What is Thoracolumbar Syndrome?

Thoracolumbar (T/L) syndrome, also known as Maigne’s Syndrome, is an uncommon area of joint dysfunction which can present itself as iliac crest pain, sacroiliac pain, hip pain, and pubic pain (including the groin and testicular area). This is a result of joint hypermobility or irritation of the superior cluneal nerves. The superior cluneal nerves travel from the T/L junction and branches into the aforementioned regions.

Who is Most Affected by Thoracolumbar Syndrome?

It is a potential cause of low back pain in athletes who are required to be in prolonged hip flexion and head extension, which causes extension overload of the T/L junction. Athletes at greatest risk for this condition are those who participate in hockey, weight lifting, equestrian competition, and football (linebackers and linemen).

With hip flexion, biomechanical limitations allow little-to-none extension within the lumbosacral spine. Combined with an already extended cervical spine there is an overloading of extension transmitted to the T/L junction leading to dysfunction. Pain can be produced when the posterior elements are loaded causing distraction of the contralateral posterior joint capsule. Increased loading will lead to torquing of the spinal segment which may impact the disc. 

Tests for T/L Syndrome

Special tests include an exceedingly painful skin rolling which is explained by inflammation occurring on the superficial cluneal nerves. Pinching during skin rolling will be sensitive or painful over the iliac crests (cluneal nerve), inguinal canal (inguinal nerve), or greater trochanter (lateral perforator nerve).

The patient will also present with point tenderness along the T11-L3 segments with pain radiating from the segmental nerve distribution of thoracolumbar origin.

Provocative injection of the posterior joints and discs can additionally provide a definitive diagnosis and can be administered by a medical doctor. Although helpful, provocative injections are not required to make a clinical diagnosis.

Plain film radiography can be utilized by analyzing stress films for gross segmental instability in the thoracolumbar region. However, radiography is not required to make a clinical diagnosis. 

What are the Differential Diagnosis?

Musculoskeletal differentials include anterior or posterior spinal nerve compromise at the T/L junction, lumbar zygapophyseal joint dysfunction, disc disruption, congenital malformations, degenerative disc disease, and fibromyalgia.

Non-musculoskeletal differentials include spinal tumors, renal disease, neurofibroma, abdominal aortic aneurysm, and inflammatory processes. 

Who can Diagnose this Condition?

Your local physiotherapist or chiropractor can assess you in the clinic to make a diagnosis. Since thoracolumbar syndrome is a diagnosis of exclusion, your health care practitioner will first need to rule out other conditions using orthopaedic tests. Conditions like lumbar radiculopathy and sacroiliac joint syndrome can present similarly and need to be ruled out. Since these other conditions have very different treatment approaches, receiving a diagnosis becomes critical in creating a recovery plan.

If you are in the Greater Toronto Area or Markham, you can consult a Rehab Hero clinician by clicking the button below:

What are the Treatment Options for this Condition?

Patient education can be used to encourage patients to avoid aggravating postures, mainly cervical extension, thoracic spine extension, and hip flexion, which will prevent re-injury.

Passive treatment of T/L syndrome includes thoracolumbar extension in a supine position (described as an thoracic anterior manipulation at the T/L junction). This can be applied by a qualified chiropractor or physiotherapist. Prone mobilizations at the thoracolumbar junction may also be used and can be applied by a registered massage therapist or by the aforementioned clinicians.

Consult a physiotherapist or chiropractor to receive a plan of management (a.k.a. treatment plan). A plan of management can be divided into a 4-phase functional restoration program. 

Phase 1 - Decrease pain and inflammation - ice, electrical stimulation, NSAIDs, postural education, myofascial therapy*

Phase 2 - Restore range of motion - muscle balancing (eccentric strengthening of transversus abdominus to control thoracolumbar trunk rotation, multifidus to control extension), flexibility, manual therapy (restoration of hypomobile segment), dissociative movement therapy, elementary stabilization, gait mechanics

Phase 3 - Improve strength and stability - intermediate and advanced stabilizations, proprioceptive retraining, dissociative movement therapy, plyometrics, weight training

Phase 4 - Return to work/ play - task specific

*Myofascial therapy (is also known as soft tissue therapy or massage therapy) can be completed by your local massage therapist, physiotherapist or chiropractor.

Exercises for Thoracolumbar Syndrome

As mentioned above, the treatment plan will include exercises which are selected with specific goals depending on your personal demands. Generally thoracic mobility exercises can be used to improve upper back active range of motion. By improving the mobility of restricted regions you may be able to offload compensatory stresses applied at the thoracolumbar junction. An example of a thoracic mobility exercise is the THORACIC ROTATION exercise:

Dissociative movement exercises may also be used to offload the thoracolumbar junction. Dissociative exercises aim to improve your ability to isolate movement one region from an adjacent region. With this condition, an exercise may involve moving the lumbar spine independently from the thoracic spine or vice-versa. An example of a dissociative exercise for the T/L junction is the SPLIT SQUAT PELVIC TILT.

Lastly a stability exercise may be used to reduce thoracolumbar hyperextension which will reduce re-aggravation of your symptoms. The goal of stability exercises is to improve your ability to hold a neutral spine (anti-rotation, anti-extension) to reduce the likelihood of falling into an extension pattern when fatigued. An example of a stability exercise is the BEAR CRAWL ARM LIFT.

To get more specific exercises for this condition and the way you experience it, book in an appointment with a Rehab Hero therapist by clicking the button below:

For a full video on beginner exercises that you can do for thoracolumbar syndrome watch our video below made by a Toronto chiropractor.

References

1. Elder T, Curtin K. Thoracolumbar Syndrome: The Great Mimic. Dynamic Chiropractic [serial on the Internet]. (2014, Oct 15), [cited November 5, 2017]; 32(20): 6-18. Available from: CINAHL Plus with Full Text.

2. Fortin J. Thoracolumbar syndrome in athletes. Pain Physician [serial on the Internet]. (2003, July), [cited November 5, 2017]; 6(3): 373-375. Available from: MEDLINE with Full Text.

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