“Doctor, I’ve been worried about my hump. Will it get worse? Can you fix it?”

Unlike the better-known dowager’s hump, the upper thoracic hump (see photos and illustrations) is more common and is found in younger as well as older people.

Patients are concerned about their humps and are very motivated to get them fixed. They should be. Along with its unattractiveness, the hump affects the heart, lungs and thyroid.

Increased thoracic curve (hyperkyphosis) has even been linked to increased mortality. One research paper finds, “The hyperkyphotic posture was specifically associated with an increased rate of death due to heart disease.”¹

The hump can also cause or contribute to hand, arm, shoulder, neck, lower back, sacrum and sciatica pain. Patients fear it is a harbinger to little-ol’-man/woman status, i.e. the dowager’s hump.

The classical dowager’s hump or dorsal kyphosis (forward curve in the mid and upper thoracic spine) is associated with old age and may involve wedged or triangular shaped vertebral bodies, compression fractures and osteoporosis. Undoubtedly, it is the end-stage of a chronic subluxation pattern and is probably related to the upper thoracic hump.

Subluxation patterns

Pattern: A consistent, characteristic form, style, or method, as:

•  A composite of traits or features characteristic of an individual or a group: one’s pattern of behavior.²

In medicine, a “syndrome” denotes a group of symptoms that characterize a disease condition. Chiropractic, being a vitalistic healing profession rather than disease and symptom oriented, refers to a group of subluxations as a pattern.

There are a few common patterns we can quickly locate (analyze) and correct (yes, correct) with Koren Specific Technique (KST). In addition to the hump pattern, there are the panic pattern, various cranial patterns, the femur head pattern and the upper cervical pattern.

What is the hump pattern?

A bump is usually easily palpated at the top of the thoracic spine or at the thoracic/cervical area.  The head is often anterior to the shoulders, exposing the upper thoracic area. The body deposits fat over the exposed area, which has been  referred to as the “hump pad.”³

The hump pattern causes loss of height and diminished lung capacity. Diminished lung capacity may not be noticed until the pattern is corrected and you tell the patient to inhale. (“I didn’t realize it, but now I can take a deep breath.”).

In illustration “A” on the far left, the woman’s head sits evenly over her shoulders; this is “normal” posture. In illustration “B”, her head is anterior to her shoulders and, over time, the hump may develop fatty tissue to protect the “exposed” area.

Because of her anterior head carriage the trapezius muscles are often tight and there is greater stress on the mid-thoracic spine and her lower back and sacrum.

When the hump is corrected…

When the hump pattern is corrected or adjusted, patients often experience immediate improvement in posture, balance, breathing and loss of inflammation along the anterior ribs. A greater overall sense of relaxation and well-being is often noticed as deep subluxation stress releases.

The goal of chiropractic care is not to correct the hump per se, but to correct the subluxations associated with the hump (the hump pattern). Once the subluxations are corrected and the segments are no longer fixated, the body is better able to restore a healthy posture.

For many, the hump may not appear much different at first; however, for some people, the hump may dramatically reduce within a few days and may disappear within weeks. Others, depending upon age and lifestyle, may take longer. But, as long as the hump remains unsubluxated, it will be healing.

Fixing the hump pattern

The key to a proper correction is specificity: knowing exactly what is out of alignment and the direction of the misalignment (listing).  This permits you to use a minimal amount of force/energy/information to correct the subluxation. Corrections will also be more long lasting.

Note: With KST hump pattern adjusting, the patient is standing or sitting.

What needs to be adjusted?

This is the typical hump pattern:

1. Upper thoracic: T-1, T-2 spinous processes superior, T-3 spinous process inferior.

2. Ribs: 1st, 2nd and 3rd anterior ribs are usually inferior on the right and superior on left. This is important. The reason the hump persists, even after vertebrae adjustments, is because the ribs are locked. There may be inflammation and sensitivity over the anterior ribs when they are challenged.

3. Other thoracics: A mid thoracic vertebrae (usually T-7 to T-9 inferior) is involved.  It may be rotated left or right. The ribs are usually inferior on one side and superior on the other side.

Note: Hump pattern patients often have lumbar and/or sacral problems/subluxations. This may be compensation for the anterior head carriage.

Slight variations

Some hump patterns have complications (oh, no!) and, unless corrected, the hump will not release. Here they are:

1. T-1 and T-2 counter-rotation: In addition to T-1 and T-2, superiority, T-1 and T-2 may be counter-rotated, meaning that T-1 is rotated left, while T-2 is rotated right or vice versa (challenge the spinous processes). In some cases, counter-rotation can cause severe nerve impingement and pain, numbness and paresthesias and weakness in the shoulders, arms, wrists, hands and fingers.

2. Transverse process (TP) and rib involvement: Occasionally, you’ll find T-1 and T-2 tilt. The transverse processes (TPs) may be anterior/superior on one side and posterior/inferior on the other. The rib articulations can be involved, causing brachial plexus problems. It isn’t easy to adjust the TP and ribs from the inferior and posterior (unless you’d like to do some surgery), so contact the superior/anterior side.

3. Thoracic discs: On occasion you’ll find thoracic disc subluxations. C-7/T-1, T-1/T-2 or T-2/T-3 discs may be subluxated on the left or right side.  Adjust, using the ArthroStim™.

4. Sternum and clavicles: On rare occasions, a patient may have the sternum and/or clavicles out of alignment.  This is often as a result of trauma.

Adjustment/correction

Finally! Let’s fix that hump. Koren Specific Technique (KST) is a quick and easy method of analyzing and correcting any part of the body.  It will quickly tell you if there is a hump pattern. After you determine the listings involved, we recommend you use the ArthroStim™ adjusting instrument to correct the involved segments.

The ArthroStim™ is a “toggle in a bottle.” I set it at 12 taps per second. In a pinch, a hand-held adjusting instrument may work. You can also use a thumb toggle (á la DNFT) but, in my experience, nothing corrects subluxations as easily as an ArthroStim™.

1. Correcting the upper thoracics: T-1 and T-2 are adjusted contacting the spinous or the lamina pedicle junction superior to inferior (S to I). T-3 is adjusted inferior to superior (I to S). If there is counter-rotation of T-1 and T-2 (i.e., one goes left, one goes right), it must be corrected and contact is usually on the spinous processes.

2. Correcting the ribs: This is very important. If the ribs are not released, the hump will not release and the upper thoracics will re-subluxate. The ribs are adjusted at their anterior. Contact is just lateral to the sternocostal junction on both sides. Line of drive is usually I to S on the right and S to I on the left. Use the sleeve with the narrow fork with the ArthroStim™.  The ribs usually correct very easily but, be gentle, because they may be inflamed from years of subluxations.

3. Correcting disc subluxations: To locate a disc subluxation in KST, we use the negative finger (2nd or index).  The procedure is as follows: Touch the area where the disc is located (between the vertebrae) and the body will tell you by the occipital drop or other biofeedback mechanism (i.e., muscle goes weak, reactive leg goes short) if the disc is subluxated. Adjustment is in the direction the negative finger is pointing; the negative finger “points” to the subluxation.

4. Fixing the lower thoracic(s): Usually T-7, T-8 or T-9, etc., is adjusted I to S. Adjust L to R or R to L if there is rotation.

5. Fixing the thoracic transverse process/rib articulation: Adjust the transverse process (TP) I to S on the high side and A to P on the anterior side. If there’s counter-rotation, either side may be out.

Will I need to correct the hump pattern on every visit?

KST adjustments usually hold for a long time. However, everyone is different and patients with severe hump patterns should be checked, at least initially, on every visit. You’ll find a re-adjustment is rarely needed.

Dowager’s Hump

Can KST procedures help dowager’s hump? Since the dowager’s hump (DH) kyphosis is due to compression fractures, unlike the upper thoracic hump, it will most likely never return to normal shape. However, people with DH don’t have to live in pain or get worse. When their subluxation patterns are corrected, the nervous system will function better. This will promote decreased pain and other symptoms, while promoting overall healing.

This is in contrast to the medical approach which is exercise, osteoporosis medications and a procedure called vertebroplasty or kyphoplasty, wherein a radiologist injects a cement into the porous sections of the fractured vertebra to stabilize the fracture, strengthen and raise the vertebral body to normal height.

KST adjustments offer a safer alternative.

Dr. Tedd Koren is the developer of Koren Specific Technique, a  quick and easy way to locate and correct subluxations anywhere in the body. For information on KST seminars, go to www.teddkorenseminars.com or call 800-537-3001.

For infor­mation on the ArthroStim™ ­adjusting instrument, go to www.impacinc.net. You can email Dr. Koren at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

References

1. Kado DM, Karlamangla AS, Barrett-Connor E and Greendale G. Hyperkyphotic posture predicts mortality in older community-dwelling men and women: a prospective study. Journal of the American Geriatrics Society. 2004;52(10):1662.

2.  The American Heritage® Dictionary of the English Language, Fourth Edition. Copyright © 2000 by Houghton Mifflin Company.

3. Aldrete JA, Mushin AU, Zapata JC and Ghaly R. Skin to cervical epidural space distances as read from magnetic resonance imaging films: consideration of the “hump pad.” J Clin Anesth. 1998;10(4):309-313. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9667347&dopt=Abstract )

History: This 60-year-old male patient presents with acute lower thoracic pain after a fall while skiing.  Axial flexion compression force occurred during this fall.  The radiographic examination demonstrates how many compression fractures?  Are these compression fractures benign or malignant?

DISCUSSION

Compression fractures of the lumbar spine are the result of a combination of truncal flexion and axial compression.  The extent of the vertebral compression and degree of comminution are dependent upon the severity of the force applied and the relative strength of the vertebra.  In the aging and geriatric patient with osteoporosis, compression fractures are quite common.  The most common segmental levels to develop compression fractures are T12, L1 and L2.^1,2

Radiographic signs of vertebral compression fracture include a step defect, wedge deformity, linear zone of condensation, displaced endplate, paraspinal edema, and abdominal ileus.^1,2,3

The Step Defect. Since the anterior aspect of the vertebral body is under the greatest stress, the first bony injury to occur is a buckling of the anterior cortex, usually near the superior vertebral endplate.  This sign is best seen on the lateral view as a sharp step off of the anterosuperior vertebral margin along the smooth concave edge of the vertebral body.  In subtle compression fractures, the “step” defect may be the only radiographic sign of fracture.  Anatomically, the actual step off deformity represents the anteriorly displaced corner of the superior vertebral cortex.  As the superior endplate is compressed in flexion, a sliding forward of the vertebral endplate occurs, creating this roentgen sign.¹

Wedge Deformity.  In most compression fractures, an anterior depression of the vertebral body occurs, creating a triangular wedge shape.  The posterior vertebral height remains uncompromised, differentiating a traumatic fracture from a pathological fracture.  This wedging may create angular kyphosis in the adjacent area.  It has been estimated that a 20 percent or greater loss in anterior height is required before the deformity is readily apparent on conventional lateral radiographs of the spine.¹

Linear White Band of Condensation (Zone of Impaction). Occasionally, a band of radiopacity may be seen just below the vertebral endplate that has been fractured.  The radiopaque band represents the early site of bone impaction following a forceful flexion injury where the bones are driven together.  Callus formation adds to the density of the radiopaque band later, in the healing stage of the fracture injury.  This radiographic sign is striking when present; however, it is an unreliable sign, since it is not present as often as might be expected.  Its presence, however, denotes a fracture of recent origin (less than 2 months’ duration).^1,3

Disruption in the Vertebral Endplate.  A sharp disruption in the fractured vertebral endplate may be seen with spinal compression fracture.  This may be difficult to perceive on plain films and tomography provides the definitive means to identification.   The edges of the disruption are often jagged and irregular.^1,3

Paraspinal Edema.  In cases of extensive trauma, unilateral or bilateral paraspinal masses may occur which represent hemorrhage.  These are best seen in the thoracic spine on the anteroposterior projection, but may occur adjacent to the lumbar spine, creating asymmetrical densities or bulges in the psoas margins.^1,3

Determining an Old versus a New Compression Fracture

Since the wedge shape deformity of the vertebral body persists after the compression fracture heals, additional roentgen signs are necessary to evaluate the time status of a compression fracture.  The presence of a “step” defect and the white band of condensation are signs of an active or current fracture (less than 2 months old).  These two roentgen signs will vanish once the fracture totally heals, which may be as long as 3 months in the adult spine.

When the question of presence or recent origin of the fracture arises, a radionuclide bone scan may be helpful.  Such scans are positive (hot) with recent fractures undergoing active repair.  These scans may stay positive (hot or warm) for as long as 18 months to 2 years following injury.  This complicates the evaluation of a patient who has been injured previously (within 2 years). A bone scan may not prove helpful in this type of presentation.^1,2,3 Additionally, MRI scans are the most accurate way of determining whether a fracture is old or new. Bone marrow edema will be present in recent fractures of 6 weeks or less duration and is more accurate than a bone scan to determine the chronology of a compression fracture anywhere in the spine.

References

1. Yochum TR, Rowe LJ, Essentials of Skeletal Radiology, 3rd ed.  Lippincott, Williams and Wilkins, Baltimore, 2005.

2. Roof R, A Study of Mechanics of Spinal Injuries, J Bone Joint Surg. (Br) 42:810, 1960.

3. Gehweiler JA, et al, The Radiology of Vertebral Trauma, Philadelphia, W.B. Saunders, 1980.

Dr. Terry R. Yochum is a second generation chiropractor and a Cum Laude Graduate of the National College of Chiropractic, where he subsequently completed his radiology residency.  He is currently Director of the Rocky Mountain Chiropractic Radiological Center in Denver, Colorado, and Adjunct Professor of Radiology at the Southern California University of Health Sciences, as well as an instructor of skeletal radiology at the University of Colorado School of Medicine, Denver, CO. Dr. Yochum can be reached at 303-940-9400 or by e-mail at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

Dr. Chad J. Maola is a 1990 Magna Cum Laude Graduate of the National College of Chiropractic.  Dr. Maola is a Chiropractic Orthopedist and is available for post-graduate seminars.  He may be reached at 303-690-8503 or e-mail This e-mail address is being protected from spambots. You need JavaScript enabled to view it .