Conservative Management Of Costovertebral Subluxation

Professional Papers _______________________________________________________

Conservative Management of Costovertebral Subluxation

Franklin Schoenholtz, DC, DABCO Arcadia, California Costovertebral lesions area frequent occurrence seen often in practice. Not much has been written on this clinical entity. The author has provided the clinician with specific diagnostic tests to assess abnormal joint movement of the costovertebral subluxation. Two rib manipulations are presented for consideration. Many variations of these maneuvers may be utilized to correct specific articular lesions. This clinical paper attempts to provide the busy practitioner with a short, clear, concise and well illustrated article on the successful management of this syndrome.

Dr Franklin Schoenholtz is a diplomate of the American Board of Chiropractic Orthopedists. He maintains a private practice at 226-228 East Foothill Blvd. Arcadia, California. He taught diversified technique and undergraduate orthopedics at the Los Angeles College of Chiropractic in Glendale, California, from 1964 to 1976. Presently, Dr Schoenholtz is the secretary-treasurer of the Board of Regents at LACC. He has written numerous articles on the manipulative management of various musculoskeletal conditions. The most recent, “Conservative Management of Selected Shoulder Problems” appeared in the October, 1979 issue of the ACA Journal.

A common complaint is of continuous soreness at the costovertebral angle which may become aggravated by certain unguarded movements such as coughing or sneezing. The author wishes to thank Tuan Tran, PhD, for his Painful episodes may occur following exertion or editorial assistance in the preparation of this clini- movements which stress the lesion, such as shaking a pillowcal paper. case out or attempting to open a window. The costovertebral sprain must be differentiated from The chiropractic profession has referred to this syndrome rib fractures, cardiac pathology, bone pathology and respiraas costovertebral subluxation, posterior rib lesion and tory syndromes. costal sprain. The disturbance is based on a structural and physiological variation in the relationship between the rib articulation and the thoracic vertebra. This article will discuss the diagnosis, examination and manipulative procedures to successfully manage this syndrome.

Examination The clinical signs obtained from palpation are invaluable. Palpatory findings will often reveal a resistance in the area of complaint. The clinical approach to the examination that the author uses is to perform three tests to establish and confirm the presence of a costovertebral sprain.

Diagnosis Pain in the thoracic spine is the most common symptom. The pain may be felt centrally with lateral radiation into the anterior chest wall. The patient will usually recall that the pain had a sudden onset following a faulty movement. The pain may be sharp and stabbing and sometimes the intercostal nerves are involved causing the symptoms to be those of an intercostal neuralgia.

1. THE SPRING TEST This test will provide the examiner with information so that reflex muscle guarding may be able to be evaluated. (Figure 1) The test is performed with the patient in a prone position. The doctor is at the head of the table and leans forward so that the heel of each hand rests on the ribs and

ACA Journal of Chiropractic /July 1980 Copyright The Journal of the American Chiropractic Association Copyright Dr Franklin Schoenholtz 2009

Figure 1. THE SPRING TEST. The patient breathes deeply and during expiration the doctor applies more weight and gently springs the ribs, the object being to create a separational stress at the costo-vertebral joints. his fingers spread laterally across the scapula. The doctor must keep his elbows fully extended. The patient is requested to breathe deeply and during expiration the doctor applies more weight and gently springs the ribs, the object being to create a separational stress at the costovertebral joints. Guarding occurs a moment after pressure is applied. If it appears before springing, then the patient is apprehensive and expecting the maneuver to hurt. When the contraction is delayed, then the patient is attempting to create a false impression. If the contraction is sustained without variation during the test, the clinician should be cognizant that either a severe continuous deep pain is present or the patient is apprehensive and is not relaxing enough for the test to be valid. The springing test is a valuable and sensitive test. If the doctor determines a disproportionate response to the springing, such as excessive guarding, it should immediately arouse his suspicion of pathological changes. 2. THE RIB MANEUVER TEST This test is important and precise in locating the involved rib. (Figure 2) It is performed with the patient placed in a sitting position with the examiner standing behind the patient. The patient is instructed to move his trunk in lateral flexion away from the painful side and raise his arm on the affected side over his head. The doctor then uses the tips of his fingers to hook the lower border of the painful rib and pulls upward. This maneuver can be reversed so that the doctor’s thumb can be placed on the upper border of the painful rib and a downward pressure can be exerted. When a costal sprain is suspected one of these two maneuvers will increase pain while the other is painless. This sign exists only in cases of rib sprain. In the case of rib fracture

both maneuvers are equally painful. When the pain is primarily muscular, it is not influenced by the rib maneuver. 3. THE RIB COMPRESSION TEST This test is performed with the examiner standing behind the patient and placing his arms around the patient’s chest. (Figure 3) The examiner requests the patient to take a deep breath while applying gentle pressure to the patient’s rib cage. If the patient has a costal sprain the gentle compressive force of the clinician will restrict rib expansion and the patient will experience symptomatic relief. However, if the lesion is present, unsupported chest expansion will create stress on the hypomobile joint, causing the patient to experience pain at the site of the lesion. When performing this test on a female patient, the examiner may recommend that the patient flex both arms at the elbows and bring them up in front of her chest to protect her from excessive pressure being applied directly to the breast area. Treatment Manipulation has proven to be the treatment of choice. Adjunctive physical therapy may be utilized to promote and maintain the normal physiological state. Many techniques exist that may be used for the successful management of this syndrome. The most common lesions are superior and inferior subluxations. The main objective of manipulation is to correct the subluxation so that freedom of movement at the costovertebral and costotransverse joints can be restored.

The author offers the following two techniques that he has found valuable in the treatment of posterior rib lesions. RIB TECHNIQUE FOR A SUPERIOR LEFT RIB SUBLUXATION (Figure 4) The patient lies on his right side, the doctor faces him and grasps the patient’s left flexed elbow with his left arm stretching the shoulder into full abduction and fixing the affected rib in the mid-auxillary line with his right thumb and thenar eminence. The thrust is inferior. RIB TECHNIQUE FOR AN INFERIOR RIGHT RIB SUBLUXATION (Figure 5) The patient lies prone with both legs flexed upward, the doctor grasps both ankles with his right hand. He then laterally torques the patient’s legs toward him using his left knee as a fulcrum. This maneuver opens the rib cage on the affected side. The doctor then places the pisiform of his left hand on the inferior border of the affected rib. He then thrusts in a superior direction. When managing a patient with a costal sprain, it has been the author’s clinical experience that fitting the patient with a supportive rib belt enhances the patient’s recovery time. The rib support helps reinforce, protect and stabilize the involved area. The patient wears the support during waking hours throughout the acute period. Summary It is understood that structure and function are reciprocal and complimentary. The costal subluxation is a classical example of an altered structure with resulting abnormal biomechanical function. Chiropractic manipulative management of this syndrome is successful for the patient and gratifying for the doctor.

Figure 2. THE RIB MANEUVER TEST. This test is important to differentiate in what direction the subluxated rib has moved. When a costal sprain is suspected, on of these two maneuvers will increase pain the pain while the other is painless.

Figure 3. THE RIB COMPRESSION TEST. The doctor compresses the rib cage while the patient takes a deep breath. Restriction of rib expansion should provide the patient with symptomatic relief.

Figure 5. RIB TECHNIQUE FOR AN INFERIOR RIGHT RIB SUBLUXATION. The patient lies prone with the doctor grasping his ankles. While using his left knee as a fulcrum the doctor utilizes the left pisiform contact to thrust the inferior rib in a superior direction.

Bibliography 1.Maigne: Orthopedic Medicine, 1976. 2.Maitland: Vertebral Manipulation, 1979. 3.Stoddard: Osteopathic Practice, 1969. 4.Stoddard: Manipulation of Osteopathic Technique, 1974.

Figure 4. RIB TECHNIQUE FOR A SUPERIOR LEFT RIB SUBLUXATION. The patient lies on his right side, the doctor faces him and grasps the patient’s left flexed elbow with his left arm stretching the shoulder into full abduction and fixing the affected rib in the mid-axillary line with his right thumb and thenar eminence. The thrust is inferior.

Copyright The Journal of the American Chiropractic Association Copyright Dr Franklin Schoenholtz 2009