What is T4 syndrome?
T4 syndrome is a variation of a thoracic (mid back) facet sprain or strain. It has the same injury mechanism but a separate diagnosis due to the combination of its specific location of the 4th vertebrae in the thoracic spine and its particular symptoms. A general thoracic facet sprain or strain causes localised pain and swelling with occasionally pain that travels towards the sides or up into the neck. In the case of T4 syndrome a dull pain is referred into the upper portion of the arm along with additional symptoms of arm pins and needles and numbness.
Your thoracic spine (mid/upper back) is made up of 12 connected bones called vertebrae (T1-T12). The vertebrae are connected to each other above and below through strong discs and joints on either side called facet joints. Your discs protect your spine by acting like shock absorbers to distribute weight through your back evenly. The facet joints on the other hand not only control but allow the movement of your back. Think of your facet joints like the steering mechanism of your spine it is their job to determine what movements can be made and the extent of those movements. The disc in the middle and the facet joints either side form what professionals refer to as the “three joint complex” that makes your spine a strong and durable structure.
Individually these joints are susceptible to injury. A strong capsule that forms around the facet joint encapsulates it and prevents either boney ends from connecting or impacting. The capsule is filled a small amount of thick fluid called synovial fluid that acts like a cushion and there is protective layer of articular cartilage that covers both boney surfaces. The cartilage, fluid and strong capsule allow the joint to move in a smooth, flexible manner. Ligaments surround the facet joint and are made of thick, tough, fibrous tissue and they overlap the joint to provide protection and stability. This stability is reinforced by the muscles that surround the joint. Your muscles are not only there to create movement but they are strategically placed to protect the structures they support.
In essence the facet joints in your spine are no different to your ankle joint and it is safe to assume everyone is familiar with the feeling of going over on their ankle and spraining it. Your facet joints like the ankle have a limit to their movement which is termed the joints “end range of motion”. Normal slow and gentle movements to don’t harm your facet joints, however sudden and excessive movements like going over your ankle have the ability to stretch the joint past its end range. The result is damage to the facet capsule, ligament or surrounding muscles. When the capsule or ligament is injured then it is known as a thoracic facet sprain and when the muscles surrounding the joint are injured then it is known as a thoracic facet strain.
Why and when does T4 syndrome happen?
A facet sprain or strain at the level of T4 can result from severe and sudden excessive movements, severe compressive forces or repetitive over stretching. The causative activity can be anything from sports contact like a rugby tackle to turning to quickly in reaction to someone calling your name. Allot of the time mild sprains are caused through repetitive strain like reaching up and forwards whilst shearing the garden hedge and also spending to long slouching whilst reading a book. Other factors including poor posture, sedentary lifestyles and weak back muscles can also contribute (please see the note on upper cross syndrome). One thing that affects many people is a poor sleeping posture as sleeping on your front can cause continued facet joint compression and lead to a sprain or strain, it is more advisable to sleep on your back or side. When the joints are injured and swollen they cause localised pain in the mid back. When the swelling levels are high, the spinal nerves that pass closely to the joint lines can become irritated. It is this irritation that causes the arm pain, numbness and pins and needles.
What does T4 syndrome feel like?
There is a sudden onset of pain in the mid back almost immediately after or even during the injury and is coupled by intense muscles spasms, creating a lot of stiffness. The pain is sharp and possibly burning to begin with, in some cases the sharp pain continues and in others it is replaced by an intense dull ache a day or two after the injury. The arm pain and symptoms will normally develop within a couple of hours of the injury. Most commonly the symptoms are only felt in one arm and on one side of the back however due to the three joint complex the facet joint on the other side can also be equally affected. As well as experiencing arm pain many patients also report sharp pains travelling up into the neck or towards the lower back on certain movements. Symptoms are aggravated by sudden movement, twisting from side to side, flexing forward and tilting back. Activities like sitting in one position for a long time and lifting can also aggravate pain levels.
It is extremely common for a sprain or strain to occur silently during an activity with the patient not yet aware that any injury has occurred. The only indication is a slight pain and stiffness which may be normal after certain activities. This happens most commonly in mild sprains and as long as you keep moving the muscles don’t have a chance to spasm in protection and likewise the joints don’t stiffen up. In these instances no symptoms are felt until the next day after they have slept in the same position for more than a couple of hours allowing the joints to stiffen and the muscles to spasm. Patients can awaken the next day with extremely high pain and stiffness levels.
How will T4 syndrome be diagnosed?
Your GP or therapist will be able to diagnose you by both listening to your history and examining you. No X-rays or further investigation should be needed to confirm diagnosis. Occasionally your GP may refer you for further investigation either by MRI or an X-ray. This will only occur if they want to rule out other injuries such as a thoracic disc herniation.
What treatments are available for T4 syndrome?
Your GP may prescribe a short course of anti-inflammatory painkillers to reduce and control the painful inflammation that occurs. Applying a covered ice pack to the mid back after the initial injury may also significantly hasten the healing process by reducing the pain and swelling. Please make sure the ice pack is covered to prevent any ice burn and for best results use the icepack use regularly for 10-15 minutes with intervals of 30 minutes. Avoiding all aggravating movements and postures is advisable, however complete rest is not. Try to move gently and often this will prevent stiffness levels from building in your neck. When you have to sit for a long time don’t try to over force a good or correct posture. Instead go with what is comfortable for you even if that is slouching a little, the key element is not to stay in that posture for too long. The golden rule basically is being a fidget!
The back will be left slightly weakened after the injury. To prevent this weakness from progressing it is important to strengthen the muscles of the upper and mid back to avoid suffering from a recurring back sprain. Starting with simple stretches and progressing to strengthening exercises will counteract any stiffness and weakness that has developed. Your therapist or GP will be able to advise you on appropriate exercises. A sprain will heal roughly within 6 weeks of its own accord, However many people seek out alternative treatment to speed up the recovery process. Manual manipulative such as Osteopathy, Chiropractic and Physiotherapy and massage therapies like Bowen technique and sports therapists have been seen to alleviate pain and stiffness levels quickly and help towards preventing future flare ups.