Does anyone have experience with rib troubles?
This pt presented with pain & TOP ++. Based on the presentation, I thought it was a broken rib... but thinking about it, there was not sufficient trauma to explain this.
PC: pain in back & chest
Hx:
3 week history of sleeping in different bed (travelling).
Possible contribution of connubial activities.
Functional problems:
pain 5/10 sneezing / coughing centred on L post / post-lat rib #4
pain 4/10 deep breath same location
TOP ++ area of L rib #4
AROM:
L SF 5cm < style="font-weight: bold;">PAIVMs:
bilateral (transverse processes):
R2: no noticeable diff. in T1,2,3,4,5
pain 3/10 T2; 4/10 T3; 5/10 T4; 5/10 T5
ribs:
P2: at 1/3 range R & L ribs 3,4,5
pain 8/10 L rib 4
pain 7/10 L rib 3 & 5, R rib 4
pain 6/10 L rib 2, R rib 3, 5
Any ideas about Dx or Rx?
In retrospect, I am thinking I should have checked for trigger points / muscle tightness of the paraspinals, traps and rhomboids to see if they were contributing to the global soreness & TOP around the costovertebral joints - it seems to me more likely that one structure (e.g. rhomboids) would be so sore rather than any separate structures (i.e. 5-6 underlying costovertebral joints). Perhaps the go is to relax overlying muscles before doing PAIVMs?
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Hey Ed, I’m on my musculoskeletal placement and this is great question as patients reporting of thoracic pain/stiffness are a fairly common occurrence. I found the question of the actual source of their complaints is a tough one to determine but you can probably look at a few things to help pin down the source. If you think the costotranverse or costoverterbral joints are involved then you can try observing or palpating the rib movement when the patient takes a deep breath or during thoracic active movements, there should be symmetrical movement on both sides as the ribs expand or rotate. If you observe some asymmetry in then movement then you can probably narrow down your search to those actual joints. I see you looked at the accessory movements for the ribs with some reproduction of their reported pain so you might also try looking at the unilateral PA on the transverse processes at each segment which might you help you differentiate if the problem is actually coming from immobility at the articulation between spinal segments or from the rib articulation with the transverse process.
Another thing you might want to look is those Mulligan techniques (or Mobilisation with Movement) that we looked at briefly in labs. MWM techniques as a treatment option are something that my supervisor keeps reminding me about and I’ve found that these have been quite effective and patients respond well to them. Try putting continuous pressure (lateral, medial or PA) on either the spinous process, tranverse process or the tubercle of the rib while asking the patient to rotate into the direction that they are restricted while +/- taking a deep breath. If the patient reports of a decrease in the initially reported symptoms with these active movements then just go right into treatment with sets of 5-6 reps while maintaining pressure with the border of your hand or thumbs. Anyway hope that helps a bit and let me know what kind of response you get after treatment with those Mulligans, I’d be interested to know the results.
Gareth
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