Tietzes syndrome costochondritis

by Virginia
(White Pine, Tennessee)

Hi Doc, I am 52 yr old, healthy,active (live on a farm and ride and train horse) slightly overweight, married female who routinely sees my awesome Chiro, gets yearly check ups as well as yearly mammograms.

This past August I had a complete hysterectomy. Surgery was a huge success but 10 day later I got an upper respiratory infection and severe bronchitis. I coughed violently and in spasms for 6 weeks.

One evening about three weeks into this I noticed pain on my left side under my left breast from the sternum all the way to my left armpit when I took a deep breath. Unfortunately, I have large breast so it is hard to get good palpation of the chest wall but as far as I could tell, everything hurt under the breast.

By that night it hurt to lay down, roll over or try to get up. Called my doc and got an X-ray to rule out pneumonia and the X-Ray was clear. A week later I was still in pain. My hubby, an eye surgeon, was thinking pleurisy.

After about a month the pain gradually lessened but I still had twinges of pain on exertion and palpable, very tender pain in the same area. Left side, between the sternum and the left breast is very tender to touch and feels lumpy, swollen, going under the breast and even when I press directly on top of the breast I feel soreness in the chest wall. This goes all the way to the outside of the left breast and under my armpit.

At this point my hubby was also thinking costochoNdritis. Also, when I lay down and press on the sternum between my breasts I had (and still have) considerable tenderness.

I scheduled my regular appt with my Chiro for an adj in Nov and not really thinking about the chest pain at that moment I didn't tell her about it because my hip was giving me a fit at the time. When I laid face down on the table for a mid back adj I felt discomfort under my left breast and then when she adjusted my mid back OUCH!! Intense pain from sternum to breast and following under the breast, to arm pit to collar bone. And then my condition flared up much worse again for another 3 weeks. I didn't put two and two together until today, Jan 24, when I went back again for another routine adjustment and WHAMO! stabbing pain, and what was very slowly getting better was made instantly much worse again with a face down, mid back manipulation.

That started some intense research that led me to this site. We are going on 5 mos now of this of pain in that area and tonight I am back to pain when taking a deep breath and when trying to sit up from laying down. I made the connection when I read that if one has Tietzes then a mid back will make it worse. I have a couple of questions:
1. Does this sound like Tietzes to you?
2. Do you think my violent chest cold could have started this?
3. I don't really have any back pain with this, except a little pulling tugging feeling when I take a deep breath, the pain is all in the front left from sternum, under the breast, to armpit and maybe a little past the armpit toward the back. Would you still be thinking Tietzes even without back pain?
4. My left breast itself also feels very tender, especially under the breast, left outer side of the breast and under the arm pit, but I just can't tell if this is some referred pain on palpation or actually the rib pain I'm feeling.

When I take a deep breath my entire breast hurts deep in the chest. Does this sound normal?
5. Could Tietzes syndrome inflammation cause a lymph node reaction as in some swelling? I feel like I may have some swollen nodes under my armpit but not sure. Could just be feeling muscle tissue/connective tissue that is sore. Thanks for your opinion and any advice! Also would love ideas on how to approach my Chiro with what I think is going on. Thank you!!

Hello Virginia,
All in all a long sad tale. I must confess it ook me 25 years in practice before I really got to understand the Tietzes syndrome chostochondritis thing, how to treat it, and that a heavy mid back adjustment would worsen the condition. So, don't be too hard on your awesome chiro, but yes you must face it with her. It's the only way we doctors learn!

The rule: the regular posterior to anterior midback adjustment is completely contraindicated in a case of Tietzes syndrome. Much better, more effective with no painful side effects is the anterior thoracic technique, she'll understand.

I would have a gynae check the lymphnodes in your axilla; as I'm sure you know they can be serious, won't be caused by Tietzes and certainly a breast condition needs to be ruled out.

Having said that, this sounds like a typical grade three Tietzes. Grade four you'll also have indigestion, grade five a swollen nodule over the costochondral joint.

It commonly starts after a bout of bronchitis, so there you are typical. It's commonly worse after a chiropractic PA heavy adjustment, so there you are typical too. Also the radiation along the length of the rib, with some discomfort at the junction of the rib and spine. It's almost always worse with deep breathing.
It may radiate to or from the midback.

The solution.

1. Lie on your side and ask hubby to gently massage all the way from your back along the offended rib, under the breast as far as he can reach and then continuing between breast and sternum. No hanky panky, now!

2. In the shower use alternating iceblock directly on the rib breastbone joint, and hot shower.

3. Lying on your back, take a little cream and using your index and middle finger to straddle the rib, gently massage away from the sternum, towards and under the breast.

4. A few anterior thoracic treatments from your chiropractor.

5. Then there are some specifics that are too technical. You could ask your chiro to email me, and I could share some thoughts with her.

All in all, a painful, debilitating condition with a tendency to become chronic, rarely serious in the sense that it's caused by malignant conditions, tho serious enough to make you miserable. One that treatable with the right chiropractic treatment, and can be made worse with the wrong treatment.

Have your breast and armpit examined.

I hope this contributes.

Dr B

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Interesting challenges of the day

1. Mr S is a 76 year old man with neck pain of some 9 months duration. Luckily, most of the discomfort is upper cervical which is only rarely arthritic; his lower cervical spine is a degenerative mess that I've left alone. After seven treatments his pain and stiffness is 50 percent better, and he's happy in the circumstances. He can sleep through the night now and that makes a huge difference.

2. Mr P is 32 year old man with very severe lower back pain radiating to the big toe which is 30 percent numb. He had an episode three weeks ago, took anti inflammatories and was soon better as is typical of the medial disc herniation. But before it healed, after a trivia it came roaring back, much worse. The characteristic crossed sign was evident; sitting in a chair, straightening the right leg provoked severe left back pain and tingling in the leg. He's doing well.

3. Severe lower back pain is scary; just ask Mrs P. Just watching her get out of the car I she was in trouble; she had a slipped disc at L4 making her lean towards the opposite side; luckily she had no pain in the leg. Despite family pressure that this was far too severe for a chiropractor, she persevered. Within five days she was standing upright, and after two weeks almost painfree. 

Despite a hectic job, she wisely took my advice and stayed home for what I call exercising bed rest.

4. Mr S has had lower back, groin and back of thigh and calf pain for fourth months.

He has a pincer deformity in the hip causing the stabs in the groin, and a degenerative facet causing the sciatica. Both are responding well to chiropractic and he's well pleased; sixty five percent better after three treatments.

5. Mr T is a wise man; he's taken a warning TIA seriously and has lost 15 pounds, and has at least as much again to lose. A change to a low starch diet and half hour daily walk has made the difference; but the walking is making his foot and back miserable. The expensive orthotic is hopeless; luckily his hips and back are fine, but he needs a simple heel lift.

6. I too have had serious lower back issues, luckily fixed by my own chiropractor; so I too have to do my exercises, take care when lifting supers full of honey, gardening and using the chainsaw. Regaining the function of your spine is just as important as the pain.

7. My own granddaughter, only 7 is hypermobile giving her pelvic, knee and ankle issues. Xrays show a mildly dysplastic hip. Years ago we would have called it growing pains. She too regularly needs chiropractic care and luckily responds well. Increased range of motion is more difficult than too stiff in my opinion. Our care is for kids too.

8. This 65 year old lady is a serious gardener; every day she is bending, lifting and digging for 2 to 3 hours a day. It regularly catches her in the sacroiliac joint, so she has a treatment once a month that sorts it out. She does her lower back exercises faithfully.

9. This 88 year old lady is an inspiration; every day she is busy in the community. With a nasty scoliosis she manages very well with a chiropractic adjustment every six weeks and exercises faithfully done.  

10. Mr X is a 71 year old retired man who wants to continue with maintenance care every six to eight weeks; he had suffered from two years of lower back pain when he first came a year ago. He has no discomfort now after 8 chiropractic treatments, but is aware that danger lurks.

11. Mrs C has been having severe headaches, and taking a lot of analgesics. It's a non complicated upper cervical facet syndrome, and she's doing well.

12. Mr D is a 38 old year man with chronic shoulder pain after a rotator cuff tear playing cricket. It responded well to treatment, but he knows he must do his exercises every day; for two years he couldn't sleep on that shoulder.

13. Mr D, a 71 year old man, has a severe ache in the shoulder and midback since working above his head. Trapped nerve tests are negative but he has advanced degenerative joints of Luschka; after just two treatments he is 50 percent better. Can we reach 90?

And so the day goes; chiropractors shouldn't be treating the elderly most medical sites state but that's so much bunkum.

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