Tietze's syndrome unresponsive to medicine and chiropractic

Rib cage anatomy

Rib cage anatomy




I am a 46 yr old female. For 2 years I have suffered from what I think could be Tietzes syndrome. I have had numerous CT/MRI/Xrays and the Doctors can not find what is causing my chronic pain.

My pain started when I had what I think was a rib head out. I couldn't bend my neck down and was having a lot of upper back pain (between shoulder blades). After being adjusted again, I was still having a lot of pain.

I then developed costochondritis about 8 mths ago and I'm thinking now I may have Tietzes syndrome. I have chronic pain in my mid back and sternum area (about the 3rd rib down). There has been a swollen hard lump there on the right side and my pain runs down through my breast area. My chest has popped several times. I cannot lay on my stomach at all because of the chest pain. It is still painful to laugh even though the costochondritis has improved.

I have mentioned Tietze's syndrome to my chiropractor but he brushes me off. I desperately need help with this chronic pain and I don't know what avenue to take at this point. Any advice would be greatly appreciated.




Hello Michelle,
I'm not sure how wide to open my mouth, and whether to stick both feet in!

I've walked the walk with Tietze's syndrome and it's been a long a difficult journey; I first encountered it as a young chiropractor, not knowing its name and it was quite painful to discover that my treatment actually worsened it, and may have actually caused it. That was the beginning of the journey; in medical terms I was faced with what's known in the jargon as iatrogenic illness; doctor caused disease.

There's a fine line between costochondritis and Tietze's syndrome; firstly the former may be due to inflammation, but Tietze's is apparently not, and hence doesn't respond
to anti inflammatories and in fact responds to very little; it becomes a chronic and debilitating condition, as you are experiencing.

The second feature is the presence of a lump over either a rib-breastbone joint, or over the joint between the collarbone and the breastbone.

The third is that often there is associated indigestion, and if it affects the collarbone, tingling in the arm.

Both have associated midback pain, often thought to be the start of the whole problem.

What I eventually realised was two things. Firstly a heavy manipulation in the midback worsens the condition. And secondly that, whilst it's not curable, it's a very treatable condition with chiropractic, but is unlikely to go away completely, and well require an occasional but regular adjustment; but the midback adjustment must be skillfully and gently done, or it will worsen the condition.

The treatment of choice is the so-called 'anterior thoracic" adjustment, and mobilisation of the whole rib.

Doctors in general, when they are out of their depth, brush off and dismiss patients' complaints. I know because I did too until I started to get interested in Tietze's syndrome, and whether chiropractic had any contribution to make. Medicine generally seems to admit there's nothing much they can do.

Which brings me back to your own chiropractor. If he has an enquiring mind, and is ready to face up to his limitations, and would to help patients with Tietze's syndrome, then I suggest you ask him to contact me. It's a difficult condition, and I make no claims to being a guru, but I have worked out a protocol that brings relief somewhere between 50-80%. It makes it manageable instead of being a daily struggle as you are experiencing.

I'm sorry if I've thrown petrol on the fire, but it's the way you may make progress. I know of no other, and it seems your doctors don't either.

Start by icing the painful spot on the sternum every day in a hot shower; alternating hot and cold helps.

Dr. Barrie Lewis


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Tietze or what?

by Alicki
(Switzerland )


Hello,

I did an intensive workout (new résolution) to do sports, so lifted some weights (just a kilo). Nothing happened for 10 days, then I got this (see picture). I stupidly added two Hours of kayak because I didnt want to let a friend down.

The pain is not in front but radiates just under the shoulder blade. No warmth, just swelling of sternocostal joint and a little on joint just below that one.
Appointment with GP on 26.08 . Pain very achy!
Could this be Tietze? Am thinking of asking for MRI .
Im a woman so want to make sure this has nothing to do with breast. I'm 43 and have had a breast reduction in past.
Thanks for any advice.
Best wishes,




Hello Alicki,
Just to be sure I have it right, you have no pain around the sternum, is that correct? The pain is more in the midback. Does a deep inspiration hurt?

Certainly the swelling you describe is typical of Tietze's sydrome; are these joints tender on palpation, compared to the other side?

Women't who have a breast procedure are more at risk.

In the full blooded Tietzes syndrome, those swollen nodes also become painful, and there is sometimes tingling in the arm, and indigestion. There are lots of variables.

A breast exam just to be certain is never a bad idea.

Give me a few answers to the questions above; and attach the picture.

Dr. Barrie Lewis


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Sep 22, 2019
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Bruised dungeon a bad fall or Tietze?
by: Carolina

Hi there, I'm a fit, thin and highly active 71 year old. Last week while hiking at night I tripped and fell and braced the full with both hands to avoid head injuries. I immediately felt pain in my chest, have had painful breathing and soreness since then. The nurse at the local Urgent Care noticed a swelling to the right of my sternum and diagnosed me with Tietze. I saw another physician and he thinks it's simply a bruised rib or pulled muscle. The xrays were normal. The swelling is small and when I duplicate the position I fell in, it corresponds to the same spot. I also have a small bruise near the swelling.

I know Tietze is a disease of exclusion and I was alarmed at the diagnosis after a 2 second exam and inconclusive xray. Is getting an MRI the only way to get a definitive diagnosis and if so, should I see a thoracic specialist? Thx!





Hello Carolina,
I take it your chest never actually came into contact with a rock or any other obstacle; something to cause a bruise. You didn't fall on your hand or fist, or a waterbottle?

I presume the painful breathing and soreness is over the sternal area, not under the armpit, or in the midback; or is there discomfort there too when breathing?

There was no sign of any problem whatsoever before the fall?

Frankly it's a bit of semantics. Costochondritis and Tietze's syndrome are first cousins, and the treatment is much the same; just the latter is likely to be more obdurate to treatment and may not go away completely. Particularly if the only treatment is medication.

An MRI may contribute something, quitely not.

I would recommend starting to apply ice immediately over the painful joint in the shower or bath, alternating cold and hot, and then massaging in the groove between the ribs.

Often the whole rib is affected, from the three joints where it meets the spine to the costosternal area. Then a gentle chiropractic adjustment is needed, note, important, an 'anterior thoracic' adjustment. A heavy manipulation from P to A will worsen the condition.

See your local chiropractor if it doesn't settle in a week or two with home care.

Let me know how you get on.

Feb 18, 2017
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Going on 7 months with Tietze's syndrome
by: Anonymous

Lung and heart are clear on X-ray and I have follow up MRI in two weeks. I have quite a bit of short breath as soon as I go out in cold or exercise for long.
Can cold weather make Tietze worse? That's my question.

Thanks
Aliicki




It's great that the tests are clear; are you still having chest pain, and that pec minor tendon?

As far as I know Tietze's syndrome is no more affected by the weather than any other joint.

Dr. Barrie Lewis



Dec 13, 2016
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Another question
by: Anonymous

Hello,

Another question if I may. When I was in Rome a few weeks ago, I pulled a suitcase around with my bad side. My joints hurt like mad for a few minutes. That was around end of October. Then a few days over that, my osteopath realised that I winced with pain every time he touched my minor pectoralis muscle. Could I have torn my minor pectoral muscle by dragging a suitcase over 100 meters on an already injured area?

Now, it's been about a month, the pain radiates to my arm and top of shoulder too.
Of course, this doesn't turn up on MRI....but if you touch the minor pec or I stretch it, I clearly wince with pain.

I'm guessing I have made things worse. Any practical suggestions on how I could recover from this? At least the minor pec muscle. Again, because of the breast op, the joint swelling, I'm guessing the whole area has gone crazy.
The check up MRI is in 2 months, but I need to do something NOW:

I don't see my osteopath before two weeks.

Many thanks in advance for your reply. Shame I'm not nearer, this is an interesting case!!




Lovely to have got to Rome in October; definitely not in midsummer. The most interesting city in Europe I've visited.

The sign of a pulled muscle is that it hurts when you contract it; in fact an "isometric" contraction where the joint doesn't move. It's very specific for the pec and difficult to describe; you might find something on google. Your osteopath will know.

Put some alternating ice and heat on the muscle, stretch it gently and start some simple shoulder exercises; they shouldn't hurt but you'll feel it.

True; it's not always nice to have an 'interesting' problem. Like the Chinese curse: may you live in interesting times.

Dr. Barrie Lewis



Dec 01, 2016
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Mysterious tietze???
by: Anonymous

Hello,

This is Alicki again - updating. We did a second MRI and firstCT that showed a small infiltration of the minor pectoral muscle which they believe is inflammation. I have to do another MRI in 3 months! Impossible to get a bone scan - the bones are ok on MRI and CT. I saw a thoracic surgeon who believes my sternous exercise provoked an inflammation of the articulation which doesn't show on MRI.
Arm is starting to ache too. Breast MRI cleared any breast involvement . Lymph nodes are up again in the area.

This is my theory: what do you think :

I had a butchered breast reduction in 2013, correction done in 2015 (June). Did strenuous exercise in August 2016. I have massive scarring in my breast (internal scars).

I think the breast reduction and scarring impaired the lymphtics of the area and the strenuous exercise over did the
joint that popped out. This would explain why the area is swollen in the evening and more or less ok in the morning.

I think this is a mixture of some sort of Tietze and lymphatic impairment and it's going to be a question of how to treat it.

Could you tell me about cases that you ve had/seen when Tietze appeared after some kind of Breast surgery? That might be helpful! Does Tietze flat up and then settle again?

I will keep updating because I think this is pretty unique condition. Meantime any feedback is welcome!

Warm regards
Alicki




Hello Alicki,
I would your thoracic surgeon is close to the mark, especially as you said you could some sort of popping sound in the costosternal joint.

What doesn't fit with pure Tietze's syndrome is the swollen lymph nodes; that is probably more to do with what you call the botched breast reduction. Surgery like chiropractic is an art, and some have good hands, others not so good.

I'm sure blood tests have been done to rule out lymphomas.

It's not uncommon after breast surgery and because it's really not frequent in the general population I've never seen statistics; my experience is that it responds quite well to chiropractic, but tends to come back; maintenance rather than a cure is the order of the day.

You're not that unique, at least not in this regard, Alicki! But those swollen lymph nodes will keep your doctors guessing; thanks for the update and I hope you gradually improve.

Dr. Barrie Lewis





Sep 30, 2016
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Tietze or what next?
by: Anonymous

Hello,

We need an MRI (chest no dye) and it showed nothing. My ostheopath who is great read the scans (he knows how) and said that my right side is a little more protruding than my left.
There was no swelling in the joints, no odema in bone, NOTHING but the bulge can clearly be seen. The odema in the soft tissue has now completely subsided, or is very minimal. The back pain has gone.

I have asked several times about Tietze to be told that because I was not/am not in terrible pain, it can't be that BUT the joints are still sensitive.

Now something else, I went to a chiro to see if he had an idea. He used a weird machine to test my back (resistance?) and was able to tell me that my right side (affected side) is much weaker than my left. He's going to try and do some kind of treatment to strengthen right side. What? I don't know - still waiting to find out - have asked for the paperwork. Does this machine (which shows green and red results on a chart) remind you of anything?

I have to see another radiologist for an unrelated problem next week and will ask her opinion.

meanwhile, if this tietze or non tietze thing is getting better, and the only thing I have left is protrusion, swelling of joints - should I still be concerned?
How long will it take for it to go away?
Can we have only 'mild' pain with Tietze??





Hello Alicki,
You can have a mild dose of anything and it certainly sounds like a mild dose of Tietze's syndrome; it can be extremely painful and debilitating and there's no known cure.

I have worked out a protocol for it that relieves most of the pain but it tends to come back. If you chiro wants to skype me, we can arrange that.

Just remember, a heavy manipulating in the mid back will bring it back with a vengeance.

I don't have much faith in those muscle machines to be honest, but that's my own prejudice, so ignore my doubts.

Take it quietly for a bit; remember the 50% rule; they pain goes away much faster than it heals.

Great that you are getting better.

Dr. Barrie Lewis




Aug 22, 2016
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by: Anonymous

Ok, the swollen nodes have gone down (phew!)and this leaves just two protruding cost sternal joints (the first two after SJC). I'm following up with doc on Friday. No swollen nodes in the back, but my ostheo said that he felt that the 3rd rib was swollen.

I'm seeing both oseothpath and doc this week and will discuss exams. This could be just a small injury further to intensive sports but it's always best to check for peace of mind!

Thanks for the support doc, really helps. I'll report back once I have had the appropriate exam.

Best
Alicki




It's no coincidence Alicki that he found the joint swollen at the back; it usually follows the whole rib.

Remember, a heavy P to A manipulation will aggravate it.

Yes, let me know.

Dr. Barrie Lewis



Aug 19, 2016
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Tietzes syndrome and lymph nodes
by: Alicki

The front 2nd? and 3rd? joints are swollen (the one below the SCJ - second and third sterno costal joints) and so are swollen lymph nodes around them. I have tingling in hands anyway from some weird condition; nothing new there. The joints are tender, but not painful. When I put my left hand on my right joint and lift my right arm above my ahead, I can feel Something coming out of place and going back into place. It cracks a little but softly.

The pain is mainly in the back (shoulder and midback). My excellent ostheopath noticed some swelling in the 3rd right rib too, back and front; seeing him again next week. But we read everywhere that Tietze is rare, so we are both wondering if it's that.
Armpit nodes and clavicular nodes are totally normal but the lymh nodes around the swelling are swollen. I've put some anti-inflamatory cream on swellling and nodes and the swelling on the nodes seems to be going down very slowly. But bone swellling still there. No breathing problems.


Any advice is welcome. I am thinking of getting an MRI done just to be sure I've not cracked Something but meanwhile insights are good. And am also wondering whether my ostheopahth could contact you if it is Tietze.




To my knowledge Tietze's syndrome does not cause swollen lymph nodes, though I could be wrong. And especially seeing you are have swollen lymph nodes at the back, I'd continue to keep a foot in both the medical and osteopathic camps.

It sounds very much like what I'd describe as an atypical Tietze's syndrome; which means I too am not sure.

A bone scan might be more useful than an MRI. Keep in touch. Sure he can contact me.

Dr. Barrie Lewis



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Tietzes syndrome

by Casey Jensen
(Middelfart Denmark)


I am a 22 year old girl living in Denmark; I have had extreme pains in my chest on and off for 6 years. I noticed a massive bubble, swelling, under my left collarbone when I was 16 while stretching after a long run.

I was after many tests diagnosed with thoracic outlet syndrome. Unfortunately neither physio, medicine, rest or acupuncture helped.

After many more years trying to find a treatment that works I found out 6 months ago I have tietze's syndrome, probably sterno clavicular.

I have had to stop all forms of exercise as even getting my pulse up on a bike will trigger the swelling which leads to extreme pain in my arm and loss of feeling in my ring and small finger.

I would love to have some information as to how a chiropractor can help me as there is little to no knowledge of the disease here.

I feel disabled as a 22 year old and find tasks such as washing and putting my hair up an issue. My boyfriend has to wash my hair for me! I am normal in weight and live a very fit lifestyle, non smoker, non drinker, and eat a very balanced organic diet.




Hello Casey,
This is indeed likely Tietzes syndrome. Do you also suffer from indigestion? However, that can only be confirmed by a thorough and careful examination from a chiropractor familiar with Tieteze's syndrome. Can you send me a photograph when the lump is present?

When it affects the sterno clavicular joint it does become intimately tied up with thoracic outlet syndrome, which also seems likely as you have problems with arms raised. That closes down the inter scalene triangle through which the artery and brachial plexus to your arm must pass.

Frankly I struggled with patients with this condition for twenty five years before I worked out a solution, so I'm not suggesting that every chiropractor on the block can successfully treat Tietze's syndrome, or even has ever heard of it.

I would recommend you start looking for a chiropractor in your area who would be interested in tackling your case. If he or she is up to it, we could discuss how I manage Tietzes syndrome, either by email, or on skype. Take your time locating the right person. Talk to friends and family and your GP. Perhaps go for an examination without treatment to discuss your case.

What I can tell you is that a heavy posterior to anterior thoracic manipulation is likely to aggravate the condition.

Let me know if I can be of further assistance.

Dr. Barrie Lewis


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Tietzes

by Nicole
(Indiana)


Hello, first I want to say that seeing the picture at the top of this page has put me somewhat at ease, as I too have swelling on the sternum.

My pain happened in my chest as a icy cold feeling that went from the sternum down to my heart. I thought for sure I was having a heart attack. I went to the ER and had ekg, blood test, and chest x rays. I actually did this twice. Everything came back negative. They released me, and said i had costochondritis.

Then two weeks later I developed a swelling on the sternum that went into my left and right breast, and left collar bone. I had a cat scan and have not received the results yet, but I've been doing lots of reading and I'm thinking tietze is what I have.

It does not hurt to bad when I breath in or out, but it does hurt to cough. Most of my pain has been localized to the left side. The difference I'm experiencing that I have not heard many people talk about with tietze is that my neck and chest are red and warm to the touch especially if I'm moving around or lifting anything. This has been going on for almost two months now.

My doctor is seeing me this week, and I'm praying that the cat scan came out clean, and that he will be willing to diagnose me with Tietze's syndrome. I feel it would be easier for me to go on with this pain and swelling if I knew it was not something more serious. Thank you for this article.




Hello Nicole,
The medical conditions that could cause this swelling and redness need to be explored; could it be a breast condition?

Tietzes can be bilateral, but it's less common.

Do you have any midback pain? Or radiating along the rib under the armpit?

Tietze's syndrome is less severe than some of the other conditions your doctor is considering, but even then it's not plain sailing. Tietze's syndrome is a nuggety condition that it took me 25 years in practice to figure out.

Once the diagnosis is made, get back to me, and we can discuss the treatment further.

Perhaps send me a photograph; you have to get the light exactly right to bring out the swelling and redness.

Dr. Barrie Lewis


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Jun 29, 2015
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Tietze
by: Nicole

Hello, it's been 6 months since I started to have sever pain in my chest. It's been 4 months since I was diagnosed with tietze. I am having a lot of pain in my collar bones....especially in my left collar bone. It feels as though it is swelling and a lot of times I get itchy on the lump that is on my second part of the sternum. I have not seen to many comments about pain like this in the collar bones. I have had testings done and catscan. My doctor says there is no swelling shown on the X-rays or catscan. I feel like my doctor has gotten tired of hearing me complain and I have given up going back. So I'm wondering if there is anything I can do to help stop the pain?




Hello Nicole,
Tietze's syndrome is a nuggety problem and there is no research, proven treatment. However, having struggled with patients with it for 25 years I've finally come up with a protocol that works. It probably won't cure you, but if you are 60-90 percent better, would you be satisfied.

I suggest you find a chiropractor in your area who either knows about Tietze's or is willing to contact me, and we can discuss my protocol.

A little warning is in order. A hard manipulation in the middle of the back will worsen the condition.

Dr. Barrie Lewis



Feb 04, 2015
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Tietze
by: Nicole

Hi Dr.B,
i have sent you an email of a couple pictures of my chest. I was not sure how to upload onto the website. i do not have back pain, but i do have the pain into my left armpit. I woke up this morning with the swelling under my right collar bone. I am going into the doctor tomorrow to find out the results from my catscan. I did have a rheumatoid blood test done and L = 0 H = 13 and i was 11. I don't know if this goes together or not. Thank you for commenting!




Hello Nicole.
Please send those photos to brlewis[at]mweb.co[dot]za

Right collar bone swelling, pain in left armpit... it's all quite confusing. Good that your doctor is taking it all seriously. Once (hopefully) all these test come back negative, let me know and we'll talk more about the treatment of Tietzes syndrome.

Dr. Barrie Lewis



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Tietzes syndrome after a bad chest

by Linda
(England)

Rib cage anatomy

Rib cage anatomy


When my daughter was 14 she had a really bad chest; after her chest was better she said she had a pain in her back between a rib and would get quite breathless.

She was sent to see a consultant; by the time we had the appointment she was really ill she was sleeping all the time so much so she would fall asleep in school even in mid sentence, she had pain all over her body.

She had cramp like pains from her neck all the way down her spine and into her feet; she could not concentrate and her memory was affected.

She was diagnosed with ME and her life just changed within a couple of months. She had to be driven to school and could only go part time she went to hydrotherapy once a week for a year.

Eventually she felt slightly better but the pain between her ribs never went away she was sent to see a cardiologist who had an interest in ME who diagnosed Tietze's syndrome then gave her an injection of steroid and lignocaine.

I got my daughter back; she could function normally again but then he discharged her. After the injection wore off all the pain and chest infections returned she was eventually sent to see a Rheumatologist who started to give the injections again; she has been having these now for four years she has completed uni been travelling and now has a job she loves. We went for her injection which she has between her ribs at the back, not in her breast bone even though to touch there hurts.

It's the constant pain between the ribs that affects her, to be informed that after this one she needs to go for a bone density scan and that he is referring her to a surgeon to see about surgery to remove inflammation or to kill the nerve. I have been reading things about the two procedures and it's not good reading but then will her life go back to not being able to function again.




Hello Linda,
Your daughter obviously has a complex case and I think it's not appropriate to comment on the specifics of her case. I haven't had the opportunity to examine her.

But in general terms, what we see commonly in chiropractic practice is that a person develops a cough for whatever reason. Sometimes it's the coughing, but a good sneeze can do it to, but a rib head becomes subluxated.

There are three joints between each rib head and the spine, and one or more can be sprained by coughing or sneezing. It causes incredibly sharp pain in the midback, every breathe being a nightmare.

Untreated the sharp pain gradually subsides and sometimes no doubts heals itself. But in others a dull ache remains and, because the fixated joint affects the rhythm of the rib during breathing, it starts to affect the other end of the rib: the joint between the rib and the breastbone. At first just tenderness begins there, then it may become painful and eventually form a swollen nodule at the joint; that's the true Tietze's syndrome. Often there is indigestion along with it, as the diaphragm is attached to the underside of the ribs.

The chiropractic treatment of the initial "sprung rib" as it's called is usually very simple and dramatic; reducing the subluxation of the rib head is something chiropractors are faced with frequently and it's cured without drama; if treated within a few days or weeks.

Once it becomes chronic, deep seated inflammation begins and spreading pain along the rib under the armpit and towards the sternum it becomes more difficult. It still responds to chiropractic care, but a "cure" becomes less likely, as with many medical treatable, but not curable, conditions.

So where does this leave your daughter? Certainly before surgeons get their knives in, I'd recommend you have a consultation without treatment with a local chiropractor. Weigh what he or she has to say and make your decision. Take any xrays and scans with you, and perhaps print this out. The find a good chiropractor link below may be of help.

One caution: there are two chiropractic manoeuvres that are classically used. One is on the rib head, from posterior to anterior. If a heavy manipulation is done, it will probably aggravate her condition.

Better is a gentle posterior to anterior adjustment, as above, and then the second type which is called an anterior thoracic adjustment. This is what really helps with a condition like your daughter has. Plus some massage between the ribs, all the way from the spine to the sternum.

I hope this contributes; let me know how you get on.

Dr. Barrie Lewis


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Tietzes syndrome

by Kim
(Uk)

Possible Tietze's syndrome

Possible Tietze's syndrome

I first noticed my collar bone was swollen 8 months ago, following a bout of tonsilitis; I had antibiotics for this which made me violently sick. I don't have any severe chest pain, but in the past I have experienced stabbing pain in the middle of my chest when rolling onto my side. I currently have a lot of upper back and shoulder pain; it's more of an achy discomfort.

I've had blood tests and an xray which hasn't shown anything. I have been told to take ibuprofen, which I haven't used. The swelling hasn't gone any bigger or smaller.





Hello Kim,
Always, when associated with an infection, as you had in the tonsils, the differential is whether it's a swollen lymph node or not. It doesn't appear to be, and your blood tests were negative.

Is the nodule tender, and if you run your fingers down the joints between the ribs and sternum, are any painful, usually on one side only.

Do you have any tingling in the arm? The brachial plexus of nerves to the arm pass right under the collarbone. Also that swelling may affect the other end of the collar bone, at the shoulder, affecting your shoulder rhythm.

A bone scan might show the swelling. I certainly think it looks like Tietzes syndrome.

It's difficult, Kim. There's no proven treatment; after years of struggling with patients with the problem, I've worked out a protocol that's quite successful, but still I can't claim it's proven.

If you'd like to see a local chiropractor, and he or she is willing to talk to me, we could skype and discuss your case and hopefully take you forwards.

One small warning; a hard manipulation in the midback may aggravate this problem.

Let me know how you get on.

Dr. Barrie Lewis


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