Definition of Rib pain
Costochondritis, also known as anterior chest wall pain, costosternal syndrome or parasternal chondrodynia is a benign and often temporary inflammation of the rib cartilage that connects each rib to the breastbone (sternum).
The rib cartilage functions as an elastic bridge between the rib (costa) and the sternum forming 2 joints: the costochondral joint (CCJ) and the sternochondral joint (SCJ). The CCJ’s and SCJ’s most frequently affected by inflammation are located in Rib 3, 4, 5 and 6.
Mild to severe pain and /or tenderness over the anterior chest (CCJ and SCJ). The pain may radiate to the back, shoulders, stomach or arms. Decreased mobility and pain are noted in the chest wall, frequently in multiple ribs.
Pain is aggravated with coughing, lifting, straining, sneezing and deep breathing. Pain can be constant or intermittent and can last for several days to multiple months/years (!).
When rib pain is accompanied with swelling it is referred to as Tietze’s syndrome. This syndrome is seen less frequently.
Who is affected?
Costochondritis is a common cause of chest pain in children and adults. It affects women more than men (70% vs. 30%) and occurs more frequently in individuals aged 40 or older.(Mayo Clinic, WebMD)
In one study of 100 patients with negative cardiac angiography, 69 had chest wall tenderness and in 16 of these cases, pressure on the costochondral area completely reproduced the pain.(Wise CM, Semble EL, Dalton CB.: muskuloskeletal chest wall syndromes in patients with noncardiac chest paiin; a study of 100 patients, Arch. Phys. Med. Rehabil. 1992 Feb; 73(2):147-9.)
In another (emergency department) study, 30% of individuals with chest pain had costochondritis.(Disla E., et al. Costochondritis: a prospective analysis in an emergency department setting. Arch. Int. Med. 1994; 154 (21): 2466-9)
Idiopathic costochondritis accounts for 10% to 30% of all chest pain in children and adolescents.(Jagvir Singh MD, of the Division of Pediatric Emergency medicine, Lutheran General Hospital of Park Ridge, Illinois)
Medscape reports 650,000 cases/year in patients between 10-21 years old.
Causes of costochondritis:
The cause of costochondritis is not well understood and frequently unknown.
Costochondritis can have a gradual onset for no apparent reason. While costochondritis is often self-limiting, it can be a recurring condition that can appear to have little or no reason of onset. Wikipedia writes: ‘in most cases of costochondritis, there is no definite cause’.
Some possible causes that can be identified are:
1. Injury (MVA, sports injury, impact injury
2. Physical strain (heavy lifting, strenuous exercise/job)
3. Lung disease (pleurisy), Sneezing, Coughing ( severe and persistent bouts)
4.. Degenerative processes (osteoarthritis, rheumatoid arthritis, ankylosing spondylitis/Scheuermann’s disease)
5. Infection of the joint by viruses, bacteria or fungi (i.e. Tuberculosis, Staphylococcus aureus (staph), Streptococci, Haemophilus influenza, Salmonella etc.)
7. Large breasts: persistent chronic loading of the anterior rib cartilages by the (significant) weight of the breasts. Underwire bras can also aggravate the lower rib cartilages.
8. Poor sitting posture
10.Vitamin D deficiency (R.C. Oh MD and J.D. Johnson, Tripler Army Medical Center, 2012)
Typically, costochondritis patients are instructed to refrain from physical activity to prevent the onset of an attack.
Treatment options currently used are limited and usually involve a combination of rest, ice and analgesics (Vicodin, Oxycodone, and Percocet) or anti-inflammatory medications (Advil, Motrin, Aleve). Anti-depressants (Amitriptyline) and anti-seizure medication (Neurontin) may be prescribed to control chronic pain.
In some cases of severe pain, cortisone injections or surgery have been utilized- with mixed results.
Stretching exercises have shown to be beneficial.
(Rovetta G, Sessarego P, Monteforte P. G Ital Med Lav Ergon. Stretching exercises for costochondritis pain.2009 Apr-Jun; 31(2):169-71. Cattedra di Reumatologia, DISEM, Università di Genova, Italy.)
The long road to a diagnosis and cure for costochondritis patients
The road to a diagnosis can be a prolonged and scary process for some patients: costochondritis symptoms can be similar to the chest pain associated with a heart attack*, lung disease, gastrointestinal problems (GERD) and osteoarthritis.
Many patients who eventually receive the diagnosis of costochondritis have had a consult with a cardiologist and/or pulmonologist and have heard: “There is nothing wrong with you”.
Some patients have to go through multiple doctor’s visits and diagnostic tests before the diagnosis is made. At that point in time they may hear that “It will go away by itself” or “It is going to take time”.
For many patient suffering long term with costochondritis who have tried medication and waiting (with limited or no results), the road to recovery has been narrow, long and never ending…..
But now there is NEW treatment available!
Recently there has been a medical breakthrough in the treatment of costochondritis.
Introducing: the Breathing Assisted Recoil Technique (BART)
by Peter Askes PT, Cert. MDT
After 29 years of orthopedic physical therapy practice in Europe (the Netherlands) and the United States, Mr. Askes has designed a multi-phase treatment technique that has shown excellent clinical results with costochondritis patients. BART is intended for all patients for whom prior forms of treatment for costochondritis have not been effective.
At First Choice Physical Therapy, we are very excited to announce the introduction of this new treatment option!
The Breathing Assisted Recoil Technique (BART) is a manual therapeutic technique consisting of 3 phases:
Phase 1: A small amount of manual traction by the therapist (using the crossed wrist stretching technique) is applied to the involved rib joint and its supporting ligaments.
Phase 2: The therapist tunes in to the rib-joint and follows the 3-dimensional movement pattern that may have been induced by the small amount of initial traction. The movement is followed by the therapist to its conclusion.
Phase 3: While the patient inhales forcefully through the mouth (initiated by verbal instruction from the therapist), the manual pressure on the rib joint is suddenly released, resulting in a recoil produced by the sudden expansion of the lung.
This produces an autogenic mobilization of the rib joint.
The clinical importance of the BART is precisely this autogenic recoil component that produces a safe and non-invasive approach to costo-chondral and sterno-chondral mobilization.
No external mobilization force is used. The patient’s body is set up to correct the rib joint restrictions through internal lung tissue recoil.
The rib joints are mobilized by internal forces thereby eliminating the risks associated with external mobilization forces produced by a treating clinician.
The gentle nature of BART makes it an excellent clinical choice for the treatment of costochondritis.
How does it work?
The recoil described above provides a means of treating a rib restriction by using the elastic tissue properties of the lungs (recoil is the ability of a stretched organ to return to its resting position).
The effect of the resulting recoil occurs through a nerve reflex: the stretching and sudden release of the rib structures involved (CCJ and SCJ) results in immediate relaxation of the surrounding muscular, ligamentous and membranous tissues.
The stimulation of proprioceptors* in these tissues increases the body’s awareness of the location of the involved (painful) area and directs the body to focus its response towards the area of restriction.
Recoil, by producing relaxation, increases our therapeutic ability to reach and mobilize rib tissues and to restore full pain-free mobility in the affected rib-joints.
(*) Proprioceptors are sensory nerve endings in muscles, tendons, and joints that provide a sense of the body's position in space by responding to stimuli from within the body. Proprioception means "sense of self".
If you suffer from costochondritis, pick up the telephone and call us at 732-698-2800.
BART is only a phone call away!