Chronic Back Pain - Triathlon Training - Help

Hi
For the last 6 months I have had discomfort in by back - in between the shoulders which flares up from time to time and goes into spasms and gets really sore. It wenr when doing reverse dips at circuits and I can't seem to shrug it.
I've been to a chiro for 3 sessions and was getting nowhere. I have been to my local physio and been given exercises and had a massage - it's still bad and I'm now about £150 down - how much more do I have to spend to fix this problem?!
It's hard to nail down which of the three sports is causing - or was it a weakness from years of bad posture in a sedentary job and the sport has just been too much? I started triathlon training a bout a year ago - only sprint distances so no crazy distances involved. I have been stretching it a lot but it never totally clears.
I guess before the training it was not perfect but I've just had the day off work as it cricked in the shower this morning and has been very painful. I have an appointment at the doc on Monday and he is going to do blood tests etc but I'm sure that wont help.
Can anyone advise as to where to go from here?

dear drekkly

the info you provide is limited, how did the pain start? did you fall? pull something too hard?, when do you get the pain? is it occurring at nght? spreading anywhere? what makes it better or worse? what position affects it? does it respond to pain killers? if so which painkiller? does it occur when you move a specific part of ur body? is it constantly there? is it a dull ache, sharp twinge...or burning pain? any other painful joint or part of your body? had this problem before?

are you well within yourself? eating well...what happens when you lift your arms up? can you lift ur arms up? what diagnosis did the physio and chiro give you? and what have they done for you...

see that the information you have given is limited?

Im not sure anybody here will be able to help if you do not provide more info...

Happy to provide whatever info is needed.

how did the pain start?
doing reverse dips at circuits - kinda twanged but not so bad I couldn't carry on - albeit in discomfort

when do you get the pain?
It's not so much pain as discomfort - it's there all the time from the min I wake up to the min I go to bed - intesnity depends on exercise but as I do 3 different sports it's hard to narrow down which one has the biggest impact

is it occurring at nght? spreading anywhere?
not at night no - it's in between the shoulder blades - wife has noticed a knotty patch on left shoulder blade but nothing major. massage made it better for a while

what makes it better or worse?
anti inflamatories helped - Naproxen - but try not to take them too often. Heat helps. I had a week off sport all together and there wasn't a marked improvement

does it occur when you move a specific part of ur body?
turning to the side makes it worse.

is it constantly there?
yes

is it a dull ache, sharp twinge...or burning pain?
dull ache most of the time but flares up badly every now and again - like today where it is very sore and stiff - but not unbearable pain that I can't move

any other painful joint or part of your body?
not so much - had knee and hip aches down the left side and achilles tendontis but exercisies are helping that

had this problem before?
no - back was not 100% right before but then whose is??

are you well within yourself? eating well
Yes. I started triathlons a year ago - lost 2 and a half stone in just over 2 years - eat carefully but well in my opinion

what happens when you lift your arms up? can you lift ur arms up?
yes it's ok - its when I twisto to the side it hurts

what diagnosis did the physio and chiro give you? and what have they done for you...

Well thats just it - the chiro gave no diagnosis - just said come back in 2 weeks all the time. That's whay I stopped - couldn't see where it was going. The physio said it could be poor posture - gave me some exercises to do and that was it. Had a massage at the physio but no long term benefit.

Hope this helps :)

Dear Dekkly

Thank you for your replies...

ill let you know what my thoughts are based on your reply then ill let you know what the problem(s) might be...

You had a traumatic onset from your reverse dips, the problem is not postural but posture may be aggravating it now....
You have a discomfort that is there all the time...something is out of place and its getting inflammed from being out of place
It does not affect you at night, so its not very serious...but has the potential to be since the discomfort is constant
It is a dull ache, i presume its deep and its now affecting some structures around it, tiring them out...
It responds to anti-inflammatories--definitely supports the thoughts so far
Heat helps,- maybe muscular, or maybe keeping the spasm controlled temporarily, if it was purely muscular, the benefits should be maintained as the muscle heals
You have hip, knee and tendinopathy issues...seems like degeneration is evident in your general musculoskeletal system
You havent had this problem before...its mainly caused by that initial trauma
you not losing appetite, and you feel well, no illness--not anything serious, not an organ---so no worries there (blood tests would unlikely show anything)
lifting you arms up do not influence it...unlikely to be muscular mainly...especially muscles attaching your scapular to the spine and neck
Mainly occurs when you turn to the side...suggesting a spinal problem
it gets sore and stiff...suggesting spinal issue

My thoughts
You probably have a subluxed rib...where it joins with the vertebrae at the back (which one im not sure)
either this or you have torn a muscle, imbalances are occuring...but if this was the case...positions will definately make this problem not evident 9it wouldnt be so constant)
another possibility is torn ligament near a vertebare causing excessive movements there...

More questions
what happens when you cough? what happens when you laugh? when you take a deep breath
what happens when you clap your shoulders together?
what happens when you bow your back?
what happens when you bend backwards like you wanna look up to th ceiling?
what happens when you bend forward like you wanna touch your toes
which side do you turn to that makes it painful? one side or both?

please reply and we reason this out together...

it might be worth having some radiological investigation before considering anymore physio or chiro...(at least to be cost effective)

cheers

thanks for the help so far. much appreciated.

More questions:

what happens when you cough?
no pain at all

what happens when you laugh?
no pain at all

when you take a deep breath
no pain - if I really go for it and suck it in so my shoulders blades go backwards then some discomfort

what happens when you clap your shoulders together?
by this u mean squeeze the shoulder blades tgther? if so then this hurts. it's one of the exercises I have been trying this week. Shoulder up then back then down then forward then up.

what happens when you bow your back?
with my head up - then nothing

what happens when you bend backwards like you wanna look up to th ceiling?
discomfort rather than pain between the shoulder blades

what happens when you bend forward like you wanna touch your toes

this hurts the most of all - middle back - between shoulder blades

which side do you turn to that makes it painful? one side or both?
after this morning both sides but this week it has been sore turning to the left - in the shoulders

one more that I may add - if I put my chin on my chest then it hurts my back in the usual place. If with my chin still on my chest i turn to the left or right then it hurts more - but higher up towards the neck

"you have torn a muscle, imbalances are occuring...but if this was the case...positions will definately make this problem not evident "

I must say that it is not 100% constant - what I meant by constant is that it is there at some point every day. I am sitting down now in a comfortable position and it is not hurting.Out of the sports I do - it was gernerally never there with running bit has started hurting just recently. Swimming is OK whilst I do it but can make it worse after. It is with cycling that it is most evident when doing the exercise. The discomfort was at its best when on holiday - although I exercised almost daily. The differenes being - I wasn't at work sitting at my desk all day, was in a different bed, wasn't swimming as much. It was still there but better than normal.

dear dekkly

it sounds like a torn muscle from your description...to be sure resisted tests will need to be done....take ur arms away from your side...bend your elbows, keeping your back straight push your elbows against a wall, what happens? (almost like you waant your shoulder blades to clap but you resisting the movement with your elbows)
secondly, while sitting, rest your hands on the arm chair and lift up like you would do a reverse dip, do once, what happens? (almost like you want to bring your shoulder blades down,)
thirdly, place one hand behind your head and resist taking your head back with your hand, what happens?
if your wife is there, ask her to place her hands on your shoulders, tell her to resist your while you try to lift your shoulders up (like in a shrug?) what happens?
Do you get pain on full range rotation?
if so...fold your arms acros your chest, turn left just before the pain increases...ask your wife to ressist this movement, what happens?
do the same for the right? what happens

my thoughts again:
I am excluding a subluxed rib hypothesis because you are not getting this pain when you expand your rib cage, you are getting your pain mainly when you move your spine, when you elongate it and when you turn it...as a variety of muscles cross from neck to spine, from spine to scapular, and within spine...
we are resisting these movements to see which aggravates...

if when your spine is stable and the resistance tests are positive..i.e keeping your back straight and pushing elbows against wall, resisted shrugging etc...then its probably a muscular problem...
if its not and you only get the pain on end range of spinal movements, I would put my money on a torn ligament in one of the verterbrae...

However it is essential that you get an xray to make sure nothing is out of place...

Your therapist maybe right to think it is posture related as if you have a faulty posture, i.e a forward neck, you could have a rigid neck/chest junction...with regards the possibility of you having arthritis...spinal dysfunction may become evident...

reply and we go on with our reasoning...

cheers

Dear Dekkly and Damien.

I've enjoyed reading your posts on this issue, and it has been interesting to follow the development of your reasoning. I think both you and Damien are doing a great job in narrowing things down and I agree on most of the comments Damien has made about the information you have been giving him.

If you don't mind, I'd humbly like to offer some thoughts that sprung to my mind whilst reading about your pain. The one thing that really stood out, was that it hurts more when you put your chin to your chest, and while holding that position, when rotating, it hurts even more. To me, that strongly suggest the involvement of a neurodynamic component. A simple test could provide further evidence to this being likely or not, and you can easily do this yourself. This link should give you a good start.

YouTube - Slump Test as described by Dutton

After slumping your upper body and lower back, with the chin flexed towards your chest, the discomfort is likely to increase, as you already told us. I'd advice you to stop the slumping at that point where you just feel the discomfort starts to increase and then proceed with the next movement in the test. The main component here is when your STRAIGHTEN OUT either of your knees and dorsiflex your ankles, does the discomfort between your shoulder blades INCREASE? Start with one leg first, compare with the other leg. If both are painless, do it with both legs simultaneously. If this also does not increase the discomfort, slump more tightly and repeat the movements, if still no increase in the discomfort between your shoulder blades, ask someone to put some pressure through (longitudinally) your upper body. A skilled therapist could explore these movements even more, changing the order from bottom-up, add rotations to your upper body and so on to search for any relevant signs. Both the chiro and the physio, in my opinion, should have done this on the first session with you, as it is a standard, simple test, that is recognized world-wide and taught in most undergraduate programs.

There is already a lot of good information in what you have shared with us, and some of this also supports my thoughts. Personally, I'd think of a torn muscle as less likely, and more towards intervertebral disc issues to be honest.

Both myself and Damien (and several others on this forum) can tell you more about neurodynamics and how a disc or its nearby structures can interfere with it, but it would be helpful to know if the slump test is positive or not before we go too deep into that discussion. Any additional information you can come up with, and details of how the slump test went would be helpful. Good luck!

Kind regards,
Sigurd Mikkelsen

Dear SigMik

I agree with you Sigmik, for one his age puts him in the category of people who tend to have disc problems, and the positive half of the slump test suggests so, i however doubt if this disc is fully herniated by virtue of the anatomy of the thoracic vertebrae (limited space within) and disc issues are less likely (not to say they dont happen). Perhaps the disc is herniated centrally and pushing on posterior structures (i.e) the dura matter...this would support the multisegmental referral pattern he gets (pain moving up his neck) when he adds the rotation. The non capsular presentation he gets now also supports a discy hypothesis...

Dear Dekkly, I definitely agree with my colleague, you probably have a disc problem...may be cause by torn ligaments supporting the vertebrae/ or by virtue of age your spine and previous sporting life your spine was prone to trauma weakened by denegeration, considering you might be arthritic in places u dont know about ....

Fill us in on the results of the slump test as suggested by SigMik...also can you tell us what the chiropractor did for this problem? Just wondering why you havent gotten any joy from Chiro..

Cheers

Sigmik/Damien

Firstly can i thank for taking interest in my case. I have got so much more out of these few communications then I have ever got from chiro/physio.

So results of th tests:

"After slumping your upper body and lower back, with the chin flexed towards your chest, the discomfort is likely to increase, as you already told us"

Yes this happens

I'd advice you to stop the slumping at that point where you just feel the discomfort starts to increase and then proceed with the next movement in the test. The main component here is when your STRAIGHTEN OUT either of your knees and dorsiflex your ankles, does the discomfort between your shoulder blades INCREASE?

I would say not noticeably with individual rises. The pain comes initially when I lower the chin but doesn't seem to increase greatly when I dorsiflex the ankles (on single rises) - the increase is most marked when I raise both legs together and THEN flex the ankles. If I lower them and flex again it is not the same.

I must say I am doing this alone at the moment and it is difficult to keep the level of slump constant - I will replicate with my wife and see if I can be more consistant.

Damien - to answer your questions from last night:

take ur arms away from your side...bend your elbows, keeping your back straight push your elbows against a wall, what happens? (almost like you waant your shoulder blades to clap but you resisting the movement with your elbows)
A: Nothing

secondly, while sitting, rest your hands on the arm chair and lift up like you would do a reverse dip, do once, what happens? (almost like you want to bring your shoulder blades down,)

A: Can't do this one as don't have an armchair

thirdly, place one hand behind your head and resist taking your head back with your hand, what happens?
if your wife is there, ask her to place her hands on your shoulders, tell her to resist your while you try to lift your shoulders up (like in a shrug?) what happens?

Answer: Nothing

Do you get pain on full range rotation?
if so...fold your arms acros your chest, turn left just before the pain increases...ask your wife to ressist this movement, what happens?

A: No = not pain just a little stiffness. It's not on the same scale as the slouch, chin down pain.
do the same for the right? what happens

Re what happened at the chiro:

OK it's a little hard to remember exactly - he wasn't a great communicator and never proferred any diagnosis of my condition. He appeared to being lots of tests with raising very legs/arms etc but really don't remember the slump test and if I did it then there was no pain. Perhaps it's because my back went into one of it's very sore periods yesterday morning after I bent over in the shower - I heard a little click and then it got very sore. The evening before after circuit training it felt very stiff/sore and the click in the shower seemed to just do it completely. Maybe when I went to the chiro the condition was just there but dormant - maybe if I went again and passed on all the excellent feedback on here it would help? I do remember him using a special implement - it was like a test tube with a rubber bung on the end and it somehow used air pressure to push the bung at speed onto part of the spine - I have probably described this very badly! He made me lie on my back with my left arm over my rights houlder and me left knee up and did something quickly that made my back click and was quite sore. He gave me ultrasound and a heat rub. I stopped going because he just seemed to be doing the same thing each week without explaining what he was trying to achieve or what he thought was the cause. The last thing he mentioned was to bring in my running shoes if it was still no better (not sure why?) I must say I have always been sceptical of chiros and the constant expense without clear explanations of how many more sessions where needed - what we trying to resolve etc put me off. I have heard this about chiros before.

So let me know if the slump test was conclusive or whether I need to repeat it again with my wife - do the findings fit in with what you were expecting?

Drekkly, well done in performing the slump test on yourself! :)

It was about as I expected. A skilled therapist, familiar and comfortable with the test, would probably be able to confirm your observations as he/she could change sequence, add rotations and adequate overpressure to the right places and so on.

This suggest that you have a neurodynamic (neuro = nerve-stuff / dynamic = movement) component to the pain in between your shoulder blades. Your nervous system is in reality one continuous structure, almost like a tree (spinal cord) with bigger and smaller branches (peripheral nerves, eg. the sciatic nerve). The whole nervous system is enclosed in protective sheets, and talking specifically about the spinal cord - the outermost protective sheet is called the dura mater. When you do any movement, obviously the nerve and its protective sheets moves with you, smoothly within the spine and extremities, elegantly adapting to the surroundings. Any structure/swelling that interferes with this nerve movement, can potentially make the nerve increasingly sensitive to movement = mechanosensitive. The most classic example is a lumbar disc interfering with the sciatic nerve and that's why a straight leg test could produce shooting pain in the leg/or back, similar to the test you did on yourself.

I'm not suggesting that anything is interfering with your nervous system (ie. no neurological issues), but I am suggesting that something might be interfering with the sensitive protective sheet around your spinal cord. It does not necessarily have to be the disc, it could be any structure that lies close to this sheet, or swelling from any of these structures. I am, as Damien, quite sure that you do not have a herniated disc, but maybe a structural change to the outer parts of your disc (annulus fibrosus), or a small injury to the upper or lower endplates of the disc where it attaches to bone, or a small injury inside the disc. A MRI-scan could potentially confirm/disconfirm this, but I don't think that is indicated at this point. Personally I'd might order a MRI if you did not improve with treatment based on my hypothesis.

My hypothesis is that when you do reversed dips, you put traction through your spine due to the weight of the lower body. This traction will have a pivot point, somewhere in your upper back where the spine is supported with your upper arm muscles. I think the triggering injury is located at that pivot point. The opposing forces at the pivot point would be increased if you (most people do) have a small jerk at the point where you push yourself up from the dips. As Damian says, it could be perpetuated or in combination with a sprained/torn spinal ligament, making that pivot point more unstable and vulnerable to withstanding the opposing forces I'm talking about. Probably we'll never know.

You should have a thorough examination of your thoracic spine, not only the simple plane movements as forwards/backwards bending, rotation and side bending, but any combination of these to explore every possible movement combination of your thoracic spine. I would also recommend a thorough palpation examination where the therapist puts pressure to different parts of your thoracic spine, again in every possible direction, preferably when you lie/sit in a neutral position compared to when you sit in your most uncomfortable position. This will not tell you if its a disc or not, but should give the therapist a preference on what type of treatment to give you, and also physical reassessment markers he/she could retest directly after giving you a treatment to see if it was beneficial to your or not.

You could try to treat yourself a bit. Sit straight, chin towards chest, notice amount of discomfort between shoulder blades. Maybe even try rotation. This is your reassessment marker. Do the slump test fully, straighten both legs 10 times, retest yourself in straight sitting position. Do 10 reps about 3-4 times or until you don't get more improvement. This is to treat the sensitivity of that protective sheet I talked about.

I'm personally not too familiar with McKenzie exercises for thoracic problems, but google it. I would think the exercises done in front lying with upper body extension could potentially be of benefit to you. Try them, reassess yourself directly afterwards! Sit straight, chin towards chest and so on.

I think any therapist you see should reason along the ways you've been given here. The initial questions asked by Damien are CRUCIAL for any therapist to understand your symptoms. If you don't get this form of communication and reasoning from your therapist, ask for it, if he/she is unable to reason, move on.

Kind regards,
Sigurd Mikkelsen

Dear Sigurd

Thankyou for your very detailed response - a lot to take in there. I am seeing my GP on Monday and need to figure out what pradctical help the NHS can give - can you confirm - do I need an MRI scan at this stage? Do I need an X Ray?
I think I can take what I know now to my exisiting therapist and see what they can do for me or try another physio centre.
Are you saying that undertaking the slump test repeatedly would help the condition? I will certainly google the other exercises you mention.
Would you recomend avoiding any particuar sports until I fix the problem - if indeed it is fixable at all? Would it just be a case of mitigating the effects?

Thanks again

Nick

Dear Dekkly/SigMik

I would trust the response from SigMik, as nothing occurs with the resisitance tests rules out a muscular issue. SigMik has given a plausible reason for your chronic pain. The graded exercises using the slump test deriatives should impove your symptoms for as long as you do not over do it. Primarily because it can easily be irritable (causing more inflamation). Your thoracic spine needs a thorough examination as suggested by SigMik, It might be a good idea to combine your self treatment with heat or a contrast treatment if you do not have a heart problem to get muscular relief and enable better movement. A visit to your doctor for some anti-inflammatoies should be helpful as this will reduce the inflammation furthermore in preparation for your self treatment as suggested by SigMik.

To SigMik, i do not feel a mckenzie approatch will help this situation primarily because like you say it sounds like a tethering of the dura matter. The Mckenzie approach purely looks at derangement from disc issues. If that is unlikely here, I think going through those principles will not make a difference. I agree with you that using graded neurodynamic exercises should be the way to go first.

To Dekkly/SigMik
A visit to the chiro maybe needed once more. Not to take anything away from the chiro as im sure he knows exactly what he is doing, logically speaking...it is perhaps better to use gentle mobilization of the vertebrae above and below to help stretch this tethering and perhaps gentle mobilizations to the tranverse processes of the involved vertebrae.

An X-ray will confirm that you might have a degenerative spine, it will unlikely show this problem, as SigMik rightly said your best bet is with the MRI and I agree its not necessary yet unless the problem is not getting solved, best to avoid unnecessary radiation/investigation if the problem can be solved clinically.

Cheers to you both and thanks SigMik for helping us narrow this problem further.

Yes, Nick, I do think in your case that it is "fixable" and there is a lot of things you can do to help yourself. I often find it is a question of doing more of the good, and less of the bad, and a skilled therapist can help you with identifying relevant factors that can contribute to your recovery. I often say that it's not about what you see (osteo, physio, chiro, etc), but WHO you see. Personally, I'd recommend you to get a referral to a musculoskeletal ESP (extended scope practitioner) clinic or look for MACP-members (manipulation association of chartered physiotherapists). I'm maybe contradicting myself a bit here, but at least I know the criteria they've been trough to get to where they are. My point being, a skilled person practicing chiro, osteo, physio, would probably be skilled no matter what profession that person would become - it's more about personal traits (I believe) than what is being taught in the different schools........

I've become quite careful with advising anti-inflammatory drugs, as resent research suggests NSAIDs to delay healing processes. Another important aspect is that your pain being of 6 months, the chances of any inflammatory mediators being active is less than likely and that the pain now has a bigger component of inadequate pain-processing issues. Anyhow, it's all about overall net-gain or net-loss, and for your part, I'd say IF you can manage without, let it wait so you can monitor the effect of the interventions this communication might trigger.

Damien do bring up a technical point to the McKenzie approach, but taking it into a functional light rather than structural (derangement), my impression is that forward bending makes it worse - intuitively one would try to see what happens if you do the opposite - backwards bending. As long as you reassess the before and after effect, you'd be the one to tell if its meaningful for you.

The slump test as an exercise could potentially help the condition, but as Damien commented, "neural" issues can tend to be a bit irritable, a bit easy to flare up with a tendency of latent pain, so take it easy. It's purely hypothetical, but moving the nerves is thought to make its "fluid" flow better as it has thixotrophic factors, potentially improving nutritional conditions within the nerve, making it less sensitive to mechanical movement...

A few points that I forgot to mention in my previous post, was how a disc issue could produce symptoms in the situations you describe. The MAIN thing you mentioned, was the difference when swimming. Swimming is a non-weightbearing exercise, potentially causing less pressure to your disc and therefore potentially less tethering to the dura mater. It does also involve a lot of repetitive movements which could irritate minor "mechanical dysfunctions" in your upper back. This together with the transition to weight bearing out of the pool could explain why you feel sore after swimming in contrast to the other exercises you do.

Also, you mentioned that its worse while cycling. First of all, cycling is a forward-bending positioned activity, also not extremely far from a sloppy slump ;). Second, it could also potentially challenge this pivoting point as I spoke of earlier, as your upper body will absorb much of the torque (rotational forces) when you work with your legs and hold on to the handlebars. Personally, I'd use components of this exercise in tailoring a rehab-programme for you.

As you suggested, bring some of this info to your existing therapist or even better, ask them to read this post ;). I'm sure your therapist might also appreciate some input and will be able to use some of this constructively.

Best of luck,
Sigurd Mikkelsen

I would just like to thank you both for the information you have given me - I feel much more informed as to what the condition might be - I don't mind so much carrying an injury or condition as not knowing what it might be and why it might be happening!
I can go back to my physio with some specific requests now and hopefully we can get my back fixed - that would be so good.
Can you just confirm what this meant

"It might be a good idea to combine your self treatment with heat or a contrast treatment if you do not have a heart problem"

I am not familiar with contract treatment and why would this effect the heart.


Finally nothin either of you say suggests that I should rest the back in order to get it better - I am ok to carry on training without the risk of worsening the condition? That was what I was worried about - training through the pain and doing myself permanent damage. In both your opnions this is not likely?

Thankyou once again and enjoy your Sunday :)

Kind Regards

Nick

Dear Dekkly

A contrast treatment (ignore the fancy name lol) just means using two opposing temps to treat i.e heat and cold... I have suggest some cold treatment because we suspect some inflammation going on in there...

Why one should be wary of a heart condition when treating with cold close to its anatomy is because there is a risk of affecting the visceral nerve supply to and from the heart and this can cause abnormal heart functions...the precaution would be to avoid treating large areas close to the heart with large exposures to cold...in this case the area of interest is almost behind where the heart is...

To be on the safe side "ice massage" technique (using an ice cube over the tender spot) may be safer. Combining this with heat treatment may be beneficial in calming the inflammation as well as relaxing the muscles in spasms that are responding due to pain...meaning you might be able to get more movement with the exercises suggested by SigMik.

It is better to have a physiotherapist assess you to see whether you have any contra-indication (again another fancy name for signs to be wary of for this kind of treatment).

I think SigMik would agree with me if I suggested to laying off any training that seems to aggravate this condition i.e cycling...only because if you keep irritating it...it flares up, then calms down...u are more likely to have scar tissue forming/adhesions...this will make it harder to treat subsequently requiring more force to loosen up...

Cheers good luck with your visit to the professionals you see and pls keep us posted with whatever progress you are making

Happy to hear that you feel more informed about what might be going on in your back, and hope that your and our efforts in trying to come up with possible ways to go with this brings you closer to achieving your goals!

Damien is quite right that I agree in laying off training and movements that seem to aggravate your pain. As I suggested, more of the good and less of the bad. It seems you do have a good grasp on what activities brings on your pain. If I were you, I would try to adapt the way I performed these activities, to see if I could do i.e. cycling without or much less discomfort. Easy stuff like keeping up your cardiovascular abilities by cycling on a stationary spinning bike (without leaning forward and less momentum through your arms if this causes pain). Even if swimming causes increased soreness AFTER training, try to break up the sessions, i.e. 10 minutes in water, 5 minutes on land, etc... Try out different strategies, and you'll suddenly hit a nail that provides you with a "way to move without pain". It's a good way to go with "gradual exposure", always a gradual, mindful return to whatever activity brings on your pain.

Keep up the good work, and keep us updated of you progress!

Kind regards,
Sigurd Mikkelsen

Great posting from everyone here, took quite a read to get up to date! haha. Awesome to see such high level of input into a case. I loved reading it because I kept thinking "oh I think it's probably this" and then the next post would say exactly what I was thinking!
To add my bit... A Thoracic derangement is very rare even in the McKenzie world. I really feel that you may have hurt a facet joint in the thoracic spine and this is causing inflammation and contributing to a neural tension problem. I believe some manual therapy in the form of mobilisations may be very helpful and hopefully your physio could help you with this - a bit of massage isn't bad but won't have a lasting effect on relaxing the muscles. Refrain from poor postures (this has already been said i.e. don't do cycling right away) as this can impair your healing process.
As for home exercises, From a McKenzie stand-point you can do the McKenzie push up with your hands further away from your body - this targets the thoracic a bit better, but if it is higher up which it sounds like it is then we often use leaning backwards over a chair in sitting or lying on a table and letting the head and thoracic spine come back off the edge (get someone to hold your feet if your worried about slipping off). - These exercises are great as they mobilise the joints and though are not as specific as a physio mobilising a specific segment they can do a certain amount of help.

Good luck

Hi All

Just been reading through all the excellent feedback again and have a few comments to make. Firstly i googled "McKenzie exercises for thoracic problems" and wondered if my pain was a little too high for such exercises? On You Tube the therapist mentioned these were for people with disc herniations who are experiencing pain in the lower back extending down the back of the leg. That's not me? Pudding Bowl suggests doing them with the hands further away from the body - perhaps I shall try this.

Pudding bowl - you also mention the leaning back over the chair exercises. I have a large inflatable pilates ball - would lying on this with the head kept on the ball and rotating the ball backwards be the same ?

Sigmik you say "Damien is quite right that I agree in laying off training and movements that seem to aggravate your pain" I have been thinking about this and hard to know straight away what is exagerating the soreness. For example Sunday I ran 10k with no pain at all during the run or after. The same with my swim yesterday. It's only when I wake up in the morning that it feels very sore. Again, not pain, as such - just soreness. The only sport where I feel it whilst exercising is cycling but I have rollers for indoors cycling and can try that in a more upright position. I guess the problem is I need a reference point - a 'normal' waking up sensation for which to reference the impact of my exercise the previous day. As I said originally I had a week off exercise alltogether at the end of the summer and I was still left with some waking discomfort in the back.

The hardest thing to do for serial exercisers is to take it easy and rest unless they really really need to ! You learn to live with discomforts and all sorts of aches and pains - especially at my age! I guess the worst that can happen as Dr Damien says is "scar tissue forming/adhesions...this will make it harder to treat subsequently requiring more force to loosen up..." ie what I'm not hearing here is - don't overdo it or you could give yourself permanent non corrective injuries.

I think I will def lay off the circuit training until there is an improvement and go easy on the cycling. I shall do the slump test exercses daily and try the leaning backwards and mackenzie exercises and see how it goes. I saw my GP yesterday and he has referred me to an NHS physio but that may be 2 months. Tempted to find a skilled non NHS physio though and get it sorted sooner though.

Thanks all again and I will keep you posted

Nick