Thoracic Disc Bulge

Injuries > Upper Back & Chest > Thoracic Disc Bulge

(Also known as Thoracic Disc Herniation, Slipped Disc, Prolapsed Disc, Bulging Disc, Herniated Disc, Intervertebral Disc Injury, Sprained Disc)

What is a thoracic disc bulge?

The thoracic spine (i.e. the mid and upper back) comprises of many bones known as vertebrae, each of which is separated by a disc (figure 1). The disc comprises of many layers of strong connective tissue wrapping around the disc. In the middle of the disc lies a soft jelly-like substance which is capable of changing shape. When this jelly-like substance protrudes from the disc due to a tear in several layers of the connective tissue, this is known as a thoracic disc bulge (figure 1).

To understand the mechanism of a thoracic disc bulge, it is useful to liken the disc to a vanilla slice. Imagine a vanilla slice wrapped in five layers of sandwich wrap. The top and bottom layers of pastry represent the vertebra (bones), the custard represents the jelly-like substance of the disc and the sandwich wrap represents the connective tissue around the disc. If you were now to pinch the front of that vanilla slice, you could imagine, the custard would squeeze towards the back of the vanilla slice and may tear two or three layers of sandwich wrap at the back of the vanilla slice. As a result the custard is no longer supported as effectively at the back of the vanilla slice and therefore bulges out at this location. In the disc, the situation is the same. Bending forward closes down the front of the disc, pushing the jelly-like substance within the disc towards the back. Overtime or suddenly, this may tear several layers of connective tissue at the back of the disc resulting in a disc bulge.

Causes of a thoracic disc bulge

There are several activities in everyday life which typically cause thoracic disc bulges provided they are forceful, repetitive or prolonged enough. These include: bending forward, slouching, activities using your arms in front of the body (e.g. washing dishes, driving etc.) and lifting (especially in combination with twisting).

Occasionally, thoracic disc bulges may occur following a trivial movement involving bending forward such as picking up a small object or sneezing. In these instances, the disc has normally been subject to repetitive or prolonged bending, slouching or lifting forces leading up to the incident.

Signs and symptoms of a thoracic disc bulge

Patients with a thoracic disc bulge may experience a sudden onset of back pain during the causative activity, however, it is also common for patients to experience pain and stiffness after the provocative activity, particularly the next morning.

Symptoms are typically felt in the mid back, sometimes between or around the shoulder blades and may be located centrally, on one side or on both sides of the spine. The patient may experience pain radiating around the ribs and into the chest, or sometimes down the arms. Muscle spasm, pins and needles, numbness or weakness may also be present.

In some cases, patients may appear to stand with their spine noticeably out of alignment as a result of the disc bulge. Symptoms are generally exacerbated with activities involving rotation, side bending, activities using your arms in front of your body, lifting, bending forwards, or prolonged sitting (especially if slouched). Breathing, coughing, and sneezing may also aggravate symptoms. Patients with a thoracic disc bulge often experience pain that is worse first thing in the morning.

Diagnosis of a thoracic disc bulge

A thorough subjective and objective examination from a physiotherapist is usually sufficient to diagnose a thoracic disc bulge. Investigations such as an MRI or CT scan may be required to confirm diagnosis.

Treatment for a thoracic disc bulge

Most patients with a thoracic disc bulge heal quickly and have a full recovery with an appropriate physiotherapy program. The initial goal of treatment is to push the bulging disc back into its original position and then keep it there so the torn connective tissue at the back of the disc can heal. The time it takes to push the disc back into its original position varies from person to person depending on their activities and compliance with physiotherapy advice. Since certain activities push the disc out and others push the disc back in, the balance of these activities dictates recovery time. If there are more activities pushing the disc out than in, these injuries will get worse and will only improve once activities pushing the disc in exceed the activities pushing the disc out. Activities typically pushing the disc out include: slouching, bending forwards, activities using your arms in front of your body, lifting, coughing and sneezing. Activities which help to push the disc back in include: lying with your back straight, standing or walking (with your back straight for periods of time that do not increase your back pain) and certain exercises determined by a physiotherapist (commonly back arches).

Generally, sitting should be avoided. However, if inevitable, optimal sitting posture is vital to minimize stress on the disc. Optimal sitting posture can be obtained by sitting tall on an appropriate chair, with your bottom in the back of the chair and a lumbar support (or a pillow or rolled up towel) in the small of your back (figure 2). If you must sit, try to keep it to short periods of less than 10 – 15 minutes at a time and no more than 1-2 hours total for the day. Sitting slouched should be avoided as it places your mid and upper back into its maximal bend (like standing and touching your toes), this will rapidly aggravate a thoracic disc bulge.

Patients should follow the R.I.C.E. Regime in the initial phase of injury. The R.I.C.E regime is beneficial in the first 72 hours following injury or when inflammatory signs are present (i.e. morning pain or pain with rest). The R.I.C.E regime for a thoracic disc bulge primarily involves resting from aggravating activities (this may include the use of a Postural Brace) and regular icing. Anti-inflammatory medication may also significantly hasten the healing process by reducing the pain and swelling associated with inflammation.

Once the disc is back in its original position, patients should perform pain free flexibility, strengthening, core stability and cardiovascular exercises to prevent stiffness and weakness from developing and to ensure the upper back is functioning correctly. Clinical Pilates exercises and swimming are also often recommended. The treating physiotherapist can advise which exercises are most appropriate for the patient and when they should be commenced.

Prognosis of a thoracic disc bulge

In patients with the perfect balance of activities, the thoracic disc may be pushed into position in as little as three days. Typically, however, patients take approximately 2 to 3 weeks to push their disc back 'in'. Once the disc is 'in', the patient should be pain free and have full movement. However, the torn connective tissue at the back of the disc only begins to heal from this point. It takes approximately six weeks of consistently keeping the disc 'in' to allow the torn tissue to heal to approximately 80% of its original strength.

Contributing factors to the development of a thoracic disc bulge

Several factors may contribute to the development of a thoracic disc bulge. These need to be assessed and corrected with direction from the treating physiotherapist and may include:

• poor core stability
• a sedentary lifestyle
• being overweight
• muscle tightness
• muscle weakness
• joint stiffness
• poor lifting technique
• poor posture 
• a lifestyle involving large amounts of sitting, bending or lifting.

Physiotherapy for a thoracic disc bulge

Physiotherapy treatment for a thoracic disc bulge is vital to ensure an optimal outcome and may comprise:

• soft tissue massage
• electrotherapy (e.g. ultrasound)
• postural taping
• postural bracing
• mobilization
• traction
• the use of a lumbar support for sitting
• dry needling
• exercises to push the disc back 'in' and to improve strength, core stability and flexibility
• education
• activity modification advice
• biomechanical correction
• ergonomic advice
• clinical Pilates
• hydrotherapy
• a gradual return to activity program

Other intervention for a thoracic disc bulge

Despite appropriate physiotherapy management, a small percentage of thoracic disc bulges fail to improve and may require other intervention. This may include further investigations such as an X-ray, CT scan or MRI, pharmaceutical intervention, assessment from a specialist or sometimes surgery. The treating physiotherapist can advise if this is required and will refer to the appropriate medical authority if it is warranted clinically. In cases of persisting or worsening neurological symptoms (pins and needles, numbness and weakness), surgery may be indicated. When a loss of bowel or bladder control is present due to the disc bulge, this is considered a medical emergency and immediate surgical intervention is usually required.

Exercises for a thoracic disc bulge

The following exercises are commonly prescribed to patients with a thoracic disc bulge. You should discuss the suitability of these exercises with your physiotherapist prior to beginning them. Generally, they should be performed 5 times daily and only provided they do not cause or increase symptoms.

Shoulder Blade Squeezes 

Begin sitting or standing tall with your back straight. Squeeze your shoulder blades together as hard and as far as possible pain free (figure 3). Hold for 5 seconds and repeat 10 times provided there is no increase in symptoms.

Figure 3 – Shoulder Blade Squeezes

Extension Over Chair 

Begin sitting tall on an appropriate chair (the top of the back rest should end at the level of your mid back). Place your hands behind your neck and gently arch backwards over the chair, looking up towards the ceiling (figure 4). Move until you feel a mild to moderate stretch pain free. Repeat 10 times provided there is no increase in symptoms.

Figure 4 – Extension Over Chair

Physiotherapy products for a thoracic disc bulge

Some of the most commonly recommended products by physiotherapists to hasten healing and speed recovery in patients with this condition include:

1. Postural Supports
2. Ice Packs or Hot Packs
3. Lumbar Supports (for optimal sitting)
4. Protective Tape (for postural taping)
5. Foam Rollers 
6. Spikey Massage Balls (for self massage)

To purchase physiotherapy products for a thoracic disc bulge click on one of the above links or visit the PhysioAdvisor Shop.

More exercises

• View more Upper Back Flexibility Exercises.
• View more Upper Back Strengthening Exercises.
• View Basic Pilates Exercises to assist with posture.

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