I Had Parathyroidectormy and 10 Months Later I Am Having Shoulder Pain and Sternum Pain Again
Cureus. 2021 Apr; 13(4): e14369.
Singular Costochondritis: Complete Resolution of Symptoms After Rib Manipulation and Soft Tissue Mobilization
Monitoring Editor: Alexander Muacevic and John R Adler
Javier Barranco-Trabi
i Department of Internal Medicine, Tripler Regular army Medical Middle, Honolulu, United states of america
Victoria Mank
1 Department of Internal Medicine, Tripler Ground forces Medical Center, Honolulu, The states
Jefferson Roberts
2 Section of Rheumatology, Tripler Army Medical Center, Honolulu, USA
David P Newman
3 Pain Management-Physiotherapy, Tripler Army Medical Center, Honolulu, USA
Abstract
Costochondritis is a self-limiting, poorly described, and benign condition that ordinarily manifests as non-cardiac chest pain. The symptoms commonly tend to resolve in a couple of weeks. Serious causes of chest hurting should exist ruled out prior to diagnosing costochondritis, every bit it is frequently a diagnosis of exclusion. Costochondritis that does non self-resolve is referred to as atypical costochondritis and is associated with loftier medical expenses and psychological burden on the patient.
In this study, we discuss the case of a 37-year-old salubrious male person patient who presented with a two-year history of intermittent pain forth the right anterolateral rib cage without whatever history of trauma. After all-encompassing diagnostic piece of work-upwards by Cardiology and Gastroenterology, Physical Medicine and Rehabilitation (PM&R) got involved. The initial diagnosis of chest pain evolved into singular costochondritis given the fourth dimension course, physical examination findings of focal tenderness, along with normal laboratory values, electrocardiogram, and imaging studies. A multimodal approach was adopted for the treatment of this patient, including manipulative therapy to determine if regional interdependence was present, followed by instrument-assisted soft tissue mobilization (IASTM) and stretching to address the potential myofascial hurting generators. Afterwards three appointments, there was complete resolution of morn pain and at that place was no hurting upon test.
This instance highlights how osteopathic manipulation techniques (OMT) can be useful in the handling of rib dysfunction, peculiarly in atypical costochondritis. Farther studies are required to aggrandize our cognition of costochondritis and physical therapy (PT) techniques, which would allow for early identification and constructive treatment of the condition.
Keywords: costochondritis, inflammation, costosternal syndrome, parasternal chondrodynia, inductive chest wall syndrome, tietze syndrome, concrete therapy, rib manipulation, soft tissue mobilization
Introduction
Costochondritis is a benign etiology of chest pain that is caused by inflammation of the costochondral joints. The chest wall pain, in most cases, is described as a dull, aching, sharp, or stabbing hurting that varies in intensity. The pain is exacerbated by deep inspiration, upper extremity movements, and exercise [1]. Costochondritis is most likely associated with a history of contempo strenuous activity or contempo upper respiratory illness [2]. Inflammation can final from several weeks to several months [3], limiting the patient'south ability to work and perform activities of daily life. Costochondritis is also known as anterior chest wall syndrome, parasternal chondrodynia, and costosternal syndrome [4].
The differential diagnosis for non-cardiac chest pain is broad, and costochondritis should be differentiated from other causes of pain such as arthritis of sternoclavicular joint, fibromyalgia, herpes zoster of the thorax, painful xiphoid syndrome, slipping rib syndrome, Tietze syndrome, traumatic muscle pain, and overuse myalgia [three]. The diagnosis is made based on the exclusion of other causes of chest pain and the power to reproduce the pain by palpation to the area [5].
The incidence and prevalence of costochondritis are not well established in the literature; however, costochondritis is a mutual diagnosis among patients with chest pain in the principal care clinician's office and emergency department, most frequently described in Hispanic populations and females. Fifty-fifty though costochondritis is a frequent diagnosis related to breast pain, the etiology, treatment, and evolution of the disease are often poorly documented [one].
Treatment of costochondritis can involve pharmacological therapy, physical therapy (PT), or a combination of both. The drug of selection for costochondritis is nonsteroidal anti-inflammatory drugs (NSAID). The NSAID of choice is patient-specific and based on the provider'south preference. It is important to hash out the agin effects of NSAID use with the patient, such as the risk of gastritis. Astringent or refractory costochondritis tin be treated with PT. However, despite being a common diagnosis, the patients are not routinely referred to undergo PT [6].
The purpose of this case study was to describe the application of a sequenced musculoskeletal treatment arroyo in a patient with atypical costochondritis. Secondly, we besides propose diagnostic and treatment recommendations that may serve to decrease the use of potentially unnecessary, costly, and invasive procedures while expediting access to effective care.
Case presentation
A 37-year-sometime male patient presented with a two-year history of intermittent hurting along the right anterolateral rib cage. The patient did not endorse a history of trauma. He had been waking up every forenoon with pain that lasted approximately xv minutes. The pain was described as sharp and called-for in nature and worsened with palpation along the costochondral cartilage between the 8th through 10th ribs and sternum. The pain resolved over time only returned while running or performing cardiovascular exercises. The patient reported that his pain ranged from 4/ten to 6/10 on the visual analog scale when present. While these morning symptoms did non affect his ability to perform activities of daily living or work, he was frustrated by the chronicity of symptoms and the lack of response to conservative measures.
Symptom onset was insidious in nature. The hurting was initially noted on the right side of the chest wall, just there was a history of left-sided chest wall pain for several months that had afterwards resolved. He underwent a diagnostic workup past Cardiology, Gastroenterology, and Physical Medicine and Rehabilitation (PM&R). The initial diagnosis of breast pain evolved into costochondritis as reported by the gastroenterologist given the focal tenderness, absence of gastrointestinal alarm symptoms, normal laboratory test values, normal breast radiographs, and a lack of history of post-herpetic rash.
After two years of recalcitrant correct-sided costochondritis, the patient was referred to the Interdisciplinary Pain Management Clinic (IPMC) for a trial intercostal nerve cake. Pre-procedural pain was a 7/10 with palpation. The procedure involved injecting 4 ml of 0.5% ropivacaine and viii mg of dexamethasone at the right T8-ix intercostal space. Mail-procedure pain was reported to be 0/10, lasting for approximately ane calendar week. Upon reassessment three weeks later, the patient reported hurting forth the thoracic spine at the T8-9 level along with his baseline anterior costochondral hurting. The patient was and then referred to the IPMC physical therapist to investigate a potential rib component of his pain equally demonstrated in a previous case study [7]. The patient'due south primary goal was diagnostic clarity. His secondary goal was the resolution of his hurting.
Concrete therapy exam/evaluation
Physical evaluation revealed that the patient's pain was localized to an area of the costochondral cartilage from the sternum to the 10th rib tip on the right side with deep palpation. The cervical spine was cleared subsequently the patient demonstrated a full range of motion (ROM), a negative Spurling's exam, normal dermatomal sensation, and absence of myotomal weakness. Thoracic ROM was assessed in a standing position. The patient demonstrated full primal plane move; still, combined thoracic extension and rotation to the right side reproduced his anterior breast hurting.
Motion palpation testing
Passive accessory intervertebral motion testing was performed in decumbent to the T1 through T12 spinous processes. Commonly utilized by concrete therapists, this technique is considered to be useful in assessing segmental spinal hypomobility [8]. The restricted move was assessed at T9 and T10 without hurting reproduction. While in prone, provocation testing involving springing on the right 10th rib angle in an anterior direction did reproduce his pain (Figure 1). Rib mobility during inspiration was assessed in supine (Figure 2). The examiner placed fingers along the rib angles bilaterally and had the patient inhale deeply. The motion of the right ninth and 10th ribs was disproportionate compared to the left side.
Effigy 1
Rib jump maneuver applied to the 10th rib
In prone, the examiner places the hypothenar area of the hand over the 10th rib angle. Force is applied in an inductive direction and and so released. The exam is positive if the pain is reproduced when the forcefulness is released.
(Photograph: Newman DP. Rib Spring Maneuver Applied to the tenth Rib. Reproduced with permission from the author, 2021)
Effigy ii
Assessment of rib excursion during inhalation
In the supine position, the examiner places the pollex and index finger effectually the 10th ribs. The patient is instructed to inhale, and the examiner assesses for disproportionate motion
(Photograph: Newman DP. Rib Jump Maneuver Practical to the 10th Rib. Reproduced with permission from the writer, 2021)
Diagnosis/prognosis
The differential diagnosis specific to this patient's symptoms upon initial evaluation to the IPMC included costochondritis, Tietze syndrome, intercostal neuralgia, slipping rib syndrome, rib dysfunction, myofascial pain syndrome, abdominal cutaneous nerve entrapment syndrome, fibromyalgia, and muscle strain. Tietze syndrome was ruled out based on the absenteeism of swelling, erythema, and heat [9]. Given the immediate but short-term response to the intercostal trigger point injection, intercostal neuralgia and myofascial hurting were loftier on the differential listing. The patient'due south signs and symptoms were consistent with the pathoanatomical diagnosis of costochondritis every bit the pain was reproduced by palpation over the costochondral cartilage; all the same, the presentation appeared atypical based on the consistent morning pain lasting xv minutes, symptoms persisting for more than than a yr, and the location of structures involved [three]. Classically, the second through 5th costochondral junctions are involved in patients diagnosed with costochondritis [x,11]. As the hurting was provoked with transmission motility of the rib and thoracic spinal segment, it was positioned in a way that the faulty biomechanics of the rib and/or spine may increase load upon the cartilage, resulting in chronic hurting.
The prognosis for complete pain resolution was poor to moderate based on the chronicity of symptoms and poor response to previous conservative measures. The prognosis would be adjusted based on the treatment response in each session.
Intervention
The proposed program of intendance involved a sequenced approach of manipulative therapy to determine if regional interdependence was nowadays, followed past instrument-assisted soft tissue mobilization (IASTM) to address the potential myofascial hurting generators (Table 1). Regional interdependence is defined every bit unrelated functional impairments remote to the pain area or diagnosis that contributes to the trouble [12]. Several example studies and a instance serial take described like multi-modal treatment protocols that have been successful in treating costochondritis [6,7,12-fifteen]. After each subsequent assessment, other therapeutic modalities would be included to both identify and treat contributory musculoskeletal faults.
Table 1
Overview of interventions practical and patient response per visit
ROM: range of move; OMT: osteopathic manipulation technique; IPMC: Interdisciplinary Hurting Management Clinic
| Visit | Patient hurting presentation | Objective findings | Intervention | Patient response |
| ane | Pain localized to the area of the right side of the rib muzzle from the sternum to the 10th rib tip; pain reported every morning upon waking and lasting 15 minutes (4-6/10 hurting level) | Pain reproduced with deep palpation; combined thoracic extension and rotation to the right reproduces the pain; pain provocation with the springing of the right 10th rib angle; asymmetric motion of the ninth and 10th rib with inhalation | 9th and 10th rib OMT; directional cupping forth the costochondral cartilage from the tenth rib tip to the sternum/four 10-second periods | No pain reproduced with thoracic ROM later on OMT; soreness later on cupping (4/10 hurting level); 50-75% reduction in AM hurting the next morning |
| 2 | A 2/ten pain level along the costochondral cartilage | Mild pain reproduction with deep palpation; pain reproduced with combined thoracic extension and rotation to the right; negative rib provocation testing; symmetrical ninth and 10th rib motion with inhalation | Directional cupping performed forth the ninth and 10th rib angle from the axillary line to the rib tip/four 10-second periods; instructed on latissimus dorsi and pectoralis major/pocket-sized stretching | No pain reproduced with thoracic ROM later OMT; soreness subsequently cupping |
| 3 | Resolution of the morning pain; no pain upon examination | No pain with ROM; no pain with provocation testing; no pain with deep palpation | Discharge from IPMC |
The patient was treated upon the initial evaluation with osteopathic manipulation techniques (OMT). OMT techniques have been shown to be effective in the treatment of rib dysfunction [14]. A posterior rotation force was applied to the right ninth and 10th rib separately with audible cavitation (Figures three, iv). Upon reassessment of active thoracic ROM, the patient's pain was not reproduced with combined thoracic extension and rotation to the right side.
Figure 3
Rib manipulation technique - image 1
With the patient lying on their side, the tenth rib is identified, and the provider places the first metacarpal phalangeal joint of the palpating manus over the rib at the costotransverse joint and slides inferiorly to induce posterior rotation to the rib. The provider then moves the patient into a supine position. While the patient exhales, the provider imparts a high-velocity, depression-aamplitude forcefulness through the patient'due south arms towards the examiner'southward hand, which remains on their back
(Photograph: Newman DP. Rib Manipulation Technique. Reproduced with permission from the author, 2021)
Figure 4
Rib manipulation technique - image 2
With the patient lying on their side, the tenth rib is identified, and the provider places the first metacarpal phalangeal articulation of the palpating hand over the rib at the costotransverse joint and slides inferiorly to induce posterior rotation to the rib. The provider then moves the patient into a supine position. While the patient exhales, the provider imparts a loftier-velocity, low-amplitude force through the patient's arms towards the examiner's hand, which remains on their dorsum
(Photograph: Newman DP. Rib Manipulation Technique. Reproduced with permission from the writer, 2021)
Tenderness to deep palpation was still nowadays; therefore, a trial of tissue mobilization over the area of the costochondral cartilage from the 9th and 10th rib tips to the sternum was performed. Described by Newman and colleagues (2020), this technique involved lubricating the skin with balm and placing a 4-cm vacuum suction cup over the distal sternum. The loving cup is manually moved laterally to the lower rib tips and and so dorsum towards the sternum for a menstruation of 10 seconds. Afterward a short catamenia of remainder, cupping is continued for another three 10-2d periods. The patient reported soreness after the handling, rated at iv/10 with deep palpation. He was instructed to assess response to handling the adjacent morning and and so follow upwardly with the clinic.
Figure 5
Directional cupping technique
(A) Placement of the cup at the costochondral cartilage. (B) Motility forth the cartilage to the 9th and 10th rib tips. After lubricating the pare with balm, the iv-cm vacuum suction cup (KangZhu, People's republic of china) was applied. The vacuum suction cup was manually moved dorsum and forth across the skin with the goal of mobilizing soft tissues along the class of the costochondral cartilage from the sternum to the rib tips. This was repeated several times, taking breaks when the discomfort was besides intense
(Photograph: Newman DP. Directional Cupping Technique. Reproduced with permission from the author, 2021)
Upon reassessment the next day, the patient reported a 50-75% reduction in forenoon symptoms. There was still tenderness and balmy bruising forth the surface area of cupping. The pain level was reported every bit two/10. A concrete examination was performed. Upon thoracic ROM, combined extension and rotation to the right reproduced the patient's pain. While there was restricted segmental mobility at T9/x with motion testing, there was no reproduction of hurting. Rib springing upon the ninth and 10th ribs did non reproduce pain. Rib movement during inspiration did non demonstrate whatsoever asymmetric move compared to the left side. There was balmy pain with deep palpation from the 10th rib tip to the sternum. Considering provocation testing did not reproduce pain, OMT to the T9/10 segment was deferred. Instead, management cupping was again applied to both address potential myofascial tightness and rule out regional interdependence [11]. The expanse of cupping was extended to incorporate the area from the sternum to the axillary line, in line with the ninth and 10th ribs on the correct side.
The patient was instructed to perform latissimus dorsi and pectoralis major/minor stretching to maintain tissue mobility that improved following IASTM. In an eight-patient case series describing an impairment-based handling program for costochondritis, latissimus dorsi and pectoral muscle tightness were observed in l% and 100% of the patients, respectively [vi]. Stretching has been shown to be efficacious in pain mitigation in patients with costochondritis compared to a command group [16]. On his third visit two weeks afterwards, the patient reported resolution of the pain. While he did not perform the stretching exercises consistently, no hurting was reported in the morning time, with deep palpation, or with jogging. Thoracic ROM, spinal joint mobility, the springing of the ribs, and deep palpation did not reproduce pain. Symmetrical rib excursion was appreciated with palpation upon inspiration. Functional testing was performed by having the patient perform sit down-ups. No pain was reproduced. The patient had met his care goals and was subsequently discharged from the IPMC.
Word
Costochondritis is a cocky-limiting disease process that does not usually require any interventions; however, it tin have up to one year for the condition to resolve [1]. The presentation of consistent chest pain every morning that abates after 15 minutes is atypical for costochondritis. Morning pain and stiffness are more than likely associated with allowed-mediated or rheumatological disorders of the musculoskeletal organization, soft tissue injuries, autoimmune diseases, vasculitis, or inherited connective tissue disorders. The patient's prognosis is based on the chronicity of symptoms. The fourth dimension duration and resolution of symptoms are inversely related; therefore, the greater the duration of symptoms, the lower the likelihood of their resolution.
Atypical costochondritis is a diagnosis of exclusion. Life-threatening atmospheric condition such as acute coronary syndrome, acute aortic dissection, pulmonary embolism, tension pneumothorax, pericardial tamponade, and mediastinitis (eastward.g., esophageal rupture) need to be ruled out outset before considering benign causes of chest pain [17]. There are expensive healthcare-associated procedures when evaluating for potentially life-threatening weather, which include laboratory testing, radiographic imaging, and in some cases, referral to multiple specialists [18]. At that place are likewise psychological stressors that are inflicted on the patient due to the thought of having chest hurting that could be a sign of a serious underlying condition.
This instance report demonstrates the benefits of applying a sequenced musculoskeletal cess and treatment approach on a patient with singular costochondritis. The patient reported complete resolution of pain afterwards iii visits of handling including OMT, directional cupping over the costochondral cartilage, and stretching after a 2-year period of symptoms. Due to the complete resolution of symptoms in a short treatment form, this sequenced musculoskeletal approach may be an effective treatment option for patients suffering from atypical costochondritis.
The pathophysiology of costochondritis is poorly understood. Therefore, we are unable to determine the verbal pathobiochemical reasons as to why OMT, directional cupping, and stretching help in the resolution of symptoms. Rabey (2008) postulates that the highly innervated costovertebral joints and surrounding structures or nociceptive afferent input to the ventral ramus from posterior spinal joints may account for a positive response to manipulative therapy [19]. These therapeutic approaches may reduce negative loading upon the joints or stimulate a beneficial neurogenic response, thereby reducing pain. Similarly, injured myofascial structures (i.e., pectoralis minor, intercostal muscles) local to the costochondral cartilage may be perceived as the pain generator when a load is applied [five]. Myofascial adhesion may be released and musculus tightness may be mitigated through directional cupping and stretching, respectively.
Though there are substantial benefits in PT techniques for pain management in costochondritis, in that location is ordinarily a lag in time betwixt the diagnosis and referral. The delay in referral to PT is unclear [2]. Some argue that costochondritis is a cocky-limiting condition, and by the fourth dimension patients are seen by a concrete therapist, the inflammation would have resolved on its own. We propose that atypical costochondritis refractory to conservative or "expect and see" management can have a beneficial response to OMT and tissue mobilization. This written report adds to the literature well-nigh the effectiveness of OMT techniques and tissue mobilization in the treatment of singular costochondritis. Allowing patients to reincorporate their activities of daily living while reducing the cost of healthcare is an important outcome that this instance highlights.
The limitations of this case study include lack of external validity and the use of only one patient for the study of the methods and techniques applied. Therefore, the decision that these techniques may be beneficial for atypical costochondritis cases cannot be generalized to the wider population. Some other limitation of our study is call up bias. Since our patient had been suffering from chest pain for two years, it is possible the patient was not able to recall all the pertinent information leading to the development of his pain and the disease progression.
Conclusions
Costochondritis is a musculoskeletal status that is poorly understood just has become the leading diagnosis related to non-cardiac chest pain. Early identification of this affliction would likely reduce the unnecessary delay in definitive direction and the need to undergo an expensive cardiac workup. OMT and tissue mobilization techniques may exist effective therapeutic interventions in the successful treatment of patients with atypical costochondritis. More case studies are required to aggrandize our knowledge of costochondritis and PT techniques, which would allow for early on identification and efficacious treatment of the condition.
Notes
The content published in Cureus is the consequence of clinical feel and/or research past contained individuals or organizations. Cureus is not responsible for the scientific accuracy or reliability of data or conclusions published herein. All content published within Cureus is intended only for educational, research and reference purposes. Additionally, articles published within Cureus should non be deemed a suitable substitute for the advice of a qualified health care professional. Exercise not condone or avoid professional medical advice due to content published inside Cureus.
The authors have declared that no competing interests exist.
Man Ethics
Consent was obtained or waived past all participants in this study
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