Costotransverse and costovertebral disorders are disorders affecting or involving the costotransverse and costovertebral joints and ligaments which are often overlooked during examination for pain source localization in this area due to possible visceral pain referral and the complexities of the thoracic neural network.

The joints between the vertebrae in the upper back and the ribs are called the costovertebral joints. A joint disorder refers to an injury affecting one of these joints. Physiotherapy is an excellent treatment for costovertebral joint disorders.

It is suggested that dysfunctions in these joints could account for pain in the thorax or functional impairments.

Anatomy:

• The costotransverse joint is an articulation between the articular costal tubercle of the rib and the costal facet of the transverse process of a thoracic vertebra.
• The costovertebral joint is the articulation between the costal facte or demi-facets (formed by the caudal side of the superior vertebra and the cranial side of the inferior vertebra) and the head of the rib. These facets form a solid angle whose base consists of the annulus fibrosis of the intervertebral disc.
• A synovial joint ensures the connection between the rib and the thoracic vertebra. Together with the thoracic cage, the costovertebral and costotransverse joints provide stability.

Cause of Costotransverse and costovetebral joint syndrome:

• Local joint compression may occur as a result of a trauma or muscle spasm
• It is more common in women and can occur at any age.
• When subjected to severe trauma, these joints can subluxate or dislocate. Due to being at the top of the rib cage, the first costotransverse joint is the most vulnerable.
• Though distinctly unusual at the costotransverse and costovertebral joint, rheumatoid artritis can occur in these joints.
• The involvement of dysfunction at these joints are a source of referred pain at the thoracic spine, with suggested involvement of the costotransverse joint concerning T4 syndrome.
• The costotransverse joint is known to be involved in patients with ankylosing spondylitis, which, combined with involvement of the costovertebral, sternoclavicular and sternomanubrial joints, would result in increased rigidity of the thorax and increased dorsal kyphosis.

Characteristics/Clinical Presentation

 

• Pain localized to the posterior thorax.
• Pain may radiate to the anterior chest wall, along the rib, sometimes into the shoulder and sometimes towards the upper limb
• Unilateral symptoms
• Pain with deep inspiration, coughing/sneezing/laughing.
• Increased pain with passive or active thoracolumbar flexion, rotation and ipsilateral side bending, lifting or twisting movements
• Hypomobility of the costotransverse and costovertebral joint
• Palpable tenderness and pain at costotransverse joint and rib angle
• Movement in adjacent thoracic vertebral and rib segments is usually restricted and may stimulate or exacerbate protective muscle spasm
• Increased muscle tension in paraspinal muscles, rhomboid muscles, trapezius muscles and levator scapula muscles
• Neck pain, head ache or both
• The sensation of having a useless or heavy limb
• Referred pain originating from under the scapula and worsens with coughing, sneezing or deep breathing
• Acute, atypical chest pain

Physiotherapy Management:

Physiotherapy interventions have been shown to be effective at improving the prognosis of back pain in the thoracic region.

• Mobilisation:

thoracic mobilization

Mobilization of the rib is in an anteroposterior direction, using oscillations with contact on the dorsal surface of the rib, adjacent to the thoracic spinal articulation.

Rib distraction mobilizations:

Rib distraction mobilizationscan be an effective initial treatment. This technique is best done with the patient in a sitting or side lying position.

A rib rotational glide: A rib rotational glide is an effective technique and sometimes preferable to the rib distraction technique if direct pressure on the rib is too painful. This technique can be administered while the patient in standing, sitting, or in reclining position.

Maitland suggests that mobilizations are effective for:

• Treatment of stiffness
• Treatment of pain, rather than stiffness.
• 3 repetitions are usually performed, followed by retesting for pain on palpation. Mobilizations are repeated to any rib that was still painful until there is no longer palpable pain.

Other manual techniques include:

• Dorsal glides of the thoracic spinal facet joints (via the ribcage).

Soft tissue techniques:

• massage (deep friction, friction and normal), stretching and trigger point release.
• Massage of the scalene muscles

Laser therapy of the ribs

Exercise therapy:

• Chest lifts as a home exercise
• Chest lifts may be a useful generic treatment technique for a rib articular dysfunction or thoracic facet joint dysfunction. With the patient in hand and knee position, reach underneath the chest with both hands, lace fingers together, and slowly and gently lift the torso.
• Repeat this maneuver a few times, slowly and rhythmically, lifting from different portions of the chest or sternum to create a movement at different segments of the thoracic spine. These techniques should be pain free.
• Push-ups to activate the pectoral musculature (after 6th visit). 5 to 10 repetitions, 3 sets
• Wall push-ups (after 7th visit), progressively build up to full push-ups. 5 to 10 repetitions, 3 sets
• Rotation exercises while seated: sitting tall, back and neck straight and your arms across your chest. Keep the legs still and rotate to one side as far as able without pain, hold for 3 seconds and repeat 10-15 times to each side, alternating sides
• Shoulder retraction: This exercise should first be performed while seated. In a later phase, a standing position can be adopted. Retract the shoulders as far as comfortably possible, without pain and hold for 3 seconds, repeating 10-15 times
• Scapular stabilization and postural re-education

 

 

 

 

 

 

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