriate and neither is nerve ablation to the thoracic area,” she said. “He also found some arthritic changes and early stages of osteopenia.”

What I had heard so far left the door open for treatment. Her fracture was from lifting and twisting, not a fall or macrotrauma, which would be far more problematic. Her months of physical therapy involved loading and strengthening her spinal muscles, so the risk of hands-on intervention was lower. 

And then, there is the question I ask everyone with long-standing pain: “In the last year, did anyone carefully, thoughtfully, and thoroughly examine your thoracic spine?”

“Um, no,” she said, much like almost everyone else we see. 

“How about we do that?” I suggested. 

Palpation and Hands-On Work

Palpating her spine while she sat in front of me, everything looked quite good except for some left rotation at the T6 area. 

After asking her to cross her arms over her chest, I sat behind her and held her elbows. I gently took her thoracic spine into a few degrees of right rotation. With about 15 degrees of rotation, movement ended and her arms began to tremble. 

“That is so interesting,” she said. “I can’t control the shaking. It doesn’t hurt, but I know I can’t go any farther.” 

“No need to go farther now,” I responded. “That’s the edge of where your brain feels safe to move. Let’s see what happens after we explore the area.” 

Knowing that the prone position was contraindicated, one of my colleagues set the table for sidelying treatment. Our client stated that the right side was a bit more involved, so we began with her lying on her left side. I started by addressing the longissimus at the T2 level. 

As I moved inferiorly, it seemed like she was finding the approach beneficial, but I thought it important to verbally confirm with the client.

“As we get closer to the site of the injury, does it feel like the cavalry is coming, or does it feel like you need to run for the hills?” I asked.

“I can’t tell you how good this feels,” she replied. “In a strange way, I feel like I’m going back in time to when this all started.” 

Carefully treating the muscles around T5 and T6, I also addressed the muscles that affected the rotational movement of the fifth rib. Once that all quieted down, it was time to recheck her thoracic range of motion. 

Repeating the same seated position, I took her again into right rotation. I was able to take her effortlessly to 45 degrees, and the change was so dramatic that I didn’t want to go farther to see what the actual limits of her range were. 

“How is that even possible?” she exclaimed. 

“If there was enough force to create a fracture, it couldn’t have been a picnic for the muscles around the joint either,” I said. “They were probably working past their max capacity when this happened, and then when the vertebra was injured, these same overworked muscles likely contracted to protect the joint.

“The problem is, many of those muscles also cross the joint, adding to the compression. Limiting the motion at first was protective, but short-term strategies applied long term become part of the problem instead of part of the solution.”

The lesson here? A common assumption in any osseous injury is that soft-tissue trauma will magically resolve once the bone heals. It’s a lovely idea, but seldom is this true without direct intervention to the tissue as well. That’s where we come in!