Rib subluxations, the costoclavicular syndrome, sternoclavicular
injury, trigger point formation, and pectoralis contractures are
the common musculoskeletal disorders associated with the anterior
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
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
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
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
Bone and cartilages
Osteitis fibrosa cystica
Tietze s syndrome
Hodgkin s disease
Pott s disease
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
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
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.
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
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
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
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.
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 (5th–9th) 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.
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
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
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.
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.
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.
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
The most important structures having significant biomechanical
influences are the sternum, ribs, vertebrae, IVDs, and costal
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
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
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.
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 T2–T6
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 T2–T10. The effect is most
noticeable in the upper ribs.
The T1–T7 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
The T8–T10 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
The T11–T12 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 L1–L2
transverse processes by the lumbocostal ligament coursing just
anterior to the quadratus lumborum.
The Costochondral and Sternocostal Joints
The 1st–7th 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 8th–11th 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
Disinfection of open skin (eg, scratches, abrasions, etc)
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:
Indirect therapy (reflex therapy)
Pulsed alternating current
Spondylotherapy (upper and middle thoracic)
Restricting strap or bandage
Indicated diet modification and nutritional
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
Indirect articular therapy (reflex therapy)
Alternating superficial heat and cold
Protect lesion (padding)
Cool pool cryokinetics (active exercise)
Light nonpercussion vibrotherapy
Spondylotherapy (upper and middle thoracic)
Restricting strap or bandage
Indicated diet modification and nutritional
3. Stage of Consolidation and/or Formation of Fibrinous
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
Moderate active range-of-motion exercises
Spondylotherapy (upper and middle thoracic)
Mild transverse friction massage
Mild proprioceptive neuromuscular facilitation techniques
Restricting strap or bandage
Indicated diet modification and nutritional
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
Articular adjustment technics
Spondylotherapy (upper and middle thoracic)
Local vigorous vibromassage
Transverse friction massage
Active range-of-motion exercises without weight bearing
Proprioceptive neuromuscular facilitation techniques
Restricting strap or bandage at night only
Indicated diet modification and nutritional
5. Stage of Reconditioning
Direct articular therapy for chronic fixations
Progressive remedial exercise
Isometric static resistance
Isotonics with static resistance
Isotonics with varied resistance
Indicated diet modification and nutritional supplementation.
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
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.
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.
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
Scaleni trigger point
Sternalis trigger point
Sternocleidomastoid trigger pt
Pectoralis major trigger point
Subclavius trigger point
Pectoralis minor trigger point
Thoracic subluxation, especially
Rib fracture (green-stick)
Unilateral swelling and non-
Bilateral swelling and milky
Bilateral swelling without
Chronic 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
In mastitis or mastodynia derived from a spinal subluxation
complex, the associated spinal major will likely be found in the
T2–T5 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 3–4 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.
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 mild–moderate 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.
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
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,
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 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
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
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.
Associated spinal majors will likely be found in the C7–T1
area. After relaxing the tissues and adjusting the
subluxated/fixated segments, apply deep low-velocity percussion
spondylotherapy over segments C7–T4 for 1–2 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
2–3 weeks. Isometric exercises are helpful in strengthening
local muscles to support weakened ligaments. Rehabilitative
exercises of the shoulder should give particular attention to the
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.
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 C7–T1 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.
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
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
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
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 24–48 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
5–7 days. Normal activity can usually be resumed in 10–14 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
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
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
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
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.
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
Management. Shoulder girdle and anterior and posterior
rib fixations should be released. Associated spinal majors will
likely be found at T2–T4. After relaxing the tissues and
adjusting the subluxated/fixated segments, deep high-velocity
percussion spondylotherapy is applied over segments C7–T6 for
3–4 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
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.
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 1–2 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
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
Release anterior and posterior fixations of the clavicle and
1st rib. Associated spinal majors will likely be found at C7–T1.
After relaxing the tissues and adjusting the subluxated/fixated
segments, apply deep low-velocity percussion spondylotherapy over
segments C7–T4 for 1–2 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, 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
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
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
Management. Associated spinal majors will likely be
found in the T1–T4 region. After relaxing the tissues and
adjusting the subluxated/fixated segments, apply deep
high-velocity percussion spondylotherapy over involved segments
for 3–4 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
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
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
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
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.
Associated secondary spinal majors will likely be found at
T5–T8. After relaxing the tissues and adjusting the
subluxated/fixated segments, apply deep high-velocity percussion
spondylotherapy over segments T4–T9 for 3–5 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
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.
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 3–5 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
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.
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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