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Background: Neck pain is a prevalent pathology estimated to affect approximately half of the population in a lifetime. There is currently no gold standard for the treatment of neck pain. Physical therapy has shown potential for improved outcomes when used to treat neck pain. The purpose of this report is to evaluate the possible clinical utility of thoracic manipulation as part of a comprehensive physical therapy plan of care with a case study and review of clinical evidence. Case Study: A 31-year-old male with a 5-month history of right-sided neck pain presented to physical therapy. His examination revealed significant cervical range of motion (ROM) restrictions, upper thoracic hypomobility and reproduction of symptoms with pressure to his right T3 facet. Intervention: The patient was treated with high velocity low amplitude thrusts (HVLAT) that were primarily directed at the cervicothoracic region, and a progressive exercise program. The thoracic HVLAT is performed with an anterior to posterior force application with the mobilizing hand in a pistol grip formation cupping the spinous processes. Outcomes: Follow up measures conducted before and after treatment included: Neck Disability Index, Numerical Pain Rating Scale, Craniocervical Flexion Test, Patient Specific Functional Scale, and cervical ROM as measured with CROM inclinometers. After 10 weeks of physical therapy the patient demonstrated improvements in these outcomes beyond their respective Minimally Clinically Important Differences. Discussion: Multiple neurophysiological and mechanical mechanisms are proposed for the effect of manipulation, but the exact mechanism is unknown. The outcomes of this case are consistent with the current body of evidence for thoracic manipulation, which while not conclusive, show a trend toward improved outcomes when combined with exercise.