Question
QUESTION: Hello and thanks in advance for your answer.  I had an injury to my mid/back (right side, between spine and shoulder blade) back while running uphill and twisting to the left on a cold, wet day last November.  The injury was a very sharp stabbing pain that took my breath away for several seconds.  For the next few weeks, I was extremely sore and awoke every morning stiff and painful until I took a hot shower.  I am a computer worker, and I also had recently started playing piano (up to 2 hrs per day) which I continued, but it definitely hurt after every practice session.  In December I started feeling dizziness when I would lie down at night for sleep, but I was sleeping OK.  However, in late December (2009) I was hit with total insomnia.  This persisted for six days before I saw the doc and got some meds for sleeping (Elavil).  I also started seeing a chiropractor, who took xrays to look for a fracture at T4, didn't see one, so adjusted T4 for four sessions.  These adjustments were very painful leaving me sore for days afterward.  As chiro adjustments had never caused this much pain before, I discontinued treatment on his advice that we should just let it rest for a while.  I started PT/manual therapy in April (2010) to try and mobilize the mid/upper thoracic region, but in general, PT generally made my dizziness worse.  My traps and neck are sore/tight.  Whenever I sit down, I tend to get dizzy.  If I am up and about, the dizziness is much less.  Interestingly, the more pain I feel in my back on the right side of T4, the less dizzy I feel.  However, the dizziness is never gone.

I sit on a swiss ball at work and while eating at home.  This seems to keep me from getting too dizzy while seated.  If I have to sit on a "normal" chair, I have to sit with extremely erect posture to keep the dizziness from being too intense.  Slouching, squatting, and some other non-ideal postures will elicit dizziness to a greater degree.

In June I had a thoracic MRI which showed some inflammation and possible edema around the right facet joint of T4 pressing on the surrounding tissues.  I have been on Celebrex since July in an attempt to reduce this inflammation.  I haven't been off it yet, so I don't know how much better it has gotten.

I continue to have pain around my T4/rib junction on the right side.  I have had acupuncture, which seems to help temporarily, perhaps calming down the trapezius.  The dizziness is milder now than in the Spring, but still present, as is the insomnia.  Initially I had right ear tinnitus, but this has improved considerably to the point where I rarely get it.

Currently I am getting chiropractic treatment for my cervical spine (C1/C2) and Thoracic (T1-T4).  I have not asked him to check the rib/T4 junction specifically to see if the rib is out of place (I assume he would check this without my asking).  His contention is that my sympathetic nervous system is affected by angry mechanoreceptors in the thoracic (and possibly cervical) spine.  I have had a cervical MRI which didn't show anything other than age related degeneration - I'm 36 years old and active/healthy up until this hit me last winter.  I am still active (cycling, rock climbing) but cautious.  It is actually when I am sitting/stationary that I get bothered most.  Sleep is still a problem, and typically while prone I can feel my heartbeat very intensely as though being prone makes my heart work harder.

I am tempted to look into procaine injections or some other injection modality for the pain at T4/Rib.

Does my current diagnosis seem plausible?  Should I consider injections to try to attack the sympathetic chain (stellate ganglion?), or should I simply continue with chiro treatment?  So far it has been a month, 8 session, and the chiro is pleased with how things are mobilizing.  But my symptoms are relatively unchanged (perhaps slightly better).

Thanks - sorry for the long winded story.

ANSWER: Hi Ted,

Well, your situation is a doozy...probably more complicated to truly address on the internet, but I'll pop in a few thoughts.   The MRI sounds unrevealing in identifying a boney stress response, but does show some inflammation.  It could be helpful to have an "over-read" by a different radiologist since sometimes they miss stuff (there is a journal article on "False Negative MRI" reports.  There is a "T4 Syndrome" that usually includes pain and arm paresthesias, but not dizziness or insomnia.  Has BPPV been ruled out?   For the T4 zone, get some Graston Technique performed (see my web site).   I'd suggeste forgetting about the concept of bones "in place" or "out of place."   It doesn't work like that.  Are you vitamin-D deficient?  Is anyone looking for myofascial trigger points?   Is your acupunctureist doing traditional acupuncture or is he/she "dry needling" trigger point or fibrotic lesions (big difference)?    You also may find that one visit to the MD Physiatrist for "facet block" by either cortisone/anesthetic or radiofrequency nerve ablation might knock out all the T4-rib pain.  Likely there are pain management doctors in your area that specialize in these.  Feel free to get back to me regarding my questions.

'Best,

Dr. G

---------- FOLLOW-UP ----------

QUESTION: Thanks for your reply.  In answer to your questions - BPPV hasn't been ruled out, but seems unlikely since my dizziness seems less about the position of my head and more about the "shape" of my thoracic region (e.g. crossing my arms in front of me will bring on more dizziness even if my head position remains unchanged).  I've been on 5000 i.u. a day of Vit D for a few months.  The acupuncture I have been getting would probably best fit "traditional".  I've had a couple of massage sessions, but none of the therapists remarked on any significant myofacial issues.  However, I haven't really gone to massage therapist who specializes in trigger point therapy.  

I've been leery of facet block injections or nerve ablation, but maybe it is time to consider.  I'd prefer to go with the conservative route, but maybe after nine months it is time.  

Is it possible that my sympathetic nervous system is out of whack due to myofacial issues?  My understanding is that the sympathetic nerves in the thoracic area run close to the vertebra/rib junctions, so that's why I wonder about a misalignment of the 4th rib.

Is Graston performed by D.C.'s or by massage therapists?  I can look for a local practitioner.  What is the reasoning for why you feel this is important for my T4 region?

Thanks again!

Answer
Ted,

I hope you consider the facet joint blocks if nothing else is helping.   As for Graston Technique, it is mostly performed by DC's.  Go to www.grastontechnique.com    Understand that about 30% of your body mass is composed of fascia.  Fascia is the connective tissue what weaves through, helps support, and allows normal function of your body, including your T4 region.   You are not just made of bones and muscles.  If you have a fibrotic fascial lesion, it will not come out with acupuncture, joint manipulation, or exercises.  The human body remains mysterious in many ways, and if you limit your treatment because of limited understanding, then you will cheat yourself from potential opportunities for a cure.  

Good luck with this.  I hope whoever resolves your condition takes the time to write it up and publish it as an interesting case study.  

'Best,

Dr. G