Structural high thoracic curves – how to manage

Structural high thoracic curves are not easy to correct. The apex of these curves usually is at the shoulder level. Therefore a direct impact of a brace on this level is not possible. It has been tried to attach a cervical pad as a counter pad in order to introduce a 3-point pressure system on to Chêneau style braces, however, this had no real effect on this curve because any pressure on the lateral neck will be too high above the place where it should be. This add on will only cause stress to the neck without any significant effect but with complications....

On the other hand high thoracic structural curves usually do not progress to a high extend and as these are short, they are not as obvious like a long thoracic main curve leading to decompensation of the trunk. So there is not much to worry about!

Nevertheless we do have an approach to the problem:

Fig. 1. Patient with a structural high thoracic (cervicothoracic) counter curve with the typical shoulder hump on the left side (see left picture).

Fig. 2. For the main thoracic curve we need to implement a 3 point pressure system in frontal plane with lateral pressure on the pelvis (PP), apical pressure from lateral on the right thoracic area (ribhump / RH) and a lateral pressure on the left side in the high thoracic region (shoulderhump / SH).

When the individual adjustments of the brace are made we usually place P3 (axillar pressure point) more caudally in order to gain some recompensation of the shoulder girdle (Fig. 3) and we shift P3 more to the midline in order to make the shoulder girdle even more oblique. To the amateur this looks like we increase the deformity. For the professional this is the way to achieve an active bent of the neck back up by reflex as the patient automatically wants to set the eyes horizontally (regain orthopty). With the implementation of this reflex we receive a (virtual) 3rd. point for the cervicothoracic curve cranially which will counteract the collapse of this curve.
Of course our well trained orthotists will be able to fine adjust P3 in these cases (cut P3 more down and shift more to the midline) after testing whether the patients are able to uprighten their necks against the P3 pad.

Fig. 3. Set P3 more caudally and shift more to the midline in order to implement a (virtual) 3rd. point for the cervicothoracic curve by reflex cranially which will counteract the collapse of this curve.

Of course in-brace corrections are only small, but with the appropriate adjustment of the brace we usually have no progression of this curve and in about 50% of cases a slight improvement.

Finally, after growth combined curves (double / triple curves) are the most stable ones. So this curve is not dangerous! This cervicothoracic curve leads to a better compensation of the trunk (better cosmetics) and more stability after growth, but for the trained eye a little shoulder hup is visible.