Monograph 20 ~ PRIORITY APPRAISAL FOLLOWING ANTERIOR THORAX TRAUMA
 
   
Monograph 20

Priority Appraisal Following Anterior Thorax Trauma


By R. C. Schafer, DC, PhD, FICC
Manuscript Prepublication Copyright 1997

Copied with permission from  ACAPress


Background
Anterior Thoracic  Neuromusculoskeletal Injuries
    Chest Pain and Tenderness
    Referred Pain
    Breast Pain
    Diaphragmatic Pain
Initial Respiratory Considerations
    Postural Effects on Diaphragm
    Potential Visceral Reactions to Postural Faults
Rib Fractures
    Clinical Features
    Roentgenography
    Golfer s Fractures
    Flail Chest
  Rib Dislocations

Arthrokinematics
Regional Characteristics
    The Sternum
    The Ribs
    The Costochondral and Sternocostal Joints
    The Interchondral Joints

Clinical Management Electives for Anterior Thoracic Strain/Sprain
  1. Stage of Acute Inflammation and Active Congestion
  2. Stage of Passive Congestion
  3. Stage of Consolidation and/or Formation of Fibrinous Coagulant
  4. Stage of Fibroblastic Activity and Potential Fibrosis
  5. Stage of Reconditioning
Commentary
Myositis and Myalgia of the Chest
  Mastitis and Mastodynia
    Clinical Features
    Diagnosis
    Management
  Pulmonary Contusion
    Pitres' (Plumb line) Chest Sign
  Sternoclavicular Dislocations
    Anterior Sternoclavicular Luxation
    Posterior Sternoclavicular Luxation
  Sternoclavicular Sprain
    Management
    Schultz s Strapping Procedure
  Sternoclavicular Disc Injury
  Sternoclavicular Fixations
  Sternoclavicular Subluxations
    Anterior Medial Clavicular Subluxations
    Posterior Medial Clavicular Subluxation
  Anterior Thoracic Strains
    Pectoralis Strain
    Determining Pectoralis Contracture
    Pectoralis Syndrome
  Thoracic Outlet Syndrome
  The Costoclavicular Syndrome
  Sternal Injuries
  Costosternal Sprains and Separations
  Sternal Fixations
    The Manubrium-Sternum Joint
    Anterior Rib Pit Fixations
    Posterior Effects
  Rib Contusions
  Rib Sprains and Strains
    Management
  Xiphisternal Sprain
  Intercostal Fixations
  Diaphragmatic Spasm (Stitches)

References and Bibliography





Rib subluxations, the costoclavicular syndrome, sternoclavicular injury, trigger point formation, and pectoralis contractures are the common musculoskeletal disorders associated with the anterior thorax.



     BACKGROUND

Soft-tissue injuries of the extraspinal thoracic region often involve the sternoclavicular joints, sternocostal joints, anterior and posterior musculature and ligaments, and tissues of the spinocostal (costovertebral and costotransverse) joints. From a clinical standpoint, the apposition of the scapulae and thoracic cage can also be considered articulations subject to mobility restrictions and positional malalignment. Scapular mobility restrictions commonly refer pain to the upper arm.


Anterior Thoracic Neuromusculoskeletal Injuries

Because of the structural-functional reciprocity of the clavicles with the sternum, pain and biomechanical disorders of sternoclavicular mobility and malalignment are typically referred to the shoulder. The reverse is true in situations of many shoulder fixation/subluxations. Likewise, because of the structural-functional reciprocity of the ribs with the sternum, biomechanical disorders of sternocostal or spinocostal mobility and malalignment are often referred to the thoracic spine. The reverse can be true in situations of thoracic fixation/subluxations.

      Chest Pain and Tenderness

When a patient presents with chest pain or tenderness as a complaint, the onset, location, duration, quality, radiation, severity, precipitating and aggravating factors should be noted. The relationship to strenuous activity, relieving factors, and any associated trauma linked to the attacks should also be recorded. Although the lungs themselves are painless, adjacent tissues such as the pleura, the musculoskeletal structures of the rib cage, and articulating dorsal spine are richly innervated and often ignite referred pain.

A history of trauma usually simplifies the diagnosis, but not always. For example, a rib may become fractured from coughing, sneezing, or just by a misstep or hug (eg, as in osteoporosis). Ribs also may become painful from ankylosing spondylitis, herpes zoster, sprains, strains, fixations, or be involved in Tietze s syndrome (sternocosto-chondritis).

It is not uncommon for musculoskeletal dysfunction to mimic pathologic process of the heart or lungs. The anterior chest wall is especially prone to diseases and dysfunctions involving neuromusculoskeletal components. When involved, such conditions will be aggravated by coughing, sneezing, upper torso body movements, and sometimes just by breathing. The patient will often be able to place his hand or finger on the painful area.

An initial priority in anterior chest complaints is to differentiate among traumatic, functional, and organic causes. Chest pains originating from cardiovascular disease commonly include myocardial ischemia or infarction, pericarditis, aortic aneurysm or dissection, mitral valve prolapse, and pulmonary embolus. These conditions must be first differentiated from noncardiac disorders causing chest pain such as costochondritis, thoracic spine disease, rib fracture, herpes zoster, pneumothorax, anxiety hyperventilation, pleurisy, pneumonia, hiatal hernia, esophagitis, esophageal spasm or tumor, gastritis, gastric or duodenal ulcers, cholecystitis, and pancreatitis.

The quality and location of pain frequently offer clues to its source. Chest pain readily arises from pathologic afflictions of the chest wall and intrathoracic organs, and many of these disorders require specialized care. Not to be overlooked, however, are disorders of the neck, spine, and subdiaphragmatic organs that refer sensations of distress to the chest. The classic origins of chest pain are shown in Table 1.


Table 1. Origins of Chest Pain

Chest Wall, Neck, and Spine Peripheral nerves Heart valves
Blood vessels Intercostal neuralgia Myocardium
Bone and cartilages Neuritis Contusion
Clavicle Skin Coronary insufficiency
Dislocation Contusion Myocardial infarct
Fracture Herpes zoster Myocarditis
Subluxation Spinal cord Postinfarction syndrome
Ribs Hematomyelia Pericardium
Costosternal subluxation Neuralgia Epicardial abscess
Costovertebral subluxation Syphilis Metastasis
Fracture Transverse myelitis Rheumatic fever
Metastasis Tuberculosis Tuberculosis
Multiple myeloma Tumor Uremia
Osteitis deformans Stomach Viral pericarditis
Osteitis fibrosa cystica Intrathoracic Structures Mediastinum
Osteomyelitis Aorta Dermoid cyst
Sarcoma Aortitis Emphysema
Tietze s syndrome Dissecting aneurysm Hodgkin s disease
Sternum Medionecrosis Lymphadenopathy
Fracture Ruptured aorta Mediastinitis
Vertebra Syphilitic aneurysm Substernal thyroiditis
Facet syndrome Bronchopulmonary tree Suppurative infection
Fracture Empyema Tumor
IVD syndrome Hemothorax Pleura
Osteomyelitis Metastasis Empyema
Osteoarthritis Pneumonia Fungus infection
Osteomalacia Pneumonitis Mesenthelioma
Osteoporosis Pneumothorax Pleurisy
Metastasis Primary tumor Pulmonary infarction
Pott s disease Diaphragm Tuberculosis
Rheumatoid spondylitis Diaphragmatic abscess Pulmonary artery
Sprain Hiatal hernia Embolism
Subluxation Esophagus Endocarditis
Mammary glands Carcinoma Subdiaphragmatic Visceral
Carcinoma Cardiospastic dilatation Reflexes
Mastitis/cystic disease Caustic liquids Gallbladder
Premenstrual syndrome Diverticulum Genitals
Muscles Esophagitis Intestines
Dermatomyositis Hiatal hernia Kidney
Epidemic pleurodynia Inflammation Liver
Myofibrositis Rupture Pancreas
Strain/trigger point Ulceration Peritoneum
Trichinosis Heart Spleen
Trigger Point Endocardium  



      Referred Pain

Chest symptoms, as stated above, may indicate visceral disease but just as often arise from referred musculoskeletal problems. Ventilatory impairment is usually suspected in dyspnea, but it may be the result of rib-cage dysfunction, spondylitis, or paravertebral muscle spasm and pain. Air hunger at rest is a cardinal sign of anxiety and often seen in chronic obstructive pulmonary disease; it is, however, also a reflex sign of rib-cage dysfunction of a musculoskeletal nature. Chest pain often points to coronary insufficiency, dissecting aneurysm, or esophageal and pleural origins; but it also may be the result of somatic rib-cage dysfunction, costochondral or costovertebral strain, or be referred pain from the gallbladder, stomach, duodenum, or pancreas.

In chest pain associated with a cough, pulmonary infections, pneumonia, lung abscess, and bronchitis are usually priority suspicions, along with pleuritis and lung or pleural tumors. Reflex considerations could include costovertebral dysfunction, costochondral dysfunction or separation, or rib fracture. In cough with thoracodynia, one normally thinks of acute or chronic lung infections, chronic bronchitis, bronchial tumor, pulmonary embolism, broncholith, bronchiectasis, postnasal discharge, or the inhalation of irritants. However, reflexes from clavicular strain affecting the recurrent laryngeal nerves, cervical subluxation, or common cerumen impaction should not be overlooked.

Thus, a history of trauma shows that injury has occurred. It does not prove that the injury alone is responsible for all the patient s complaints.

      Breast Pain

Pain and tenderness commonly follow a breast bruise. Pain, bloody and nonbloody discharges, masses, swellings, and retraction are significant symptoms of breast disease. Redness indicates inflammation, either traumatic or pathologic in origin. It may also indicate superficial lymphatic involvement (eg, inflammatory carcinoma). Associated nipple ulceration points toward Paget s disease of the breast (intraductal carcinoma) unless both nipples are involved (eg, in benign dermatologic disease). A related discharge may be a forerunner of malignancy, especially if the discharge is spontaneous and associated with a breast mass.

      Diaphragmatic Pain

Diaphragmatic pain, usually aggravated by inspiration, is frequently referred to the lower sternum. Referred tenderness is often found along the subcostal ridge. The direct cause is often difficult to differentiate. Its most common origin is an exercise "stitch," intercostal neuritis, epigastric distress, hepatic overload, peritonitis (eg, chronic appendicitis), or a subphrenic abscess or hernia.



Initial Respiratory Considerations

Quiet respiration is under the dominance of the bellows-like diaphragm with some help via intercostal, levator costarum, and scalene activity. There is minimal movement in the thoracic joints.

When the diaphragm contracts, its dome lowers so that the vertical length of the thoracic cavity is increased. This increase in vertical diameter is also contributed to by the raising of the upper ribs. When the diaphragm relaxes, the elastic rebound of the abdominal wall plus some contraction pushes the viscera and the diaphragm upward during expiration. The elastic recoil of the lungs and the subatmospheric pressure produced in the pleural cavity are also active during exhalation.

During forced inhalation, the diaphragm, levator costarum, external intercostals, anterior internal intercostals, serratus posterior superior, and scalenes are the most active muscles. The thoracic spinal extensors, sternocleidomastoideus, scaleni group, pectoralis major and minor, trapezius, latissimus dorsi, serratus anterior and posterior inferior, subclavius, and levator scapulae are contributors. During respiratory activity, it is important that the quadratus lumborum fixates the 12th rib, or the diaphragm would not have a stable attachment from which to maintain its tension.

During forced exhalation, the posterior internal intercostals, the abdominal group, and the serratus posterior inferior are the most active muscles. The latissimus dorsi, serratus posterior inferior, quadratus lumborum, and iliocostalis lumborum offer assistance. The muscles of the abdomen essentially serve as antagonists to the diaphragm during expiration.

      Postural Effects on the Diaphragm

Gravity has a distinct effect upon the work of the diaphragm. In the upright position, the expiratory excursion of the diaphragm must overcome the gravitational pull on the thoracic viscera. This occurs by abdominal contraction pushing the subdiaphragmatic viscera superiorly.

Breathing is much easier when a patient is horizontal because the diaphragm is relieved of weight from above. Likewise, diaphragmatic excursion is much greater in the horizontal than the vertical position. Excursion is inhibited more in sitting than in standing because the abdominals are relaxed in the sitting posture. When the abdominals are weakened by ptosis, hernia, or paralysis, respiration becomes purely thoracic. The reverse is true in pneumonia, pleurisy, and rib fracture.

      Potential Visceral Reactions to Postural Faults

Many physical activities require ideal lung capacity, and respiratory balance and the maintenance of proper intra-abdominal pressure depend on good body mechanics.

The Diaphragm.   In the ideal physical attitude, the position of the head well poised and the chest held high is important because the anterior mediastinal ligaments attached to the diaphragm originate in the deep cervical fascia and are attached to the lower cervical vertebrae. When the mechanics are poor, a lowered diaphragm is the rule, and proper coordination of the muscles of respiration is lost. This abnormal position may decrease vital capacity by more than half. Venous and lymphatic return is greatly assisted by the rhythmic contractions of the diaphragm. When the diaphragm has been lowered, it has a much shorter range of excursion and is thus much less effective as a circulatory aid.

Respiratory Efficiency.   Because only a small part of available lung tissue is ample for the minimal requirement of gaseous exchange in the relaxed state, respiratory efficiency is difficult to measure during the nonactive state. The small gain in maximal diaphragmatic excursion and vital capacity resulting from postural changes can be considered inconsequential. Thus, the physiologic efficiency in the erect posture, relaxed or rigid, should not be considered "normal" because the efficiency of the metabolic and circulatory systems is reduced.


Rib Fractures

Most rib fractures are extremely painful even if minor because respiratory motions cause constant grating of highly innervated fracture endings. Both displaced fractures and fatigue cracks may be found. A compound fracture may communicate with the skin or the pleura and other thoracic contents. Cellular emphysema is a common complication that often disappears spontaneously.

The longest and most prominent ribs (5th9th) are most often fractured. The upper ribs are better protected; the lower ribs are more mobile and susceptible. The weakest site for anterior compression injury is where the rib has its greatest change in curvature. This is just anterior to the costal angle.

      Clinical Features

Diagnosis must frequently be made without the classic signs of fracture. The history, pain, and point tenderness offer the best nonradiographic clues. Pain is felt sharply on inspiration or coughing. Localized tenderness is usually evident. The break can sometimes be felt with the fingers. Crepitus may exhibit, but it is absent if the fracture is incomplete or fragments override. Because ribs are highly mobile, preternatural mobility may have little value. Broken ribs cut like knives. If the lung is punctured, the patient may cough up bright, red, frothy blood.

      Roentgenography

Roentgenography may be obvious or nonconclusive. If a film presents no evidence, and pain, disability, and dyspnea persist for a few days and a localized periostitis is apparent, the disorder should be treated as a fracture even if evidence is lacking on film.

Rib fractures are usually obvious but may be missed within overlapping axillary shadows. Fracture of a costal cartilage may be invisible unless partially calcified. Breaks run obliquely or irregularly where calcification has not yet occurred. In seeking signs of rib fracture, one should not overlook careful evaluation of the costospinal junctions (often associated with costovertebral subluxation) or the costosternal junction. Except for the very high or low ribs, costotransverse ligaments ruptured by a severe force may lead to superior subluxation of the ribs.

      Golfer s Fractures

Some rib fractures are peculiar to certain sports. For example, novice golfers who complain of pain and discomfort in the upper back near the shoulder may present "golfer s fractures." This injury usually involves the posterior aspect of multiple middle ribs (4th 7th). Right-handed golfers exhibit left-sided fractures, and vice versa. Numerous rib injuries occur in wrestling, but few show early radiographic evidence.

      Flail Chest

This traumatic distortion is a dangerous state that requires immediate respiratory assistance and surgical attention. It is often called a "staved-in" chest: the result of several anterolateral segments being disrupted from the sternum so that they are freely movable because of fracture or dislocation. It is readily recognized by paradoxical breathing where the chest wall sucks in with inspiration and pushes outward on expiration.


Rib Dislocations

The most common "slipped rib" separation occurs at the junction of the osseous rib and its costal cartilage, and thus is easy to confuse on palpation with a lateral rib fracture. The end of the freed rib springs open and invariably slips superiorly. It usually occurs in the 10th rib area in thin young women often from a strong hug from a boyfriend or a lateral fall against blunt furniture. In the years beyond middle age, fracture is far much more common than dislocation.




     ARTHROKINEMATICS

The thoracic cage serves as a unique biomechanically coupled system composed of the sternal complex, 12 pairs of ribs, costal cartilages, and thoracic vertebrae. As a whole and individually, these structures are quite strong and elastic prior to the osteoporosis so common in old age. Morehouse/Cooper state that the thoracic cage of an infant can withstand compression loads up to 200 lb without injury. Healthy young men can withstand up to 2,800 lbs.


Regional Characteristics

The most important structures having significant biomechanical influences are the sternum, ribs, vertebrae, IVDs, and costal joints.

      The Sternum

The sternum serves as a protective plate for the heart and aorta against anterior forces. Anatomically, the sternum is divided into three main osseous parts: the manubrium, body, and xiphoid process.

The Manubrium.   The thick manubrium at the superior part of the sternum articulates laterally with the medial clavicles and 1st ribs at its superolateral aspect and with part of the 2nd rib at its inferolateral aspect. The manubrium s superior border (jugular notch) is ideally on a level with T2. Its inferior aspect, ideally on a level with T4, joins the superior aspect of the body of the sternum in a synchondrosis. The symphysis here allows hinge-like movements during respiration.

The Body of the Sternum.   The middle part of the body of the sternum is composed of four synchondrotic segments that become fused in the young adult. Its lateral aspects offer a series of costal notches to accept the anterior aspects of the costal cartilages.

The Xiphoid Process.   This coccyx-like process extends downward from the inferior aspect of the 4th segment of the sternal body and divides the superior aspect of the rectus abdominis. The joint between the body of the sternum and the xiphoid process, ideally on a level with T8, is a synchondrosis that becomes a synostosis during middle age.


      The Ribs


With the exception of an anomaly, each of the 12 thoracic vertebrae normally has a corresponding pair of ribs. A typical rib is angled inferiorly from its vertebral attachment as it curves outward and serves as a curved lever. The lower the rib, the more acute the angle. At its anterior aspect, each rib curves medially and upward.

Except for the short 1st rib, this means that the lateral aspect of a rib is lower than either its posterior or anterior attachment. The anterior attachment is lower than its posterior attachment. This flattened, curved design of a rib, and the fact that a rib is under compression between the spine and the sternum, offers it special biomechanic advantages against A-P forces and rapid rebound when compressed linearly.

Because a rib is preloaded through its long axis, it has a tendency to spring open if freed from one of its fixed points. This tension is maintained essentially through mechanical design and intercostal tonicity. Thus, an A-P force acting on a rib must first overcome the expansion tendency of the rib before it can overcome the tensile strength of the bone. Because inspiration increases tension on the thoracic elastic elements and elastic tension gives resistance to deformation or compression, an expanded thoracic cage is in a much better state to withstand a blow or support a load. It is for this reason that football players are taught to inspire just before making a block.

All rib angles increase with inspiration and decrease with expiration, and all rib lengths increase with inspiration and decrease with expiration. This is called the "caliper," "ice tongs," or "pump-handle" A-P effect. It occurs essentially at the costovertebral joints and is fairly restricted to the T2T6 area. Also during respiration, the lateral aspect of a rib raises and lowers with inspiration and expiration. This lateral "bucket-handle" effect is due to the relatively fixed points of articulation anteriorly and posteriorly and the lateral inferior-superior motion. The lateral aspects of the ribs are pulled away from the midline, and the transverse diameter of the thoracic cage is increased. This movement chiefly elevates and everts the lower borders of ribs T2T10. The effect is most noticeable in the upper ribs.

The T1T7 Area.   The ribs of this region, called "true" ribs, articulate with the sternum anteriorly. Their length progressively increases inferiorly. Because of strong attachments at the sternum and the costovertebral and costotransverse joints, A-P distortion should be inhibited in this area. Yet, Grieve reports that it is not uncommon to find a flat midscapular area that is normal in all other respects. This could indicate that acquired biomechanical forces have overcome inherent structural forces.

The T8T10 Area.   The ribs in this area, called "false" ribs, are joined anteriorly below the sternum by cartilage with no direct osseous support. Their length progressively decreases inferiorly.

The T11T12 Area.   These ribs, called "false floating" ribs, are relatively free anteriorly, lacking both osseous and cartilaginous support. They end within muscle tissue. They do not actually "float" because they articulate posteriorly with their numbered vertebrae. Their length progressively decreases inferiorly. The 12th rib is attached to the tips of L1L2 transverse processes by the lumbocostal ligament coursing just anterior to the quadratus lumborum.


      The Costochondral and Sternocostal Joints

The 1st7th anteriorly cupped rib ends join their costal cartilages at synovial synchondrotic costochondral joints that are surrounded by periosteum. There is little motion at these joints. The anterior costal cartilages articulate with the sternum at synovial synchondrotic joints. The sternocostal joints are similar to the costovertebral joints; ie, synovial joints divided by an intra-articular ligament. The capsules are thin but strengthen by anterior and posterior radiate ligaments.

During inhalation, the sternum moves anteriorly and superiorly when viewed from the side. The angle formed by the first rib and the manubrium closes when viewed from the side. The costosternal angles open when viewed from above. The costal cartilages of true ribs rotate upward and forward, and the false ribs slide on each other at the interchondral joints. These mechanisms are reversed during expiration. Alert clinical observation is necessary.

      The Interchondral Joints

The 8th11th ribs are held to the sternum by fused costal cartilage. They anteriorly articulate (slide) superiorly and inferiorly within synovial-like joints that later become fibrous and then fuse in old age. The fibrous capsules are quite thin but strengthened by the interchondral ligaments. The interchondral articulation between the 9th and 10th ribs is united by an extremely fibrous joint.




     CLINICAL MANAGEMENT ELECTIVES FOR ANTERIOR THORACIC STRAIN/SPRAIN


1. Stage of Acute Inflammation and Active Congestion

The major goals are to control pain and reduce swelling by vasoconstriction, compression, and elevation; to prevent further irritation, inflammation, and secondary infection by disinfection, protection, and rest; and to enhance healing mechanisms. Common electives include:

Disinfection of open skin (eg, scratches, abrasions, etc)
Cryotherapy
Cold packs
Ice massage
Vapocoolant spray
Pressure bandage
Protection (padding)
Elevation
Indirect therapy (reflex therapy)
Iontophoresis/phonophoresis
Auriculotherapy
Meridian therapy
Pulsed alternating current
Spondylotherapy (upper and middle thoracic)
Bedrest
Restricting strap or bandage
Indicated diet modification and nutritional supplementation.


2. Stage of Passive Congestion

The major goals are to control residual pain and swelling, provide rest and protection, prevent stasis, disperse coagulates and gels, enhance circulation and drainage, maintain muscle tone, and discourage adhesion formation. Common electives include:

Indirect articular therapy (reflex therapy)
Alternating superficial heat and cold
Pressure bandage
Protect lesion (padding)
Cool pool cryokinetics (active exercise)
Light nonpercussion vibrotherapy
Meridian therapy
Spondylotherapy (upper and middle thoracic)
Bedrest
Restricting strap or bandage
Indicated diet modification and nutritional supplementation.


3. Stage of Consolidation and/or Formation of Fibrinous

Coagulant

The major goals are the same as in Stage 2 plus enhancing muscle tone and involved tissue integrity and stimulating healing processes. Common electives include:

Mild articular adjustment technics
Moist superficial heat
Thermowraps
Spray-and-stretch
Moderate active range-of-motion exercises
Meridian therapy
Vibromassage
Spondylotherapy (upper and middle thoracic)
Mild transverse friction massage
Mild proprioceptive neuromuscular facilitation techniques
Bedrest
Restricting strap or bandage
Indicated diet modification and nutritional supplementation.


4. Stage of Fibroblastic Activity and Potential Fibrosis

At this stage, causes for pain should be corrected but some local tenderness likely remains. The major goals are to defeat any tendency for the formation of adhesions, taut scar tissue, and area fibrosis and to prevent atrophy. Common electives are:

Mild heat
Articular adjustment technics
Spondylotherapy (upper and middle thoracic)
Local vigorous vibromassage
Transverse friction massage
Spray-and-stretch
Active range-of-motion exercises without weight bearing
Meridian therapy
Proprioceptive neuromuscular facilitation techniques
Rest
Restricting strap or bandage at night only
Indicated diet modification and nutritional supplementation.


5. Stage of Reconditioning

Direct articular therapy for chronic fixations
Progressive remedial exercise
Passive stretching
Isometric static resistance
Isotonics with static resistance
Isotonics with varied resistance
Plyometrics
Aerobics
Indicated diet modification and nutritional supplementation.

 



     COMMENTARY

Myositis and Myalgia of the Chest

It is not unusual for a localized myalgia and tenderness to be traced to a strain. In contrast, diffuse thoracic myalgias are often the result of systemic conditions such as from an incessant cough, septicemia, strenuous exercise, or even trichinosis.

Inflammatory myositis can result from a traumatic, a neurologic, a lymphatic, a circulatory, an autoimmune, a bacterial, a parasitic, or a viral focus. Some common examples of the pathologic variety include Coxsackie viral infection, dermatomyositis, lupus erythematosus, polyarteritis, polymyositis, rheumatic fever, scleroderma, trichinosis, and tuberculosis.

      Mastitis and Mastodynia

An inflamed breast or breast pain is occasionally presented with or without a history of bruising. A complaint of breast pain is heard four times more frequently in general practice than a complaint of nipple discharge pointing to a pathologic origin. It should also be recognized that mastitis is not restricted to females. It occasionally arises in males and suggests a subclinical hormonal imbalance or an inflamed hair root leading to a deep abscess.

        Clinical Features

Stinging, burning, or pulling unilateral mastodynia (mammalgia) is the second most common complaint reported in female breast cancer, but related acute tenderness is rare. Rapidly growing cysts are both tender and painful, and a tender mass with a history of trauma makes a hematoma suspect. Bilateral pain and tenderness are common in diffuse fibrocystic disease. Most benign breast lesions are painless. A mass that becomes tender during the menstrual period suggests a fibroadenoma. Nonclinical cyclic pain and tenderness are usually bilateral but more pronounced on one side. A painful breast in a lactating woman is characteristic of a galactocele. More often, it is referred pain when not associated with lactation.

        Diagnosis

Many complaints of mastodynia have a nonpathologic origin. The procedures described below are designed for such lesions. As an aid to differential diagnosis, mastodynia and associated symptoms are shown in Table 2.


Table 2. Mastodynia and Associated Symptoms

Syndrome: Breast Pain Primary Suspect Disorders  
No other symptoms Costosternal subluxation Scaleni trigger point
  Costovertebral subluxation Sternalis trigger point
  Intercostal neuralgia Sternocleidomastoid trigger pt
  Pectoralis major trigger point Subclavius trigger point
  Pectoralis minor trigger point Thoracic subluxation, especially
  Rib fracture (green-stick) T2-T5
     
Unilateral swelling and non-
Bloody discharge
Acute mastitis Abscess
     
Bilateral swelling and milky discharge Chiari-Frommel syndrome Forbes-Albright syndrome
  Drug reaction Lactation
     
Bilateral swelling without
discharge
Drug reaction Premenstrual syndrome
  Gynecomastia Trauma
     
Tenderness absent Carcinoma Chronic cystic mastitis
     
Tenderness present Benign cyst Juvenile mastitis
  Fat necrosis  
     
Mass Abscess Inflammatory mastitis
  Carcinoma Pectoral hematoma
  Cystic mastitis  



After suspicions of pathology are ruled out, a common protocol is to motion palpate the spine and relate findings with the patient s complaints. Confirm findings with appropriate orthopedic and neurologic tests. Check pertinent upper-extremity tendon and superficial reflexes and upper-abdominal superficial reflexes, and grade the reaction. Check involved joint motion and muscle strength against resistance, and grade resistance strength. Interpret resisted motion signs. Test for autonomic imbalance if suspicions of vagotonia or sympathicotonia arise.

        Management

In mastitis or mastodynia derived from a spinal subluxation complex, the associated spinal major will likely be found in the T2T5 region. After relaxing the tissues and adjusting the subluxated/fixated segments, it is helpful to apply deep high-velocity percussion spondylotherapy over related segments for 34 minutes. Treat trigger points discovered, especially those found in the pectoralis major or serratus anterior muscles. Cool compresses are helpful during the acute stage, moist warm compresses later. Any form of electrotherapy near the heart is contraindicated. Supplemental nutrients B6, C, niacin, pantothenic acid, and calcium are recommended by several authorities. Counsel the patient to avoid appropriate antivitamin and antimineral factors.


      Pulmonary Contusion

Blunt chest injury commonly leads to pulmonary contusion, which is characterized by covert edema, reflex bronchorrhea, lung hemorrhage, and progressing atelectasis. This is especially true in high-velocity accidents producing a compression-decompression injury to the chest. Physical findings in mildmoderate cases generally include rapid respiratory and pulse rates, wet rales, and a copious cough that may be blood stained. In severe cases, hypoxia, respiratory acidosis, secondary pleurisy, and deteriorating respiratory insufficiency may lead to death in spite of heroic efforts. Suspicions mandate immediate referral.

        Pitres' (Plumb line) Chest Sign

The axis of the sternum is marked on the chest wall with a skin pencil, and a string is stretched between the center of the sternal notch and the symphysis pubis. This line normally coincides with the line of the sternal axis. If this does not occur, as in cases of monolateral pleurisy, the angle that it forms with the sternal line indicates the degree of pleural effusion within the thorax.


Sternoclavicular Dislocations

        Anterior Sternoclavicular Luxation

Shoulder girdle movement at the sternoclavicular joint is slight but essential. At the medial end of the clavicle, displacement may occur either anteriorly, as is more common, or posteriorly relative to the sternum. The latter is often associated with dyspnea and cervical edema from vasculature compression. Thus, this sign could signal an impending medical emergency.

The sternoclavicular joint is the least stable major joint of the body, although complete dislocations are rare. Coned-down x-ray views, tangential views, or tomograms are often necessary to clearly show displacement. When dislocations occur and are reduced, a deformity may persist. The displacement of the clavicle in forward dislocation is typically anterior, superior, and medial.

Management.   When specialized care is not available and emergency care must be applied immediately, a good method of reduction is the two-person approach. One applies lateral traction to the patient s horizontally abducted arm while the other applies corrective pressure to the medial clavicle. Once reduction has been made, a reverse Figure-8 bandage is applied. As pain and disability are severe, reduction usually requires the services of an orthopedist.


        Posterior Sternoclavicular Luxation

These luxations are often hidden by soft-tissue swelling. In mild chronic cases, a distinct depression is palpable. Acute posterior dislocations can be a medical emergency requiring the immediate attention of a thoracic surgeon. Overt dislocations should be reduced by a specialist because of the vital tissues behind the sternum.

Emergency Care.   Because of the many vessels in this area, surgical referral may be vital. For temporary aid, place the patient supine with a sandbag between the scapula to help pull the clavicle out of the retrosternal area and relieve the vital retrosternal structures. Mild, steady, posteriorly directed pressure over the lateral clavicles by one person while another attempts to grasp the medial end of the clavicle with a light towel and apply traction is helpful. In some cases, this may be all that is necessary for temporary relief. A Figure-8 harness such as used for clavicle fracture is then applied to hold the shoulders back during transport.


      Sternoclavicular Sprain

Sternoclavicular sprains vary from minor to complete dislocation, displacing posteriorly (retrosternal), posterior-medial to overlay the manubrium, or anterior-inferior to overlap the 1st rib. It is important to alert the reader again that posterior displacement easily involves the vital vessels in this area and typically requires referral to a thoracic surgeon.

In any acute separation, the most significant sign is that of demonstrable and significant false motion of the acromioclavicular joint from joint laxity. If examination of the seated patient can be made before swelling develops, good evaluation can be made by pivoting the joint after the scapula has been stabilized by the nonpalpating hand. A swollen joint may give a false impression of a tender but stable joint.

Grade I injury:   Sprain and slight tearing of the costoclavicular and sternoclavicular ligaments. There is usually no separation. Tenderness is found over and around the articulation.

Grade II injury:   Severe subluxation of the clavicle with partial tear of the costoclavicular strap and rupture of the sternoclavicular ligament.

Grade III injury:   Dislocation exhibiting complete rupture of the costoclavicular and sternoclavicular ligaments. Above signs and symptoms are exaggerated. Displacement is demonstrated in roentgenography on oblique views and tomography.

Management:   Associated spinal majors will likely be found in the C7T1 area. After relaxing the tissues and adjusting the subluxated/fixated segments, apply deep low-velocity percussion spondylotherapy over segments C7T4 for 12 minutes. Treat trigger points discovered, especially those found in the scalene, sternalis, subclavius, and sternocleidomastoideus muscles. Support with a Figure-8 bandage and large axillary pads are often necessary until stability resumes. Other helpful forms of treatment include cryotherapy during the acute stage, followed later by moist heat. Any form of electrotherapy near the heart is contraindicated. Supplemental nutrients B-complex, C, D, calcium, and manganese are recommended, as well as counseling the patient to avoid appropriate antivitamin and antimineral factors.

The attending physician should demonstrate therapeutic exercises to strengthen weak muscles and/or stretch contractures. The patient should conduct slow stretching and strengthening range-of-motion exercises progressively, but avoid abduction for 23 weeks. Isometric exercises are helpful in strengthening local muscles to support weakened ligaments. Rehabilitative exercises of the shoulder should give particular attention to the pectoralis major.


        Schultz's Strapping Procedure

Following the correction of any associated subluxation to the anesthetized joint, a splint can be improvised by cementing a strip of foam rubber to a tongue depressor. Place the splint over the joint horizontally, foam side against the skin, so it is centered over the affected articulation. Secure it with a few strips of tape so it will not move during strapping. Next, place a piece of cotton padding or felt large enough to cover the sternoclavicular joints and most of the sternum. The superior aspect of the pad should be cut in a V notch or curve to avoid pressure on the throat. Prepare 10 strips of 1-1/2" tape, long enough to extend from just above the nipple anteriorly to a few inches below the opposite scapula posteriorly. Start at the back of the injured side. Bring the first strip upward diagonally over the shoulder close to the neck, then slightly above the affected joint and toward a point midway between the axilla and the nipple for males (females will require a modified technique). The tension on the tape is from back to front. The second strip is placed on the opposite side in the same manner. Place the remaining eight strips in a crisscross overlapping manner, moving downward. During strapping, the injured clavicle should be depressed firmly with the free hand as the tape covers it. For greater restriction and to anchor the crisscrossed tape ends, place several horizontal strips across the anterior thorax from the clavicles to the nipples. The arm of the affected side is then placed in a simple sling.

      Sternoclavicular Disc Injury

In some injuries of the sternoclavicular joint just below the severity of a dislocation, the articular disc may be pulled from its sternal attachment in a manner similar to mechanisms inducing a semilunar tear of the knee. The patient will complain of localized pain on movement. A "catch" may be felt by the patient, especially during ipsilateral glenohumeral flexion and circumduction. As in the knee if the cartilage is fragmented, referral for surgery may be required if conservative measures fail to hold.


      Sternoclavicular Fixations

Kessler/Hertling explain how free mobility of the sternoclavicular joint is necessary for normal shoulder mobility. For example, the clavicle must afford a degree of shaft rotation during elevation of the arm and somewhat during shoulder retraction and protraction. Anterior and posterior clavicular glide is necessary for normal shoulder retraction and protraction. Mennell tests this motion in the supine patient by grasping the clavicle between his thumbs and index fingers at the junction of the clavicle s inner and middle thirds and carrying the clavicle upward and downward through its anterior-posterior range of motion. Superior and inferior clavicular motion is necessary for normal elevation of the arm and shoulder depression, but this is difficult to determine except by gross shoulder motion observation.

Gillet reported that clavicular fixations, especially at the sternal joint, are frequently related to readily palpable fixated ligamentous and muscular tissues in the C7T1 area extending laterally from the spine. Immobility at either the medial or lateral joint of the clavicle can be easily determined by placing a thumb firmly on the joint and (1) moving the patient s shoulder back and forth in an A-P direction, and (2) then cupping the patient s ipsilateral elbow with a stabilizing hand and moving the humerus in a superior-inferior direction.


Sternoclavicular Subluxations

        Anterior Medial Clavicular Subluxations

The usual mechanism of force to produce an anteromedial subluxation is a posterolateral impact that drives the shoulder anteriorly and medially. If sternoclavicular subluxation does not occur in the young, a greenstick midshaft fracture often results.

Acute disability occurs with significant subluxation, and sometimes false joint motion can be palpated. Pain is acute and aggravated by joint motion, and there is acute point tenderness at the sternoclavicular joint. Secondary capsule injury may be expressed by intracapsular swelling, edema, and generalized tenderness. Crepitus suggests attending fracture fragments or articular comminution, thus making adjusting procedures contraindicated.

The examiner should also evaluate the integrity of the pectoralis major and subclavius. In older cases, a degree of fixation will inevitably be present. This is easily determined by placing two fingerpads on the sternoclavicular joint and widely circumducting the patient s abducted arm.

During correction of the subluxation, even mild dynamic thrusts should be reserved for nonacute fixated situations. When subluxation accompanies an acute sprain, correction should be more in line with gentle traction pressures after the musculature has been relaxed. Obviously, the probability of fracture fragments or osteoporosis must be eliminated prior to any form of manipulation.

Classic Adjustive Technic.   Have the patient placed supine on a low padded table. The doctor stands at the side opposite the subluxation, about perpendicular to the patient. He places his cephalad pisiform securely against the medial aspect of the clavicle and grasps the patient s arm of the affected side with his caudad hand. A short gentle thrust is made that s directed posteriorly and laterally while simultaneously applying traction on the patient s arm upward and medially.

Alternative Adjustment Procedure.   The patient is seated on a low stool. The doctor stands behind the patient toward the involved side. If the patient s left clavicle is involved, the left arm is abducted and the elbow is flexed. The doctor s left arm is hooked under the patient s axilla, and contact is applied with two or three fingerpads on the medial eminence of the clavicle. The patient s proximal arm rests on the doctor s forearm. Next, the doctor s right arm reaches around the right side of the patient s neck and he places two or three stabilizing fingers on the contact fingers. If possible, stabilization is applied to the back of the patient s dorsal spine by firm contact against the doctor s chest. The adjustment is made by applying posterosuperior leverage traction on the patient s shoulder joint by the doctor lifting his left elbow backward and upward while simultaneously applying posterior and lateral pressure with his contact and stabilizing fingers.

Postadjustment Management.   A common regimen is to treat as a severe sprain with initial cool packs for 2448 hours, aided by a pressure pad and stable strapping. Follow with physiotherapeutic measures such as hydrotherapy, but any form of electrotherapy near the heart is contraindicated. Mild progressive exercises of the young shoulder girdle may begin in 57 days. Normal activity can usually be resumed in 1014 days, but support should continue for about a month. During the last 2 weeks, the pressure pad is not necessary during inactive periods. Hurried recuperation will likely invite recurrence and extend convalescence.


        Posterior Medial Clavicular Subluxation

This is a most difficult subluxation to correct once it has become fixated. Fortunately, it is rare.

Adjustive Procedure.   The patient is placed supine with a small firm roll between the scapulae. The object is to try to gently "spring" the clavicle forward and laterally by applying bilateral posterior pressure against lateral structures. The doctor stands on the side of involvement facing the patient. His lateral hand firmly cups the patient s shoulder cap and lateral clavicle and the other hand takes contact on the patient s upper sternum as far from the involved joint as possible without contacting the contralateral sternoclavicular joint. Using the pillow as a fulcrum, several gentle posteriorly directed thrusts are made simultaneously with both hands while elbows are locked.


      Anterior Thoracic Strains

Thoracic muscle tears most often involve the pectorals, serratus, intercostals, and latissimus dorsi at rib junctures. Of all such strains, pectoralis injury can be the most disabling. It may be a part of a hyperabduction or infraclavicular syndrome.

        Pectoralis Strain

Pain and tenderness may be at either the humeral tendon attachment or origin at the lateral sternum and 1st to 5th ribs. Pectoralis major tears from overly enthusiastic effort are often visible and palpable in the area of the anterior axillary fold. A firm swelling may be palpable about 2 inches below the coracoid process and is associated with a deep regional ache.

Management Direction.   Thoracic strains and slight tears can be treated with rest and cool packs for 48 hours, followed by the usual nonelectric physiotherapeutic measures and support for strains. Disability subsides in several days and normal strength returns in another week if initial swelling is not severe. Graduated exercises should be conducted with careful monitoring.


        Determining Pectoralis Contracture

With the patient placed supine and the hands clasped behind the head, the elbows are allowed to slowly lower laterally toward the table. If the elbows do not approximate the tabletop, shortening (eg, from spasm, inflexibility, contracture) of the pectoralis group is likely. This maneuver is commonly referred to as the pectoralis flexibility test.

        Pectoralis Syndrome

This syndrome gives a clinical picture of posttraumatic strain of the pectoralis major and minor potentially leading to contracture. The injury is infrequently seen outside athletics (eg, shotput, javelin) or the vigorous physical drills common to military training (eg, pushups). Sometimes falling forward on the elbows will produce an isolated pectoralis minor strain.

Symptoms may mimic a longitudinal fracture of a rib. The pain is usually diffuse with point tenderness at either the tendon attachment at the humerus or along its insertion at the sternum and 1st to 5th rib. Pain, an ache, or paresthesia may radiate to the arm and fingers. Use of the pectoralis flexibility test is helpful. A palpable rupture should be referred for surgical repair.

Management.   Shoulder girdle and anterior and posterior rib fixations should be released. Associated spinal majors will likely be found at T2T4. After relaxing the tissues and adjusting the subluxated/fixated segments, deep high-velocity percussion spondylotherapy is applied over segments C7T6 for 34 minutes. Trigger points discovered should be treated, especially those found in the anterior chest, shoulder girdle, and latissimus dorsi muscles. Nutrients B1, C, RNA, calcium, and magnesium are recommended in the literature, as well as the need to counsel the patient to avoid appropriate antivitamin and antimineral factors.

Other helpful forms of treatment include cryotherapy and light massage with eucalyptus oil in the early stage, followed by tolerable tendon friction massage of involved muscles to patient tolerance. Helpful modalities during rehabilitation are moist heat, massage, and hot needle-spray showers. Any form of electrotherapy near the heart is contraindicated. Taping (Grade II) or at least an arm sling (Grade I) may be necessary in the early stage to rest the injured tissues and enhance healing. After the acute stage, the doctor should demonstrate slowly progressive therapeutic exercises to strengthen weakened muscles and/or stretch contractures. Temporary TENS is often helpful in situations of intractable pain.


      Thoracic Outlet Syndrome

Thoracic outlet syndrome is described in the literature under a variety of titles such as thoracic inlet syndrome, neurovascular compression syndrome, cervicobrachial syndrome, or scalenus anticus syndrome. The clinical picture presents signs of both neurologic and neurovascular compression. Pain and numbness usually follow the distribution of the ulnar nerve (C8) and worsen when the patient is recumbent. Shoulder droop, arm weakness, finger cramps and discoloration, tingling, cold hands, areas of hyperesthesia, tremor, atrophy of the hand muscles, and a palpable mass in the supraclavicular fossa are common. These symptoms are accentuated by active exercise.

The cause of thoracic outlet syndrome can usually be attributed to binding adhesions, a 1st rib subluxation, or lower cervical IVF narrowing producing indirect compression on nerve roots with secondary myositis and/or fascitis. The adjacent sympathetic chain is often involved. The disorder may be due to an acute subluxation complex or the effect of progressive spondylosis. In rare instances, the compression is caused by a deep abscess or a clavicle fracture callus. A cervical rib is rarely the cause unless the rib has recently suffered trauma. Carpal tunnel syndrome is a common misdiagnosis.

Precipitating factors include poor posture, occupational or reactional overstress, activity myositis, or intermittent trauma to the subclavian artery. Contributing factors include weak shoulder girdle muscles, spinal stenosis, and anatomical variants narrowing the upper thoracic cap such as a cervical rib. Always eliminate the possibility of a lung tumor.

        Management

A spinal major will likely be found at or near C7. After relaxing the tissues and adjusting the subluxated/fixated segments, apply deep low-velocity percussion spondylotherapy over upper thoracic segments for 12 minutes. Lubricate the patient s neck and strip the muscles, veins, and lymphatics from above downward according to patient tolerance. Treat trigger points discovered, especially those found in the scalene muscles. Supplemental nutrients B-complex, E, niacin, calcium, magnesium, and valarian root are recommended. Counsel the patient to avoid appropriate antivitamin and antimineral factors.

Other helpful forms of elected treatment include moist heat, shortwave diathermy, cervical traction, ultrasound for heat and massage at the cellular level, interferential therapy, pulsating alternating current, iontophoresis with calcium, local vibration-percussion, high-voltage therapy, tolerable tendon friction massage of involved muscles, and therapeutic exercise. A shoulder sling may be necessary in the early stage to relieve pressure on the depressed clavicle.


      The Costoclavicular Syndrome

This symptom complex is due to the neurovascular bundle being compressed between the 1st rib and the clavicle at the point where the brachial plexus joins the subclavian artery and courses over the 1st rib. Typical causes include carrying heavy objects on the shoulder, sagging atonic shoulder muscles, and clavicular anomalies. Symptoms are similar to those of the scalenus anticus syndrome and reproduced by the costoclavicular maneuver (see below). Classic features include a swelling above the clavicle, pain and paresthesia radiating into the arm and hand, a possible axillary hematoma, and upper extremity circulatory insufficiency. Because of symptoms reflected from circulatory impairment, carpal tunnel syndrome is a common misdiagnosis.

Costoclavicular Maneuver.   With the patient sitting, monitor the patient s radial pulse from the posterior on the side being examined. Extend the patient s shoulder and arm posteriorly, and then depress the shoulder on the side being examined. This maneuver narrows the costoclavicular space by approximating the clavicle to the 1st rib, tending to compress the neurovascular structures. When the shoulder is retracted, the clavicle moves backward on the sternoclavicular joint and rotates in a counterclockwise direction. An alteration of the radial pulse or a reduplication of other symptoms is a probable sign of compression of the neurovascular bundle (viz, the costoclavicular syndrome).


        Management

Priority attention should be given to clavicular subluxations, lower cervical and upper dorsal subluxations, and associated cervical and thoracic trigger points. During the acute stage, cold, compression, and elevation are helpful adjuncts. Later, electrical stimulation to and stretching exercises of the shoulder girdle, anti-inflammatory therapy, and supplemental nutrients C, B-complex, and manganese are reported to speed the healing process.

Release anterior and posterior fixations of the clavicle and 1st rib. Associated spinal majors will likely be found at C7T1. After relaxing the tissues and adjusting the subluxated/fixated segments, apply deep low-velocity percussion spondylotherapy over segments C7T4 for 12 minutes. Treat trigger points discovered, especially those found in the scalene, sternalis, subclavius, and sternocleidomastoideus muscles. Other helpful forms of treatment include cryotherapy during the acute stage, followed by moist heat or shortwave diathermy, ultrasound, interferential therapy, pulsating alternating current, or high-voltage therapy. Demonstrate therapeutic exercises to strengthen weak muscles and/or stretch contractures.


Sternal Injuries

Sternal injuries, rib fractures, "slipped" ribs, and vertebral body fractures are the most common effects of severe thoracic trauma seen in general practice. Any injury strong enough to fracture the sternum is likely to produce severe damage to underlying parts. The examiner should always seek signs of approaching cardiac tamponade and arrhythmia that demand priority attention. A flail sternum may require immediate ventilatory assistance and intubation. Developing tension pneumothorax is always a possibility. Sternum fractures are rare except in automobile injuries when the steering wheel is forced against the sternum. Similar injuries sometimes occur in industry. In rare instances, especially in somersaulting gymnastics, the manubrium may be ruptured from its attachments.

Accurate diagnosis can be labored. Closed sternal fractures or those of the costal cartilages are most difficult to view on roentgenography except with elaborate techniques. The tenderness from a sternal bone bruise even without major damage lingers for an abnormally long time, frequently mimicking fracture. Xiphisternal sprains are sometimes seen, which are persistently annoying and difficult to treat because of irritation from rectus activity.


      Costosternal Sprains and Separations

Rib cartilages may be ruptured at the costosternal junctions that are often impossible to view by roentgenography. Symptoms frequently mimic a gallbladder disorder or gastric ulcer. Management is the same as that for rib fracture. The pain is usually not as severe, but a subtle shoulder dislocation (often spontaneously reduced) may be associated. A rib belt often corrects pain in a few days, but healing may take several weeks because of the relative avascularity of cartilage. If conservative strapping and sprain therapy do not afford progressive relief, surgery may be required to excise a cartilage fragment.


Sternal Fixations

        The Manubrium-Sternum Joint

The hinge joint between the manubrium and the body of the sternum is normally active in forced breathing and extreme A-P movements. Fixation at this joint restricts these slight but helpful motions. Such fixations are frequently mobilized spontaneously during an upper dorsal adjustment directed anterosuperiorly of a prone patient.

        Anterior Rib Pit Fixations

Anterior rib fixations resulting in decreased chest excursion can be determined by motion palpation of the thoracic cage during deep inhalation with the patient either standing or supine. The skin of the lateral thorax near the midline is tractioned with broad bilateral palmar contacts, with the examiner s thumbs placed near the sternum on the rib being examined. As the patient inhales deeply, both thumbs should move equally. Thumb motion restricted unilaterally suggests the side of fixation.

These fixations feature a vague pain over the parasternal area at the costosternal junction. Some anterior intercostal neuralgia may be involved. One or more of the upper three ribs are most frequently involved.

Management.   Associated spinal majors will likely be found in the T1T4 region. After relaxing the tissues and adjusting the subluxated/fixated segments, apply deep high-velocity percussion spondylotherapy over involved segments for 34 minutes. Treat trigger points discovered, especially those found in the posterior serratus, latissimus dorsi, and mid trapezius muscles. Any form of electrotherapy near the heart is contraindicated.

Posterior Effects.   Articular fixations at the costosternal articulations can produce hypermobility in the related thoracic vertebrae. This is usually manifested as an increased spread of the spinous processes on full flexion. However, if a costosternal area is in a state of fixation and the corresponding anterior longitudinal ligament is in a state of shortening, the local area will be forced into an exaggerated state of kyphosis even in the erect position.


Rib Contusions.   Impacts on the free ends of floating ribs painfully involve related muscles. Disability is severe and often beyond the control of conservative measures. Both movement and breathing aggravate and prolong disability, even during bed rest. Concomitant kidney damage must be ruled out. Strenuous or body contact activity should not be resumed until gradual exercises include vigorous running and twisting motions without discomfort.


Rib Sprains and Strains

There are three age groups prone to rib strains and sprains: (1) the young adult involved in contact sports with inadequate protection, (2) the elderly with a degree of osteoporosis, and (3) any age group involved in an accident where excessive force is applied to the thoracic cage. Rib strains and sprains rarely occur independently.

Elderly people often enter a complaint of rib sprain that on close examination will reveal a fracture. The precipitating trauma may be no more than a misstep or receiving a hug.

It was stated previously that rib cartilages may so rupture at the costosternal junctions that are often impossible to view on radiographs. Symptoms frequently mimic a gallbladder disorder or gastric ulcer. Management is the same as that for rib fracture, but the pain is usually not as severe. A subtle spontaneously reduced shoulder dislocation may be associated.

        Management

Associated secondary spinal majors will likely be found at T5T8. After relaxing the tissues and adjusting the subluxated/fixated segments, apply deep high-velocity percussion spondylotherapy over segments T4T9 for 35 minutes. Treat trigger points discovered, especially those found in the posterior serratus, latissimus dorsi, and mid trapezius muscles. Supplemental nutrients B1, B6, and pantothenic acid are recommended, as well as counseling the patient to avoid appropriate antivitamin factors.

A rib belt often corrects pain in a few days, but healing may take several weeks because of respiratory motion and the relative avascularity of cartilage. Although a lightly applied elastic bandage is helpful, immobilization is contraindicated because it restricts inhalation. Beneficial forms of adjunctive treatment include early cryotherapy, followed by ultrasound if not contraindicated. Some clinicians use iontophoresis with xylocaine, but remember that any form of electrotherapy near the heart is contraindicated. If conservative strapping and sprain therapy do not afford relief, referral for surgery may be required.


      Xiphisternal Sprain

During youth, xiphisternal sprains are sometimes seen. They are persistently annoying and difficult to treat because of irritation from rectus activity. This joint usually ossifies during early adulthood.

      Intercostal Fixations

If the intercostal muscles are in a state of hypertonicity, the ribs will abnormally appose and the thoracic cage will exhibit an area of lateral flattening that restricts mobility on contralateral bending. The patient will assume a somewhat "hunched" posture in the neutral position, depending upon the extent of fixation.

Intercostal fixations are best determined laterally near the rib angles. Palpation should reveal opening posteriorly during flexion, anteriorly during extension, on the convex side during lateral bending, and on the side opposite to the direction of vertebral body rotation.


      Diaphragmatic Spasm (Stitches)

Acute unilateral crippling but temporary pain on inspiration in the area of the lower ribs and upper abdominal quadrants is called stitches by athletes who experience them when winded. The spasm usually occurs on the right. Disability during sports (especially long runs) arises because air hunger is combined with a painful diaphragmatic spasm. Fortunately, the attack usually subsides spontaneously with 35 minutes of rest. Running downhill or with a full stomach seems to encourage an attack. Relief is quickly achieved by placing the patient supine with knees flexed and arms raised. This athletic form of stitches holds little clinical concern unless it is superimposed on a chronic abdominal or pelvic disease. Underlying chronic peritonitis (viz, seeping appendicitis), for example, will quickly establish diaphragmatic spasms during jogging, horseback riding, or any activity that "bounces" (irritates) the lesion.

        Diagnosis

Diagnosis is usually by elimination. Once thoracoabdominal pathology has been ruled out, a common protocol is to motion palpate the spine, and relate findings with the patient s complaints. Check pertinent superficial reflexes, and grade the reaction. Check abdominal muscle strength against resistance, and grade resistance strength.

        Management

Associated spinal majors will likely be found at C3-C5, T6-T11. Also release anterior and posterior rib fixations. After relaxing the tissues and adjusting the subluxated/fixated segments, apply deep high-velocity percussion spondylotherapy over segments T5-T12 for 3-4 minutes. Treat trigger points discovered, especially those found in the rectus abdominis, serratus anterior, iliopsoas, and thoracic iliocostalis muscles. Other helpful forms of treatment include prudent abdominal shortwave diathermy and tendon friction massage of involved abdominal or thoracic muscles. Stretch any adhesions that may be found in the upper abdomen or under the lower ribs. Supplemental nutrients C, niacin, pantothenic acid, and calcium are recommended, and the patient should be advised to avoid appropriate antivitamin and antimineral factors.



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