Mid-Back Pain

Thoracolumbar Junction Pain Protocol

The thoracolumbar junction plays a critical role in maintaining the overall stability and mobility of the spine. It is at this junction that the ribs, vertebrae and musculature are asked to perform movements characteristic of both the mobile lumbar spine and the rigid thoracic spine. This dual role of stability and mobility can often lead to pain and dysfunctional movement of the back. In response to observing this painful condition in many of my patients I have developed a three exercise Thoracolumbar Junction Pain Protocol detailed below.

The thoracolumbar junction is an anatomical region where the thoracic spine (upper back) and the lumbar spine (lower back) meet. It is located in the middle-lower part of the back and includes the last thoracic vertebra (T12) and the first lumbar vertebra (L1). The joints between the thoracic vertebrae as well as their articulations with the ribs provide a very stable structure with which to protect our vital organs. While the joints between the lumbar vertebrae are designed to allow more flexibility and movement. Thus the joints at this junction provide a transition zone between the more rigid upper back and the more mobile lower back.

Serratus Posterior Inferior muscles play an important role at the thoracolumbar junction. Theses muscles are located on each side of the spine, originating from the lower thoracic and upper lumbar vertebrae and inserting into the ninth to twelfth ribs. Their primary function is to depress the ribs during exhalation, assisting in the expulsion of air from the lungs. This is particularly important during forced expiration, such as during activities like coughing or intense exercise. In addition to breathing mechanics these muscles are also involved in postural control of the junction, influencing both rib and spine position.

Dysfunction at the thoracolumbar junction generally manifests as joint and muscular pain as well as loss of range of motion. The majority of patients I see with pain in this area have elevated lower ribs as well as excessive extension of the vertebrae, leading to tenderness at the Serratus Inferior Posterior muscles. To correct this dysfunction and eliminate pain in this area we must address rib and vertebrae position as well as the stiff and irritable Serratus posterior inferior muscles.

When we inhale, our lower ribs move up and our spinal vertebrae extend (think leaning backwards). Problems arise when our lower ribs get, “stuck,” in an elevated, inhaled position due to faulty breathing mechanics. Subsequently, as your vertebrae flex while exhaling, while your ribs remain in an inhaled position, tension is created at the rib-vertebral joints. The first step is perform a breathing exercise that puts the ribs and vertebrae in an inhaled position together.

Supine Rib Depression

If you notice your lower ribs jutting our in front, often referred to as, “rib humps,” that is a sign that your ribs are stuck in exhalation, and that is the position we are looking to improve. Begin by laying on your back with your knee bent, feet flat on the floor or slightly elevated on yoga blocks. Pull your heels gently into the ground, flattening your lower back into the ground and hold - this is your starting position. Now inhale through your nose for 4-5 seconds letting your ribs expand out in all directions. Now fully exhale through your nose for 4-5 seconds using your abdominals to pull your lower ribs down. On the next exhale, keep your lower ribs down by keeping tension in your abdominals throughout the 4-5 second inhale. Those lower ribs will rise up a bit and that is ok, they are just moving into a more appropriate exhaled position. Perform this exercise daily for 3 minutes.

Jefferson Curl

Ribs that are stuck in an exhaled position tend to promote an extended posture in the thoracolumbar junction vertebrae. More specifically, we begin to lose the ability to fully flex this part of our spine, limiting our movement options with forward bending and rotation. This extension biased posture can spill over into the lumbar spine further limiting movement. After performing the breathing exercise to mobilize your ribs into flexion, perform a Jefferson Curl to recover lost motion in the lumbar spine and thoracolumbar junction. Stand with feet at a hips width, feet pointed straight ahead. Place and hold a yoga block between your knees or thighs. Now begin by dropping your chin to your chest, then slowly bend your upper back as you drop your hands towards your feet. Continue bending forward, unloading your low back and tilting your hips forward. Pause briefly, then slowly stand up extending your spine and returning to the starting position. While performing, imagine flexing each individual vertebrae as you move to touch your toes, then extending each individual vertebrae as you slowly stand back up. Perform this exercise daily for 3 sets of 1 minute, taking a 30 second rest between sets.

Foam Roll Thoracolumbar Junction

The Serratus Posterior Inferior gets irritated because the vertebrae and ribs are stuck in extension. In this positional context, the Serratus never fully shortens into a neutral, resting state. Thus, our third activity in our Thoracolumbar pain protocol is to use a foam roller to calm down this irritated muscle. Sit on the ground, and place a foam roller behind you and slowly lean back until your mid-back is resting on it. Your feet should be flat on the ground. Place your hands behind your head to stabilize your neck and perform a crunch, activating your abdominals. Keeping your abdominals contracted, lift your hips up to apply more weight onto the foam roller. Push and pull with your feet to roll the roller up and down along your spine, finding the thoracolumbar junction at the bottom of your ribs. When you find this spot, alternate between rolling up and down the area and rotating back and fourth putting pressure to the left and right of the spine. Perform this daily for 2-3 minutes.

Perform this protocol daily for 2-3 weeks and you should see a reduction in pain and an improvement in your range of motion. If the dysfunction persists it can impinge on the nerve roots in the area leading to a painful condition called Maingne Syndrome. Characteristics of this syndrome include groin pain and/or pain that wraps around your torso. At that point, it is important to contact a skilled Physical Therapist for, “hands-on,” manual therapy.