Thoracic Hyperkyphosis

Thoracic hyperkyphosis is defined as an increased forward curvature of the thoracic spine greater than 40°¹. Prevalence rises with age, but there is no single universally accepted definition of hyperkyphosis or of “normal” age-related curvature². It is more common in women than in men.

Normal thoracic curves:

• 20–40° in youth

• 48–50° in older women, ~44° in older men²

  

Subtypes

• Scheuermann’s disease³: Juvenile form due to vertebral growth disturbance; typically halts at skeletal maturity.

• Postural kyphosis³: Most common; no vertebral deformity. Related to poor posture, weak musculature, and ligament laxity.

• Congenital kyphosis³: Present at birth; progresses without treatment.

• Age-related hyperkyphosis⁴⁵: Common in older adults. Many have normal bone density. Estimated prevalence in those >50 years is 10–45%. In those >65 years: ~50% of men and ~65% of women⁶.

Anatomy

The thoracic spine normally has 20–40° of kyphosis¹⁷ in the sagittal plane. Hyperkyphosis exceeds 40°⁸. In standing, the line of gravity shifts anterior to the vertebral bodies, increasing loading and potentially amplifying kyphosis. Typical changes include tight posterior ligaments and increased tone/shortening of deep spinal extensors and long back extensors⁹.

Epidemiology & Causes

• Rising prevalence with age, especially in women after 50.

• Estimated prevalence: 20–40% in people over 60⁶.

• Kyphosis angle increases ~9° per decade⁶.

• Risk factors: musculoskeletal and neuromuscular disorders, sensory deficits, idiopathic causes⁵¹¹¹².

• Psychosocial factors: depression, anxiety, insecurity, distress¹¹³.

Biomechanical Contributors

• Increased spinal load and muscular demand in upright posture accelerate degeneration and contribute to pain¹³.

• Habitual posture (forward head, limited shoulder mobility) from poor ergonomics and heavy schoolbags can worsen curvature⁴¹⁴.

Clinical Presentation

Thoracic hyperkyphosis may be postural (flexible) or structural (fixed); many patients have elements of both.

• Postural kyphosis: Reversible with cueing and correction⁷.

• Structural kyphosis: Permanent deformity (e.g., Scheuermann’s). Postural kyphosis can become structural over time⁷.

Common findings:

• Visible “rounded back”⁵

• Gradual onset/progression⁵¹⁵¹⁶

• Thoracic back pain

• Reduced pulmonary function⁹¹⁷

• Decreased mobility

• Osteoporotic vertebral fractures¹⁸

• Difficulty rising, walking, or balancing

• Fatigue

• Dyspnea in severe deformity¹⁵

Differential Diagnosis

• Scheuermann’s disease

• Osteoporosis

• Traumatic changes (e.g., compression fracture)

• Tumor

• Infection

• Degenerative disc disease⁵¹⁹

Diagnostic Work-up

Radiography

First-line imaging is conventional X-ray. Obtain both AP and lateral views²⁰²¹.

• AP view: Assesses vertebral bodies.

• Lateral view: Assesses vertebral height, disc height, end-plate irregularities, erosions, and curve alignment²⁰.

If needed, CT or MRI can further delineate spinal curvature and characterize kyphosis²¹.

Outcome Measures

• Occiput-to-wall distance: Forward head/trunk measure.

• VAS (Visual Analogue Scale): Pain intensity²².

• Quebec Back Pain Disability Scale: Self-report functional status²³.

Examination

Typical age-related hyperkyphosis features:

• Pain and dysfunction in back and shoulders¹³

• Reduced ROM and increased stiffness

• Limited physical function²⁴

• Respiratory difficulty

• Increased risk of osteoporotic fractures²⁵

• Increased mortality in older adults

Begin with observation of gait and movement (e.g., while undressing)¹⁶. Assess standing posture in neutral (feet under hips, knees extended, arms relaxed, gaze horizontal)³¹⁶. Tragus-to-wall testing may be used. A thoracic Cobb angle of 40–45° indicates hyperkyphosis.

Tools to Quantify Kyphosis

• Modified Cobb angle

• Pantograph

• Debrunner kyphometer: Landmarks at C7 and T12; read angle on dial.

• Flexicurve: Mold from C7 to lumbosacral junction; trace on graph paper for index calculations.

Medical Management

Physical (first-line): Conservative physical care is recommended initially for thoracic hyperkyphosis⁵.

Pharmacologic: Antiresorptive or anabolic bone medications in low bone mass or vertebral fractures can prevent new fractures but have not shown direct reduction of hyperkyphosis itself⁵.

Surgical: Approach depends on flexibility:

• Flexible curves: Posterior approach; otherwise anterior or combined approach with instrumented fusion²⁶.

• Osteotomy: Selected cases may benefit.

• Osteoporotic collapse: Kyphoplasty may restore height with balloon and cement.

• Vertebroplasty/Kyphoplasty: Minimally invasive options with evidence for pain relief, functional improvement, height restoration (up to ~90%), and kyphosis correction of ~8.5–14°²⁶ (overall evidence still limited²²⁶).

Extensive surgery carries substantial risk (~33% complications) and is reserved for documented progression, severe pain, or neurologic deficits⁵.

Physiotherapy for Thoracic Hyperkyphosis

Early, structured physiotherapy—manual therapy, taping, bracing, and individualized exercise—can reduce curvature, improve posture, and slow progression. Goals include better biomechanics and function to reduce pain, enhance mobility, and prevent complications such as reduced ventilation and balance deficits²⁷.

Treatment goals:

• Reduce excessive thoracic kyphosis angle

• Improve postural control and alignment

• Increase joint and soft-tissue mobility in the thoracic spine

• Prevent progression and sequelae

• Decrease back/shoulder pain

• Strengthen spinal and core stabilizers

• Improve lung capacity and breathing mechanics

• Promote participation in ADLs and quality of life⁵

Manual Therapy

Thoracic mobilization

• Facet-focused mobilization to improve flexibility and reduce stiffness.

• Myofascial techniques for tight musculature and fascia⁵.

• Scapular mobilization to normalize shoulder mechanics commonly altered in hyperkyphosis.

Self-mobilization

• Diaphragmatic breathing lying on a foam roller to encourage thoracic expansion and better breathing mechanics.

• Thoroughly instructed home drills to maintain mobility⁵.

Stretching

Targeted flexibility

• Pectoralis major/minor stretch (e.g., on foam roller)

• Prone hip-flexor stretch (iliopsoas/rectus femoris)

• Supine hamstring stretch with 90° hip flexion²⁸

Corrective Exercise

Postural training

• Scapular stabilization: Strengthen mid-lower trapezius, rhomboids, serratus to support alignment.

• Spinal extensor training: Counteract excessive kyphosis and improve endurance.

• Aim to enhance postural control, reduce stiffness, and foster structural adaptation²⁹³⁰.

Pain Modulation

• Heat, cold, and TENS may aid short-term pain relief, especially in acute flares⁵.

Strengthening

Examples

• Prone trunk lifts to neutral: strengthens extensors and trapezius.

• Trunk lifts with backpack load: progressive extensor loading.

• Quadruped contralateral arm/leg raise: improves stability and reduces forward collapse⁵.

Breathing Training

Diaphragmatic breathing

• Improves oxygenation and activity tolerance, increases rib mobility, and reduces dyspnea.

Balance & Gait Training

• Integrate balance and gait work to lower fall risk (often elevated with hyperkyphosis). Can be incorporated via Pilates-style or tailored stabilization programs.

Yoga

• A safe adjunct to blend strength, mobility, breath, and relaxation; RCTs show benefit in posture and function²⁹³¹³².

Bracing

Indications

• Consider in stiff curves or when exercise alone is insufficient. Always pair with physiotherapy; bracing alone has limited effect²⁷⁵¹⁶.

Common braces

• Milwaukee brace: Posterior pads apply corrective force; typically 23 h/day for 1–2 years¹⁶.

• Lyon Antikyphosis Brace: Effective in many adolescents/adults²⁷.

• Kyphologic Brace: Modern design with documented in-brace correction³³.

• Gschwend brace: Widely used in parts of Europe²⁸.

Taping

• From AC joint anteriorly, over trapezius, diagonally to ~T6 may reduce kyphosis; more research needed⁵.

Spinal Orthosis

SpinoMed

• ~2 h/day for 6 months can reduce kyphosis angle, increase standing height, strengthen extensors, and reduce instability⁵.

Conclusion

International evidence supports conservative care—systematic physiotherapy with stretching, strengthening, manual therapy, balance and breathing work, plus judicious use of bracing and activity modification—as effective for thoracic hyperkyphosis²⁸. Individualized programs yield the best outcomes.

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