Another Look at the Thoracic Spine | Modern Manual Therapy Blog

Another Look at the Thoracic Spine

Since incorporating the SFMA into more of my caseload, I have been coming back to the thoracic spine more so than normal.

I normally looked at this area if my cervical, shoulder, or lumbar patients were not improving or plateaued before reaching their goals. Prof. Rocabado said it best, "It's not no pain, no patient." Despite referring to the TMJ, this saying applies to any area that may be contributing to the patient's movement dysfunction.

A lack of mobility in the thoracic spine could cause a stability issue in

  • the cervical spine
  • the lumbar spine
  • the scapulothoracic area
    • these areas will compensate for a lack of mobility in the thoracic area with a loss of stability
    • if these areas initially present as restricted, it is fine to release them using STM and/or joint approaches, but if the patient has a loss of stability, be prepared to instruct them on appropriate stabilization exercises
Or, it could cause a mobility issue at
  • the glenohumeral joints
    • thoracic extension is needed for full elevation
Manipulation to the thoracic/upper thoracic spine may improve
  • shoulder elevation
  • cervical pain
  • cervicogenic/tension HA
  • thoracic mobility - naturally
  • cervical stability
  • lumbar stability
Look for joint restrictions in the junctional areas, CT and TL. Females tend to have them around the bra strap area.

Recent Case Example 
A 36 yo female referred for severe HA and pain in bilateral upper traps. She was having trouble lifting her kids and even pushing shopping carts. She presented initially with 8/10 pain in the upper traps, cervical spine bilaterally, and frontal/temporal cranium areas. Her only limitation was moderate in OA forward bending, and bilateral 1st rib. All cervical motions were WNL, 9/9 on the hypermobility scale.

After IASTM to the cervical spine and 1st rib mobilizations, plus light subcranial shear distraction, she happily left with 0/10 pain. However, the next 3 days were 9/10 and constant. Her next visit, I treated her lighter using IASTM. Her OA motion was now normal. We continued with 1st rib mobs and this improved to grade 3 shortly. 

The next visit, she was better, but had 3-5/10 cervical spine pain and HA, but it was less frequent. I screened thoracic rotation, which was moderately limited to the right. This was the only limitation in motion I could find after screening her entire body.

After instructing her on open book thoracic rotation exercises, she left feeling much better. For the next two weeks (she had to cancel a few visits), she was able to prevent the onset of HA by just performing open book exercises! The next visit, I will teach her cervical stabilization, as an added precaution.


  1. Blake Thedinga DPTApril 29, 2012 at 9:51 PM

    First of all, thanks for all of the invaluable info. and case studies. Just curious about the hypermobility scale, is it by Beighton, et al.? I had to do a little research as I graduated about 1 year ago and they didn't teach us this in PT school or maybe I slept through it. How often do you implement this into your eval.? How many pts. score 9/9?

  2. No problem! Glad you're learning. It is the Beighton scale. I don't think I learned it in school, I learned it from Mariano Rocabado. I do not implement it too much, but I do see it a lot because my caseload is at least 50-75% TMD at any given time, and many of them are ectomorphic hypermobile females.