Today is Part 2 of a detailed series on the thoracic spine from Eric Schoenberg. If you missed it, be sure to check out Part 1. -EC

At this point, we need to quickly touch on the concept of “neutral.” This is certainly a hot topic in the physical therapy and strength and conditioning worlds, as it should be. For our purposes, we like to be clear that when someone is too flexed (i.e. fully slumped posture), our cue is to “extend back to neutral.” In addition, when someone is too extended, the cue would be to “flex back to neutral.” This holds true in all segments of the body and in all three planes of motion (e.g. pelvic tilt, genu valgus, etc.) The problem that we tend to see is we don’t grade our correction and “overcorrect.” This results in fixing one problem only to create a new one in the opposite direction.

In Malcolm Gladwell’s new book, David and Goliath, he refers to this as the “inverted U curve.” Its application here is that IF an athlete truly lacks T-spine mobility, then once we properly gain it, continued efforts to improve (rather than just maintain) this mobility will ultimately create a brand new problem (hypermobility). This needs to be considered when we write new programs and lends itself nicely to the importance of thorough evaluation and re-evaluations.

To quickly recap part 1, for the purpose of this series, a cue to “extend the T-spine” is really a case of moving out of excessive flexion and learning to control flexion throughout the throwing motion.

In part 2 of this series, we will focus on the postural alignment and movement examination and its implications in developing an individualized exercise prescription for the athlete. As a quick side note, it is of particular importance to recognize that the body segments don’t work in isolation. This is a simple statement; however, when attempting to capture the role of a particular body segment or group of exercises, we are missing the big picture if we try to develop a concept without appreciating the kinetic chain.

In our opinion, the hallmark of an effective examination is the ability to properly identify the athlete’s unique postural alignment and movement tendencies. These exams must be done with the shirt off to appreciate the bony and soft tissue anatomy. With respect to the thoracic spine, we first identify whether that athlete is in flexion, neutral, or extension.

Here’s an example of an athlete with a flattened T-spine, and shoulder blades that have no idea what to do!

Additionally, we need to appreciate the position of the scapula and its impact on the appearance of perceived thoracic flexion. An athlete that presents with scapular anterior tilt, abduction, and/or internal rotation can easily fool you into thinking that the athlete’s upper back is “rounded” or kyphotic. An athlete with a flat thoracic spine (hypokyphosis) will have a more prominent scapula due to lack of normal contour of the T-spine and ribcage. In extreme cases, we will see the following:

1. Hypokyphosis (lack of T-spine flexion)

2. Scheurmann’s Disease (greater than 60 degrees, and structural)

On x-ray, these cases will show a change in the normal vertebral “wedging.” The intervention in this case is NOT to attempt to fix the mobility issue, but first determine if the issue is osseous/structural in nature. Just like any other joint (the hip immediately comes to mind), you can’t stretch bone and any attempt to do so will result in an unhappy athlete! These are extreme examples, but certainly something that warrants inclusion in this article.

However, more commonly in the physical therapy or strength and conditioning settings, we will see more “middle of the road” cases where there is too much or too little thoracic mobility. As you can see in the lateral view below, this athlete appears to be in excessive thoracic flexion, but it’s really just anterior tilting of the scapulae.

However, in the posterior view, you’d be able to appreciate that the T-spine is relatively extended compared to accepted norms (40° flexion = normal curve).

Moving forward, static alignment does not tell the whole story, so don’t test it alone and don’t let it fool you. All too often, I hear people trying to prove a point about pitching mechanics or exercise technique and the only proof is a still photo. This practice needs to stop because it is impossible to capture the complexity of human movement and make a conclusive statement from a screen shot. This concept is why the combination of the postural exam and movement analysis is so critical.

Athletes don’t get injured when they are standing still. They get injured moving (incorrectly!). For that reason, watch your athlete’s move. The concepts of FMS or whatever collection of multi-joint movements you like to combine to form a “movement examination” are great tools to collect data on your athlete’s preferred movement patterns. However, it is also critical to watch the athlete perform the unique movements of their chosen sport.

In our case, we like to talk to our athlete’s about pitching and we certainly like to watch them throw. Asking questions like: “What do you struggle with mechanically” or “where do you break down when you get tired” gives us valuable insight into movement tendencies and injury risk. With respect to exercise, we observe closely to make sure we are achieving the desired result of the exercise. In addition, we ask our athletes where they feel a particular exercise to help determine activation patterns and sequencing (motor control).

In addition to watching our athletes throw/pitch, swing, and/or run, we employ simple movement tests such as standing bilateral shoulder flexion (and abduction) to gather critical information about movement quality, timing, and relative stiffness.

With respect to the video above, consider the excessive extension moment at the thoracic (and lumbar spine) due to increased relative flexibility resulting from poor anterior core stiffness. This video brings up a lot of questions in my mind:

• Does this athlete need more mobility work into thoracic extension?
• If he attempted these exercises, how can you be sure the motion will even come from the right place?
• If an athlete is truly “lax” congenitally, then why would they lack mobility at the T-Spine and nowhere else?
• Are you sure his lack of shoulder flexion is due to decreased thoracic mobility?
• Or, is he too flexible in his spine and too readily pulls into extension due to the stiffness of his lats?

My point here is we need to consider the fact that improperly prescribed exercise will make the athlete worse than no exercise at all. So, if you’re not sure, don’t guess. Refer out or continue to re-assess until it becomes clear what the athlete needs.

Another simple movement test that we will have the athlete perform is standing thoracic flexion and extension. Here we will assess the timing (quality), location, and amount of available range of motion that the athlete is working with.

It is also good practice to watch an athlete perform an exercise prior to putting it in his program.

This athlete (also pictured above) demonstrates faulty movement by not getting out of extension at the top of his pushup prior to initiating the “pike” portion of the yoga push up. When corrected, in the video below, he did a better job of getting his T-spine in position to allow his scapula to have a better platform to upwardly rotate and elevate as his hands moved overhead. This was not a mobility issue; this was a patterning or motor control problem.

I should mention that in a full examination, we would consider movement testing of thoracic rotation and sidebending, ventilation, rib cage alignment, quadruped position/movement, etc. But, for the purposes of this series, we again are choosing to focus primarily on the sagittal plane. Pay attention to the way in which the athlete returns from flexion to get a good idea of his/her recruitment strategies.

In conclusion, the combination of static posture, movement testing, and unique athletic movement allows us to create a well-rounded profile of the athlete’s strengths and weaknesses. Be sure that your examination a) identifies areas of limitation that need to be addressed and b) determines the reason why the athlete has these impairments.

In the third and final part of this series, we will discuss the concepts of relative flexibility and motor control as it relates to the topic of thoracic spine extension.

Also, if you’re interested in more information like this, we would love to see you at one of our Elite Baseball Mentorships, with the next one taking place in June. Click here to learn more.