853 - Rib Pathos

Patholobioligical mechanism of costochondritis

• Characterized by inflammation of costochondral junction of ribs or sternocostal joints

• Key feature is lack of swelling

• Diagnosis of exclusion

Most common costochondral junctions to get costochondritis

Junctions 2-5

S+S of costochondritis

• insidious onset

• May Occur post thoracic surgery or with/after infectious process

• Chest pain that can radiate extensively

• Pain with deep breathing

Symptom nature for costochondritis

Often sharp, pressure like pain, can be nagging or aching as well

Aggs for costochondritis

Upper body movement, trunk movement, exertion

Eases for costochondritis

Avoiding aggs and quiet breathing

24 hr pattern for costochondritis

Activity dependent

Objective examination for costochondritis

Pain with palpation of affected segment, may radiate to chest wall

No swelling present at the costochondral or sternocostal joints

Potential pertinent hx for costochondritis

• may not report any meaningful hx relavent to diagnosis

• May report recent infection

• May report recent thoracic region surgery

Potential predisposing factors for costochondritis

Repetitive activity

PT management for costochondritis

• spinal mobs and/or joint manips to hypomobile areas

• SNAGs targeting the rib angle

• Address muscular imbalances in the trunk and scapular musculature

Main difference between costochondritis and tietze syndrome

Prescience of swelling and may benefit from a corticosteroid injection

Medical management for costochondritis

Typically not warranted or pt may be prescribed anti inflammatory

PT diagnosis for first rib dysfunction

Usually a pattern of painful shoulder abduction

Pathobioligcal mechanism for first rib dysfunction

• types: fracture, subluxation, and hypomobility

• Subluxation in a superior direction can result in stress on the local structures

• Subluxation may be caused by tension from the scalenes

S+S of first rib dysfunction

Neurological or vascular symptoms in the UQ

Radiating symptoms into the UE

Nature of symptoms for first rib dysfunction

May report stiffness, deep ache, may also report n/t in the UQ

Aggs for first rib dysfunction

Shoulder abduction, overhead activities, slouched posture, CL cervical rotation or lateral flexion

Eases for first rib dysfunction

Avoiding abduction or overhead activities

24 hr pattern for first rib dysfunction

Activity dependent

Objective examination for first rib dysfunction

• positive cervical rotation lateral flexion test

• Hypomobile first rib accessory motion

• Decreased cervical rotation and lateral flexion ROM

Potential pertinent hx for first rib dysfunction

May not report any meaningful hx relevant to diagnosis

May report hx of trauma or MVA

Potential predisposing factors for first rib dysfunction

• altered respiratory patterns may increase effort from accessory muscles of respiration, and therefore alter rib mechanics

• Impaired posture

PT management for first rib dysfunction

• mobs in the inferior direction

• Edu on self mobs

• Edu on breathing techniques to reduce accessory muscles use

• Address postural dysfunction/impairments as relavent

Medical management for first rib dysfunction

• imaging: radiographs if trauma

• Surgery: not common

PT diagnosis for slipping rib syndrome

Thoracic flexion or rotation

Pathobioligical mechanism for slipping rib syndrome

• hypermobility of the anterior ends of the false rib costal cartilages

• Leads to slipping of the affected rib under the superior adjacent rib

Slip/movement of rib can lead to

• intercostal nerve irritation

• Intercostal muscle strain

• Lower costal cartilage sprain

• General inflammation of area

Pathobiological mechanisms for slipping rib syndrome

• may be a traumatic or insidious onset

• More common in adults And females

• More common at ribs 8-10

S+S of slipping rib syndrome

• anterior chest wall pain or anterior upper abdomen

• Intermittent, sharp stabbing pain followed by dull, achy sensation that can last hours to days

• Slipping or popping sensation

Nature of symptoms for slipping rib syndrome

Sharp stabbing followed by dull aching

Aggs for slipping rib syndrome

Bending, coughing, deep breathing, lifting, reaching, rising from a chair, stretching, turning in bed

Eases for slipping rib syndrome

Avoiding aggs

24 hr pattern for slipping rib syndrome

More activity dependent but may worsen throughout the day once flared up

Objective exam for slipping rib syndrome

Pain with palpation of the affected rib (anteriorly)

Positive hooking maneuver

Potential pertinent hx for slipping rib syndrome

May report injury to the chest wall

Hx of rapid twisting, pushing, or lifting motions such as throwing a ball or swimming

Potential predisposing factors for slipping rib syndrome

Hypermobility syndromes like EDS

PT management for slipping rib syndrome

• treatment based on severity

• Ice/heat for inflammation and symptom relief

• Edu to avoid aggs

• Gentle joint mobs to ribs and T spine

• Ther ex to address any muscle imbalance contributing factors

Medical management for slipping rib syndrome

• imaging: not indicated unless ruling out fracture

• Pharm: anti inflammatory for mild cases and local anesthetic intercostal nerve block for mod cases

• Surgery: severe cases may respect anterior end of rib

PT diagnosis for rib fractures

Often symptomatic with rotational movements

Pathobiological mechanisms of rib fractures

• occurs when forces exceed the capacity of the bony matrix, or can occur when normal forces are acting on a bone that is already weakened

• Weakest portion is just anterior to the rib angle

Ribs 1-4

Protect neuro vascular structures of the UE

Ribs 5-9

Protect the lungs and the heart

Ribs 10-12

Protect the kidneys, diaphragm, and spleen

4-9

Most commonly fractured ribs

Rib fractures may occur as a result of

• direct trauma → crush type

• Axial loading → torsional or bending type along tensile side of rib

• Forced twisting motions → tensile or torsional type

• Osteoporosis

• Metastatic lesion from cancer

• Persistent or severe coughing spells

• Receptive UE movements

S+S for rib fractures

Significant pain with inspiration

Ventilators insufficiency

• tachypnea

• Cyanosis

• Accessory muscle use for respiration

Nature of symptoms for rib fractures

Sharp pain may occur with inspiration

Aggs for rib fractures

Inspiration, UE or trunk movement, coughing, direct pressure on the area

Eases for rib fractures

Shallow breathing, accessory muscle breathing, splinting of affected areas

24 hr pattern for rib fractures

• sleeping may be disrupted bc of pressure on area or twisting

• Symptoms may increase throughout the day d/t pain with breathing

• May have stiffness first thing in the morning

Objective exam for rib fractures

• severe pain with inspiration

• TTP over the area

• Breathing assessment → use of accessory muscles, may see ribs retract with inspiration

Potential pertinent hx for rib fractures

May report hx of obvious trauma and/or twisting or other UE or trunk activities

Potential predisposing factors for rib fractures

• osteoporosis

• Lung patho → can cause stiffening of tissues in the thorax

• Hx of cardiac, breast, or lung surgery

• Long term steroid use may decrease strength of bone

PT management for rib fractures - initial phase

Pain management and promotion of healing

• taping, cryotherapy, splinting

• Trunk and UE movement as tolerated

• Breathing and respiratory exercises to normalize patterns

PT management for rib fractures - as fracture heals

Restore joint mobility and thoracic muscle strength

• fracture stable in 1-2 weeks and healing in 6

• Ensure appropriate mobility in T spine and ribs

• Ensure balance of strength and length in thoracic musculature

• Ensure appropriate mobility of C spine and UE

Imaging for rib fractures

• X-ray: first step

• CT of chest: preferred screening method

• Bone scan: may be used if there’s a strong suspicion but others are negative

Flail chest

• life threatening

• 3 or more ribs fractured in at least 2 places

• Affected segment collapse inward during inspiration and outward during expiration

• Requires surgery to stabilize