The term “costovertebral joint dysfunction” and “costochondritis” describes abnormal motion between a rib and its vertebral connection(s) or sternum connection(s). Dysfunction involving the costovertebral joint complex is common, and is a frequently overlooked source of chest or abdominal pain. Studies suggest that 10- 30% of “chest pain” is of musculoskeletal origin.
The costovertebral and costotransverse joints must align & move so that the axis of rotation passes through both. Most thoracic and costovertebral motions occur in coupled patterns. During respiratory excursion, as the shaft of the rib rises, the neck is relatively depressed. Movement of the upper ribs occurs primarily in a “pump handle” elevation manner, while the lower ribs move in more of an anterior to posterior “bucket handle” fashion. Costovertebral joint mobility increases progressively from superior to inferior.
Rib injuries may result from trauma, arthropathy, postural strain, or repetitive injury- especially compression or rotation. Athletes who participate in wrestling, rugby, football, golf, or butterfly stroke swimming may be predisposed. Restrictions of the upper ribs may occur subsequent to carrying heavy weight on the shoulders or a whiplash injury. Patients with biomechanical deficits, including a forward head posture, upper crossed syndrome, hyperkyphosis, scoliosis, or dysfunctional respiration may be predisposed to thoracic and rib dysfunction. Costovertebral and rib cage pain is a common complaint during pregnancy.
Symptoms sometimes begin following sudden, unguarded, or explosive movements, like coughing or sneezing. Patients will often report a history that includes twisting, reaching, pushing, or pulling. Costovertebral joint dysfunction presents clinically as localized pain, 3-4 cm lateral to the spine with possible radiation of symptoms along the associated rib. Radiating complaints may include hyperalgesia or paresthesia. Presenting complaints of costovertebral joint dysfunction range from focal and burning to sharp, stabbing, and radiating. Patients will sometimes describe concurrent costovertebral and costosternal pain as if they were “shot by an arrow.” Patients with costovertebral joint dysfunction often report variable periods of improvement. Patients may experience pain and stiffness following activity, especially upon arising the next morning. Symptoms may increase when lying down. Symptoms may increase when taking a deep breath.
The pain is often provoked by: breathing, coughing, sneezing, twisting, or bending. Reaching, pushing, or pulling requires scapular muscle activation and may provoke symptoms where the scapular stabilizers attach. Costovertebral joint dysfunction of the upper thoracic region may be provoked by “pump handle” movements, like reaching or carrying loads on the shoulder, while mid and lower costovertebral problems are provoked by “bucket handle” motions of bending, lateral flexion, and rotation.
Undiagnosed rib dysfunction often causes unnecessary worry about more sinister causes, but failure to diagnose a threatening origin has much greater consequences. Pain and mechanical dysfunction in the costovertebral region is common and may become a “biased” diagnosis for manual medicine providers. Not all costovertebral pain is of primary mechanical origin, and sometimes presents concurrently with a more ominous diagnosis. Clinicians should be astute in performing a review of systems (particularly cardiac, pulmonary, GI, and renal), as viscerosomatic referral is a common source of thoracic complaints. Cardiac complaints often include a sensation of “pressure” or “squeezing” in the substernal region that may or may not radiate to the left arm and jaw and is provoked by exertion. Fracture may be suspected in patients with a history of trauma, particularly in older patients.
Imaging studies are not generally warranted in the initial work-up of simple costovertebral pain. Radiographs may be necessary in cases of “significant trauma”, suspicion of fracture or instability, age over 50, lack of improvement with conservative care, or neuromotor deficits. The presence of red flags, including unexplained weight loss, history of cancer, corticosteroid use, osteoporosis, fever, or drug/alcohol abuse also warrants further investigation. (2,29)
The differential diagnosis for costovertebral joint dysfunction is lengthy, including cardiac, pulmonary, interabdominal, and retroperitoneal diseases. (6,30,31) Visceral origins of thoracic complaints include angina, myocardial infarction, mitral valve prolapse, aortic aneurysm, pneumonia, carcinoma, pneumothorax, pleurisy, embolus, esophagitis, neoplasm, hepatitis, cholecystitis, ulcer, hiatal hernia, pancreatitis, polynephritis, herpes zoster, and aneurysm. (30) Musculoskeletal origins could include: disc lesion, discogenic pain, stenosis, neoplasm, costochondritis, Tietze’s syndrome, intercostal strain, fracture, intercostal neuralgia, DISH, T4 syndrome, anklylosing spondylitis, and myofascial pain syndrome.
Conservative care has been shown to be a cost effective option for musculoskeletal chest pain related to rib dysfunction. Treatment should progress from restoration of joint mobility to stretching and myofascial release of hypertonic tissues, and finally, correction of postural faults. Initially, patients may need to limit moving their arm from a dependent position, including pushing and pulling. Women may benefit by temporarily switching to a sports bra to help better diffuse pressure over affected ribs. Anti-inflammatory modalities, including ice, interferential muscle stimularion, and ultrasound may be helpful. NSAIDs may help to temporarily reduce pain and inflammation.
Manipulation is the mainstay of treatment for costovertebral joint dysfunction and often leads to rapid recovery. The use of a foam roller may be beneficial. Stretching and myofascial release may be appropriate for the paraspinal, intercostal, and scapular stabilizing muscles. Clinicians should assess for and correct biomechanical deficits, including upper crossed syndrome, scapular dyskinesis and dysfunctional respiration. Scapular strengthening exercises are appropriate for patients with shoulder girdle dysfunction.
Simple acute costovertebral joint dysfunction typically responds very quickly to manual therapy and manipulation. If you think you may be experiencing rib pain, give us a call today (434)293-3800.