Rib pain causes may be inherited as from a scoliosis or from trauma.
These normally long and slender bones pertain to the mid back, or thoracic spine. But occasionally folk may inherit a gene that gives them one on the seventh cervical vertebra; then it's usually short and stubby, but may have a lengthy piece of cartilage attached, unseen on xray.
Mostly these are rudimentary, small and of little consequence, but very occasionally these cervical anomalies can be large and interfere with two vital structures that pass to and from the arm; the artery and nerves that supply the upper limb.
Below you can see the marvelous graphic artist's impression of these unusual enlarged transverse processes of the seventh cervical vertebra. On the left is the inter scalene triangle through which the axillary artery passes on its way to the arm.
Through this triangle, between the scalene muscles, the very large brachial plexus of nerves also pass. If there's an anomalous cervical bone taking up space it can severely affect the arm.
Sharp stabs in the mid back at the chiropractic coalface is an every day affair. Mostly, dealing with it is fairly straight forward, but these anomalous structures can make life a lot more difficult.
1. Cervical ribs
Hereditary conditions like a cervical rib, a short leg, or leg length inequality in anatomical terminology, or old trauma can't easily be undone.
But sharp mid back pain after a sneeze is straight forward provided you don't delay for weeks.
The classic sign of a cervical rib is that the arm tires very quickly, and may tingle and ache, especially when working above your head.
Chiropractic usually helps, but will certainly not in any way cure the condition. Surgical removal of the cervical rib may constitute a cure, but it's a grisly operation via the armpit, sometimes injuring the artery or nerves.
Here is an aside worth considering; when is it better to accept some disability rather than risk a potentially dangerous operation, or medication, which might improve the condition, but may also worsen the condition? It's a difficult question, requiring wisdom and a willingness to discuss fully with those experts involved to weigh what the benefit versus risks ratio is. The general anesthetic alone, especially in the very young and elderly, is not without risk.
On a personal note, my anesthetist confided in me after a minor operation that she very nearly lost me when I was only forty years old. It was a sobering confession.
The classic test is Adson's test which assesses the pulse in your wrist as you go through complex series of movements to narrow the gap in the interscalene triangle.
Holding the telephone between your shoulder and your neck will greatly aggravate any cervical rib pain, provoking a possible pinched nerve in neck ...
2. Lumbar ribs - pain under rib cage
Less uncommon, the first lumbar vertebra may have a rudimentary rib. Usually there is an associated anomaly at the base of the lumbar spine, which is more likely to give trouble than the rib.
However, this lumbar rib may be associated with the many conditions associated with the thoraco-lumbar junction. A Maigne's syndrome that may refer to the buttock and groin via the Superior Cluneal nerves, a Meralgia paresthetica causing numbness and sometimes pain and tingling on the side of the thigh. And other slips of nerves belonging to the Femoral nerve complex passing to the inguinal and genital areas.
Short leg is the most common cause of a scoliosis.
Whilst these anomalous ribs, or a subluxation at the thoracolumbar junction may cause pain under the cage, on the right one needs to consider whether the gall bladder, or liver aren't the spokes in the wheel. The usual right upper quadrant abdominal palpation can usually make the differential diagnosis.
For discomfort under the left cage, less commonly a spleen condition perhaps should be considered. However this is rare and the old adage is followed; if you hear hoof beats, think horses first, and only zebras later. But striped animals aren't just found in the bushveld; occasionally they may be one lurking in the chest cavity.
Abdominal palpation should be part of the normal examination in all
such cases. An enlarged and tender liver or spleen obviously calls for a second
opinion, and further tests.
Here's an interesting, typical case file from the chiropractic clinic.
A 27 year old woman for no reason suddenly developed very severe left
lower thoracic pain. It happened whilst running, which she did
regularly. She did gym the evening before, perhaps injuring herself.
Taking in a deep breath provoked the stabs suggesting a rib condition.
The twelfth was exquisitely tender on palpation, as was lateral
There was also spreading pain under the left rib cage, but palpation of the spleen and upper quadrant were negative.
She responded very rapidly to the usual chiropractic adjustment, with 50 percent less pain after one treatment and almost none after three. The Maigne's syndrome exercises and an orthotic in the shoe to correct for a short leg were vital to prevent a regression. Rib and back complaints are not uncommon.
A short leg may have been caused by a femoral or tibial fracture, but it's also an inheritable feature. It frequently causes the scoliosis often associated with rib pain.
It's not difficult to imagine how a short leg on your reading left in the case above could be one of the spine and rib pain causes.
Here's an important thought. Ask your child to bend forwards, knees straight, and check the spine. Is there an obviously uneven back? An unskilled yet observant person can detect this rib pain cause.
Grandad, whilst you are showing that very important little person in your life some insights into one of your hobbies, you too might ask the lad or lass to bend over and have a look at the shape of their spines; an ounce of prevention and all that. Once they reach sixteen the spine is formed and it's late to make significant changes.
Obviously, in today's devious world, it may we wise first to gain the parent's permission. Done together, in any case, it would carry more weight.
It's not difficult to understand, looking at the x-ray below, that your doctor of chiropractic will be considering beyond that crooked spine other rib pain causes. Once again, though, it's the horses and the odd stray zebra story.
One of the quite rib pain causes is cancer of the pancreas; it's known classically to refer pain to the back and must be included in the differential diagnosis if there is any suggestion of unexplained weight loss, malaise and fatigue; and if the patient is not responding to chiropractic treatment of the spine and ribs as expected.
An apex to the curve often exists around the thoraco-lumbar junction making this area vulnerable. A T12 or 12th rib subluxation often may cause rib and back pain possibly causing pain under rib cage.
Sneezing, especially if twisted at the time, or getting up from a chair, is a common cause of acute, sometimes very acute, mid back rib pain.
Each rib attaches to the spine via three joints. Subluxation of one of these joints causes very severe, stabbing mid back pain. See the red arrows below. The so-called "sprung rib" in chiropractic jargon. The painful sprung rib is a condition that responds, almost always, very quickly to the the Chiropractic adjustment.
Another of the rib pain causes is trauma to the rib cage. A shoulder charge in rugby, a powerful jerk by your car safety belt that may save your life, but leave you with severely contused ribs...
Another, I confess, is an overly robust mid back manipulation. I admit myself to seven cracked ribs in 33 years, all seven recovered with no sequelae but at the time there was quite severe pain with every breath.
Aside: Would you sue your chiropractor for cracking a rib? Was it negligence? Was s/he contrite? Did you get a vase of flowers?
All human beings, doctors included make mistakes periodically. If you sue your doctor every time something goes wrong, you will be a little richer, perhaps a lot richer, feel vindicated; but on the downside, there's always the risk that s/he becomes despondent and makes a career change. Is it worth putting several thousand patients out of their doctor/ chiropractor because he made a mistake like using a little too much force and cracking a rib?
The other downside is that doctors will be reluctant to get on and do what they have to do if there's the slightest risk. Patients will take longer to recover, or not recover, just because doctors have become so intimidated.
Happily none of the seven sued me!
Breastbone pain can be very debilitating.
A dysfunctional rib, for whatever reason, affects not only the three joints between the rib and the spinal vertebra, but also the joint between the rib and the breastbone.
Breastbone pain, aka Tietzes syndrome
comes in four grades, the fourth being a swollen node over the joint.
It can be extremely debilitating, lasting for years. If over the left
side of the chest, patients often think they are having a heart attack
or angina. Hence the term "heart-attack rib".
Trauma to the
chest is a common cause such as a fall on the fist whilst skating, but
also after mastectomy and breast enlargement surgery.
Part of the so-called "inter scalene triangle" a first rib subluxation is a vital part of the arm pain syndromes. Affecting both the artery to the arm and the nerves, a "thoracic outlet syndrome" is a major cause of the pain and tingling in arms and hands syndromes that face your chiropractor every day.
The frozen shoulder for example, and a carpal tunnel syndrome are frequently associated with a first rib fixation. Dealing with this rib pain cause is what makes Chiropractic very successful in treating the arm pain syndromes.
The transitional areas of the spine - headache from the atlanto occipital joint, the lower cervical spine, the thoraco-lumbar juction and the lumbo-sacral areas are the most difficult in the management of the spine.
The first rib - T1 rib - is not unusual in this regard, at the cervico-thoracic junction.
Medical illness @ rib pain causes
Whilst it's a lot less common at the Chiropractic Coalface, every chiropractor knows that a case of walking pneumonia, a lung tumour, pancreatic cancer, breast cancer can cause mid back pain, simulating a rib condition.
Metastases from breast cancer to the ribs; it's important that you report other medical conditions to your chiropractor. Are you taking post menopausal hormones? Research shows that you can expect dramas in your future health.
Just recently I had a patient who had non Hodgkins lymphoma of the thymus gland; treatment was only possibly if the surgeon could put his hand into an aperture made between the ribs. This caused tremendous stress of the joints at each end of the ribs involved.
She is happy to be alive, and chiropractic help enables her to cope with the rib pain; it's not perfect, but she's happy.
USEFUL LINKS @ rib pain causes
Interesting letters from readers