Professional Papers _______________________________________________________

Conservative Management of Costovertebral SubluxationFranklin Schoenholtz, DC, DABCO Arcadia, California

ACA Journal of Chiropractic /July 1980

The chiropractic profession has referred to this syndromeas costovertebral subluxation, posterior rib lesion andcostal sprain.The disturbance is based on a structural and physiologicalvariation in the relationship between the rib articulationand the thoracic vertebra.This article will discuss the diagnosis, examination andmanipulative procedures to successfully manage thissyndrome.

Diagnosis

Pain in the thoracic spine is the most commonsymptom. The pain may be felt centrally with lateralradiation into the anterior chest wall. The patient willusually recall that the pain had a sudden onset followinga faulty movement. The pain may be sharp and stabbingand sometimes the intercostal nerves are involved caus-ing the symptoms to be those of an intercostal neuralgia.A common complaint is of continuous soreness atthe costovertebral angle which may become aggravated bycertain unguarded movements such as coughing or sneezing.Painful episodes may occur following exertion ormovements which stress the lesion, such as shaking a pillow-case out or attempting to open a window.The costovertebral sprain must be differentiated fromrib fractures, cardiac pathology, bone pathology and respira-tory syndromes.

Examination

The clinical signs obtained from palpation are invalu-able. Palpatory

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ndings will often reveal a resistance in thearea of complaint.The clinical approach to the examination that theauthor uses is to perform three tests to establish and con

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rmthe presence of a costovertebral sprain.

1. THE SPRING TEST

This test will provide the examiner with informationso that re

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ex muscle guarding may be able to be evaluated.(Figure 1)The test is performed with the patient in a proneposition. The doctor is at the head of the table and leansforward so that the heel of each hand rests on the ribs and

Dr Franklin Schoenholtz is a diplomate of the American Board of Chiropractic Orthopedists. He maintains a private practice at 226-228East Foothill Blvd. Arcadia, California. He taught diversi

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ed tech-nique 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 atLACC. He has written numerous articles on the manipulative man-agement of various musculoskeletal conditions. The most recent, “Conservative Management of Selected Shoulder Problems” appearedin the October, 1979 issue of the ACA Journal.

Costovertebral lesions area frequent occurrenceseen often in practice. Not much has been writtenon this clinical entity. The author has provided theclinician with speci

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c diagnostic tests to assessabnormal joint movement of the costovertebralsubluxation. Two rib manipulations are presentedfor consideration. Many variations of these maneu-vers may be utilized to correct speci

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c articularlesions. This clinical paper attempts to provide thebusy practitioner with a short, clear, concise andwell illustrated article on the successful manage-ment of this syndrome.The author wishes to thank Tuan Tran, PhD, for hiseditorial assistance in the preparation of this clini-cal paper.

his

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ngers spread laterally across the scapula. The doctor mustkeep his elbows fully extended. The patient is requested tobreathe deeply and during expiration the doctor applies moreweight and gently springs the ribs, the object being to create aseparational stress at the costovertebral joints.Guarding occurs a moment after pressure is applied.If it appears before springing, then the patient is apprehensiveand expecting the maneuver to hurt. When the contraction isdelayed, then the patient is attempting to create a false impres-sion. If the contraction is sustained without variation duringthe test, the clinician should be cognizant that either a severecontinuous deep pain is present or the patient is apprehensiveand 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 thespringing, such as excessive guarding, it should immediatelyarouse his suspicion of pathological changes.

2. THE RIB MANEUVER TEST

This test is important and precise in locating theinvolved rib. (Figure 2) It is performed with the patient placedin a sitting position with the examiner standing behind thepatient. The patient is instructed to move his trunk in lateral

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exion away from the painful side and raise his arm on theaffected side over his head. The doctor then uses the tips of his

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ngers to hook the lower border of the painful rib and pullsupward. This maneuver can be reversed so that the doctor’sthumb can be placed on the upper border of the painful rib anda downward pressure can be exerted.When a costal sprain is suspected one of these twomaneuvers will increase pain while the other is painless. Thissign exists only in cases of rib sprain. In the case of rib fractureboth maneuvers are equally painful. When the pain is primarilymuscular, it is not in

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uenced by the rib maneuver.

3. THE RIB COMPRESSION TEST

This test is performed with the examiner standingbehind the patient and placing his arms around the patient’schest. (Figure 3) The examiner requests the patient to take adeep breath while applying gentle pressure to the patient’s ribcage. If the patient has a costal sprain the gentle compressiveforce of the clinician will restrict rib expansion and the patientwill experience symptomatic relief. However, if the lesion ispresent, unsupported chest expansion will create stress on thehypomobile joint, causing the patient to experience pain at thesite of the lesion.When performing this test on a female patient, the ex-aminer may recommend that the patient

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ex both arms at theelbows and bring them up in front of her chest to protect herfrom excessive pressure being applied directly to the breastarea.

Treatment

Manipulation has proven to be the treatment of choice.Adjunctive physical therapy may be utilized to pro-mote and maintain the normal physiological state.Many techniques exist that may be used for thesuccessful management of this syndrome. The most com-mon lesions are superior and inferior subluxations. The mainobjective of manipulation is to correct the subluxation so thatfreedom of movement at the costovertebral and costotrans-verse joints can be restored.Figure 1.

THE SPRING TEST.

The patient breathes deeply and during expiration the doctor applies more weight andgently springs the ribs, the object being to create a separational stress at the costo-vertebral joints.

Figure 2.

THE RIB MANEUVER TEST.

This test is im-portant to differentiate in what direction the subluxatedrib has moved. When a costal sprain is suspected, on of these two maneuvers will increase pain the pain whilethe other is painless.The author offers the following two techniques that hehas found valuable in the treatment of posterior rib lesions.

RIB TECHNIQUE FOR A SUPERIOR LEFT RIB SUBLUX- ATION (Figure 4)

The patient lies on his right side, the doctor faces himand grasps the patient’s left

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exed elbow with his left armstretching the shoulder into full abduction and

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xing the affectedrib in the mid-auxillary line with his right thumb and thenar emi-nence. The thrust is inferior.

RIB TECHNIQUE FOR AN INFERIOR RIGHT RIB SUBLUX- ATION (Figure 5)

The patient lies prone with both legs

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exed upward, thedoctor grasps both ankles with his right hand. He then laterallytorques the patient’s legs toward him using his left knee as afulcrum. This maneuver opens the rib cage on the affected side.The doctor then places the pisiform of his left hand on the inferiorborder of the affected rib. He then thrusts in a superior direction.When managing a patient with a costal sprain, it hasbeen the author’s clinical experience that

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tting the patient with asupportive rib belt enhances the patient’s recovery time. The ribsupport helps reinforce, protect and stabilize the involved area.The patient wears the support during waking hours throughoutthe acute period.

Summary

It is understood that structure and function are reciprocaland complimentary. The costal subluxation is a classical exampleof an altered structure with resulting abnormal biomechanicalfunction.Chiropractic manipulative management of this syndromeis successful for the patient and gratifying for the doctor.