Have you ever had a weird back discomfort that you can’t quite pin-point where exactly it is but you kind of sorta feel it in your back and maybe even around the side of your flank. The discomfort or pain may also be uncomfortable with certain twisting, lifting, bending movements and maybe even with coughing, laughing, sneezing, straining?? Whether or not you have or haven’t felt this, one of the possiblities (differential diagnosis) of this may be due to a displaced or subluxated rib.
Having ruled out other possible musculoskeletal sources of thoracic pain such as muscle strain, vertebral or rib fracture, zygapophyseal joint arthropathy, active trigger points, spinal stenosis, costovertebral (CV) and costotransverse (CT) joint dysfunction, ankylosing spondylitis, diffuse idiopathic skeletal hyperostosis, intervertebral disk herniation, intercostal neuralgia, and T4 syndrome. As well as pain that can be referred to the thoracic region from visceral sources, which may indicate serious diseases such as cancer, cardiac, pulmonary, gall bladder, hepatobiliary, renal, and gastroesophageal conditions which can all potentially cause referred thoracic or scapular pain. Rib dysfunction syndrome, Costotransverse / Costovertebral Dysfunction can be an often overlooked condition with regards to thoracic spine pain, though there are some identifiable signs and symptoms which this presents with and it usually responds well to manipulative techniques!!
The basics – the thoracic spine has twelve vertebrae and attached to each of the twelve vertebrae there are ribs on either side making up the rib cage. The ribs articulate i.e. sit in a groove like area near the vetebral body, making up a joint – the costovertebral and the costotransverse joints and held together with ligaments. The costovertebral joints serve to connect the rib heads to the thoracic vertebrae and the costotransverse joint servese to connects the rib to the transverse process of the vertebrae. The innervation i.e. the nerve supply to the costotransverse joint is from the ventral rami which supplies the antero-lateral parts of the trunk, and the limbs and also innervate the muscle and skin along the side of the body, chest, ribs and abdominal wall. Due to the innervation of the ribs, a displaced rib can initially mimic and or be confused with cardiovascular, pulmonary, or gastrointestinal referred pain due to this close relationship between the somatic and the autonomic nervous systems in the thoracic area. In the literature cases reports can be found of patients admitted to coronary care units for presumed myocardial infarctions only to be treated for rib dysfunction syndrome. Many internists have discovered that primary pulmonary pathology can manifest clinically as vague thoracic area discomfort or pinpoint thoracic or chest wall pain.
Musculoskeletal Causes of Thoracic Pain:
Spinal Disorders –
- Thoracic disc herniation
- Throacic discogenic pain
- Thoracic spinal stenosis
- Thoracic facet arthropathy
- Neurogenic disorders
Rib Cage Disorders –
- Costovertebral syndrome
- Tietze’s Syndrome
- Intercostal strain
- Rib fracture
- Intercostal neuralgia
- Pectoralis strain
- Serratus anterior strain
- Slipped rib syndrome
Structural rib dysfunctions as a result from subluxations, torsions, or damage to the rib articulations can cause non-physiologic motion patterns that stimulate the ventral ramus of the segmental nerve root producing localized discomfort. Physical exam findings of costovertebral (or costotransverse) joint dysfunction typically present with localized pain to the posterior thorax that may radiate to the anterior chest or along the associated rib. Pain maybe sharp and stabbing and/or aggravated by specific movements, pain can also be focal burning and aching. Symptoms are usually unilateral and painful upon deep inspiration, coughing, or sneezing.
Passive or active thoracolumbar flexion, rotation, and/or lateral flexion as well as thoracic compression may increase symptoms. Palpable tenderness of the involved costotransverse joint and rib angle maybe noted on joint challenge in addition adjacent thoracic vertebral and rib segments may be restricted, and can stimulate or exacerbate protective muscle spasms. Hyperalgesia of the corresponding skin may be noted with neurologic and skin roll testing. Imaging studies are not usually necessary unless there is a recent history of trauma or continued rib discomfort during appropriate rest and therapy.
Chiropractic spinal manipulative therapy (SMT) as well as trigger point and/or myofascial relase techniques tends to be the treatment of choice for costovertebral / costotransverse dysfunction. The main goal is to control pain / discomfort and attempt to restore “normal” mechanics to the joint and the throacic segments. Rehabilitation for the thoracic spine and rib cage should also be included in the treatment plan for those with costovertebral joint dysfunction. Stretching and mobilization of the articular structures, postural reeducation of the deep paraspinal muscles, and scapular stabilization can be added to aid in strengthening the upper body and establish proper body awareness.
Scaringe J, Ketner C. Manual Methods for the Treatment of Rib Dysfunctions and Associated Functional Lesions. Topics in Clinical Chiropractic. 1999; 6 (3): 20 – 38.
Triano J, Erwin M, Hansen D. Costovertebral and Costotransverse Joint Pain: A Commonly Overlooked Pain Generator. Topics in Clinical Chiropractic. 1999; 6 (3) 79 – 92