Conditions & Treatments - T4 Syndrome


The thoracic spine region is comprised of 12 vertebrae and the rib cage with its articulations which enhance the stability of the thoracic spine (1, 2). In the vertebral column, the compressive load at T1 is about 9% of body weight, increasing to 33% at T8 and 47% at T12 (1). Although, there are many potential sources for pain at the thoracic region, research for this region remains limited (1, 2, 3). Various sources of thoracic pain that are musculoskeletal in origin can include: “muscle strain, vertebral or rib fracture, zygapophyseal joint arthropathy, active trigger points, spinal stenosis, costovertebral and costotransverse joint dysfunction, ankylosing spondylitis, diffuse idiopathic skeletal hyperostosis, intervertebral disk herniation, intercostal neuralgia and T4 syndrome (3)”. In this article, we will discuss T4 syndrome in more detail.

T4 Syndrome Symptoms
Symptoms associated with T4 syndrome include constant or intermittent upper thoracic pain which may also be accompanied with back stiffness and upper extremity numbness and/or paresthesia (3, 4, 5, 6). This paresthesia may be glove like in distribution for one or both forearms/hands (3, 4, 5, 6). Referred pain into the neck and scapular regions along with generalized headaches which are dull and achy may be associated with T4 syndrome as well (3, 4, 5, 6).

T4 Syndrome Description/Cause

The cause of T4 syndrome is inconclusive but may be associated with joint hypomobility and faulty postural alignment (2, 4, 5 ,6). Both the thoracic intervertebral disks and thoracic zygapophyseal joints are thought to be primary pain generators in T4 syndrome based on their pain patterns (5, 6). It is also hypothesized that sympathetic dysfunction somehow related to vertebral dysfunction in the upper thoracic region (T2-7) causes a referred or reflex phenomenon in the arm or hands (4). Women in the age range of 30 to 50 years of age are also 4 times more likely than men to develop this condition (3, 4, 6). Activities such as lifting, excessive bending, pulling, reaching, shoveling, performing overhead activities, prolonged sitting and poor posture can exacerbate this condition (4, 6).

Physical Therapy Findings in Patients’ with T4 Syndrome
Upon palpation and joint play assessment, patients will often display tenderness and hypomobility at and around the T2-T7 segments with the T4 segment being most involved (4, 6). A thorough neurological examination should also be conducted to rule out any neural involvement as the neurological examination presents normal in patients with T4 syndrome (4, 6).

T4 Syndrome Treatment Options for a PT
• Postural/Functional Training
• ROM exercises
• Stretching
• Strengthening/Stabilization
• Manual Therapy/Joint Mobilization
• Modalities (heat, ultrasound)

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Last revised: October 16, 2010
by Jennifer Hill, MPT, CSCS



1) White A. An Analysis of the Mechanics of the Thoracic Spine in Man. Acta Orthopaedic Scandinavica Suppl. 1969;127:8-92.
2) Edmondston SJ & Singer KP. Thoracic spine: anatomical and biomechanical considerations for manual therapy. Manual Therapy. 1997;2(3):132-143.
3) Fruth S. Differential Diagnosis and Treatment in a Patient with Posterior Upper Thoracic Pain. Physical Therapy. 2006;86(2):254-268.
4) Souza T. Differential Diagnosis and Management for the Chiropractor: Protocols and Algorithms. Jones and Bartlett Publishers. 2009;113-114.
5) Young B, et al. Thoracic Costotransverse Joint Pain patterns: A Study in Normal Volunteers. BMC Musculoskeletal Disorders. 2008;9:140.
6) DeFranca GG, Levine LJ. The T4 syndrome. J Manipulative Physiol Ther. 1995;18(1):34-7.

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