One case presentation that I commonly see in my office is one called the T4 Syndrome.
People who have T4 syndrome are often middle aged women. The symptoms of numbness or tingling in both arms arise at night, and throughout the day, they have stiffness, even trigger points in the muscles in the upper back, and may or may not have headaches. The headache is often felt starting in the upper neck and wrapping around the sides to the front of the head, although they are not always consistent.
If you have T4 syndrome, you are always stiff in the upper back, between the shoulder blades and in the base of the neck. A lot of the stiffness and pain that you feel is in the T4 area of the thoracic spine and between the shoulder blades. Other segments up and down the upper thoracic spine can be involved, but they usually average out to be in the T4 segment.
When I examine you if you have T4 Syndrome, I notice some certain characteristics. First, you’ll have a forward head posture and we’ll see that your neck curve is reversed on x-ray. One of the patterns that is very common in society is this hard-as-a-board stiffness in the shoulder blade area, and weak, achy muscles in the neck. People with this usually have rounded forward shoulders; painful knots in the neck muscles, shoulder muscles and chest muscles; and rib pain that restricts your breathing.
There are no nerves that go directly from the upper back to the arm. Those nerves exit the spinal cord at the neck, and with T4 syndrome, there are no pinched nerves, and there are no other neurological signs that show that these nerves are involved. Researchers think that there is an autonomic affect from the upper back being stiff that causes the tiny blood capillaries in the nerves to be cut off. It’s part of the sympathetic nervous system being too active.
The Thoracic Outlet
As I examine you, I usually find that the ribs are tender and prominent as they attach to the spine between the shoulder blades. This rib dysfunction usually carries over to a slight to moderate tenderness at the rib attachments up front as they ribs meet the sternum (breast plate.) Sometimes people will tell me that their ribs feel “stuck” in front, or that it feels like there’s an ice pick in their ribs.
The muscles on the sides of your neck, called the scalene muscles also get tight with this posture. These muscles will pull up on your first rib, which is at the part where your shoulder meets your neck. The scalene muscles will make the first rib feel higher, and stiffer than it should be.
Then, the muscle that attaches from your ribs in your chest to your shoulder, the pectoralis minor, is usually tight. This is contributing to your shoulders being rolled forward, and may even be making your shoulder feel sloppy as you use it. It can make those popping or clunking noises and sensations.
Because your head is held forward, and your shoulders are rolled forward, the muscles have to work extra hard to keep you upright. This can make you feel very fatigued as you work at a desk, and can further cause painful knots in your muscles. Of course, the upper back gets stiffer with this.
After your examination, I usually treat you with my chiropractic adjustments.
When I adjust people, I usually work from the bottom-up. Because the shoulders are involved, it’s necessary to reduce the pressure that I find in the lower rib cage. This is usually done when you are face down, but I also have a pet technique that involves you standing. After that, I work on the heart of the problem–at T4, or wherever the specific dysfunction is located. Reducing the pressure at this area with a chiropractic adjustment will usually take away 90% of the problem. It’s like feeling the ice cold hardness of your muscles melt away. If I were to just stop here, you would notice that your posture is improved, your neck has more range of motion, and your shoulders are confidently held in the more upright position.
But, since there are usually other parts in the neck suffering form this presentation, we move forward. A lot of muscles from the upper back attach to the neck, and a lot of these muscles are focused on C2. The C2 segment is in the very top of the neck, and has a very prominent process that you can feel through your neck muscles. Getting the C2 adjusted and moving freely again feels fantastic. Sometimes a good C2 adjustment makes it seem as though someone turned the lights up brighter.
As we work on the neck, we also adjust the first rib. The first rib, when it acts up, is responsible for a lot of neck tightness and achyness on the side. This can also send a diffuse ache down the arm. This adjustment melts all of that away.
A good adjustment isn’t the end of the story, though. This kind of presentation usually needs several more visits over the next couple of weeks, depending on how long you’ve had it, or the severity of your presentation. This also needs more of your attention at home. It’s important to keep your spine mobile and strong in the muscles of the back and the neck, and there are specific home exercises that you must do to maintain your strength and mobility. These are prescribed to you in our office based upon our examination findings.
To use one example, people need to have better rotation in the thoracic spine: the part with the ribs. This section of the spine needs to have some rotation in it too, and rotational exercises help out shoulder-blade stiffness a lot.
T4 syndrome is very common, yet not a lot of people have heard about it. Hopefully, with your knowledge of the symptoms, you will be able to recognize it when you see it, and refer your friends to a chiropractic physician for treatment.
Todd Lloyd, DC
Chiropractic Physician in St. George.
Excellent article, Dr. Lloyd. It is informative and written in a style that is easy to follow. Patients benefit when their doctors are better informed. Keep up the good work, and good writing.