Costovertebral Joint dysfunction
- Abnormal motion between rib and its vertebral connection |
- Common cause of abdominal/chest pain |
- Can be at the costovertebral or costotransverse joint (see below)s |
Costotransverse/Costovertebral joints
- Costovertebral joints have rich innervation - branches of intercostal nerve from the ventral rami
- For rotation
Rib anatomy
- Upper ribs move in a pump handle elevation
- Lower ribs move in more anterior to posterior "bucket handle"
Causes
- Trauma |
- Arthropathy |
- Postural strain |
- Repetitive injury (compression/axial rotation) |
- Athletes - football, wrestling, rugby, golf, butterfly stroke swimming |
- Restrictions on upper ribs occur due to heavy weight on shoulders/whiplash |
- Forward head posture, Upper crossed, hyperkyphosis, scoliosis, dysfunctional respiration |
- Pregnancy |
Presentation
- Occurs after sudden, unguarded, explosive movement (coughing/sneezing, reaching, pulling, pushing) |
- Usually localised pain 3-4cm lateral to the spine - can radiate along the rib |
- Hyperalgesia/paresthesia can occur |
- Burning, sharp, stabbing, radiating as if they were "shot by an arrow" |
- Pain and stiffness common after activity or lying down |
- Provoked by breathing, coughing, sneezing, twisting or bending |
- Reaching, pushing,pulling actives scapula musculature |
- If upper ribs affected, pump handle motions are affected (reaching/carrying loads on shoulder) |
- Mid and lower ribs affected, bucket handle affected (bending, lateral flexion and rotation) |
- Palpation reveals paraspinal spasm/hypertonicity |
- ROM limited on Tx |
- Limited MP on Rib joint - costovertebral spring test (T8-T10 most common) |
- Chest expansion to rule out AS |
- CONSIDER OTHER CAUSES OF RIB PAIN (CV, GI,F#) ESPECIALLY IF THE CLINICIAN CANNOT REPRODUCE THE PAIN DURING TESTING |
- Vitals, GI, Chest, CV exam, observation for herpes zoster should be considered |
Imaging
- Only necessary if: |
- Significant trauma, suspicion of f# |
- Instability |
- >50 years old |
- Lack of improvement with conservative care |
- Neuromotor deficits |
- Red flags: unexplained weight loss, Hx of cancer, corticosteroid use/osteoporosis, fever, drug/alcohol abuse |
DDx
- Angina |
- Myocardial infarction |
- Mitral valve prolapse |
- Aortic Aneurysm |
- Pneumonia |
- Carcinoma |
- Pneumothorax |
- Pleurisy |
- Embolus |
- Oesophagitis |
- Neoplasm |
- Hepatitis |
- Pancreatitis |
- Polynephritis |
- Herpes Zoster |
- Disc |
- Stenosis |
- Neoplasm |
- Costochondritis |
- Tietze's syndrome |
- Intercostal strain |
- F# |
- Intercostal neuralgia |
- DISH |
- T4 syndrome |
- AS |
- Myofascial pain syndrome |
Management
- Avoid pushing/pulling |
- Women should wear sports bras |
- Myofascial stretching/release of intercostals, paraspinal, scapular stabilisation muscles |
- Correction of postural faults (upper crossed, scapula dyskinesis, breathing exercises) |
- NSAIDs |
- SMT of affected joints in the ribs |
- Foam roller |
- Unresponsive/repetitive restrictions may indicate other pathology |
|
