RIB PAIN TREATMENT CaseFile
Chest pain
(Keywords: RIB PAIN TREATMENT CaseFile, chiropractic help, chest pain, hip arthritis, leg length inequality, iatrogenic illness). NB. CASE FILES DO NOT CONSTITUTE SCIENTIFICALLY PROVEN EVIDENCE. For that we need to do "radomised controlled trials". A group of people with a particular condition are divided into two groups, the one getting the real McCoy treatment, and the other a sham.
HISTORY
Six months ago Mrs T fell on her back and ribcage. Her bicycle skidded in the snow, and she found herself lying deep in a drift. She had immediate pain in her midback and ribs on the right. The pain radiated towards the midaxillary line (under the armpit).She went to her doctor who diagnosed "gekneusde ribben" - bruised ribs, and felt no X-rays were needed. He prescribed antiinflammatories tablets. Within 5 days she had severe diarrhoea, she stopped the medicine, but six months later she still has daily diarrhoea. Initially the pain was mild, but several days later, and for the following three weeks, she had severe back and chest pain. Her blood pressure rose alarmingly, and she developed a rapid heartbeat. She "went through the mills" (the Dutch have the quaintest sayings!), meaning that she underwent a thorough cardiovascular checkup during which time nothing was found by the cardiologist. The symptoms were ascribed to a bad reaction to the antiinflammatory medicine. The heart related gradually lessened as predicted by the specialist. But the pain in her mid-back and the diarrhoea remained. She also remarked that, since the fall, pain in the right groin seems to have started. At the first consult she described how the back and ribs felt "thick" and hindered her movement. Like there was a "thick pancake on her back"! Nothing relieved the pain. A particularly with-it lady, very much in contact with her body (a former star athlete, she still has a standing Netherlands record set at the Olympics many decades ago. She just missed the bronze. Mrs T claimed that her posture had deteriorated seriously since the fall; she was very fit prior to the injury. Indeed, she had seriously bent her chassis...
EXAMINATION
A skew pelvis was immediately evident, low on the left, due to a short left leg, and nothing to do with the injury (a so-called incidental, but important, finding). A mild C-shaped scoliosis is evident, convex left, but she has no significant low back pain of note. A few creaks and groans periodically. Range of motion of the lumbar spine was full and free. On motion palpation a severe fixation in the right sacro-iliac joint was evident. Thus it came as no surprise that flexion, internal rotation and adduction of the right hip were also reduced, with a hard "end-feel". (Another incidental finding) Side-bending to the left provoked pain in the 9th,10th and 11th ribs on the right. Percussion with a reflex hammer over the spine and ribs provoked no pain. (Six months ago that may well have been different.) Compression of the ribcage, both from front-to-back and side-to-side provoked no pain. There was no tenderness over the costo-sternal (breastbone) joints, but there was restricted movement of all the lower rib-breastbone joints on the right on deep breathing. Motion palpation of the costo-vertebral joints (T10 and T11) on the right revealed profound fixations and tenderness. The "bron" of the problem. The source.
TREATMENT
CONSULT 1 : HISTORY and EXAMINATION
Subjective: Right mid-back and chest pain since a fall six months ago. Objective: Side-bending to the left > pain in the ribcage on the right. Assessment: Costo-vertebral sprain. Plan: Chiropractic Manipulation of the rib. No treatment at the first consultation. Second complaint: Eartly right hip arthritis. Is there anything to be done? Yes! Chiropractic mobilisation of hip.
CONSULT 2 : Report of Findings
At the second consultation, we routinely go through - the history with the patient to check that no important details had been omitted.
- We then explain in some detail to the patient what the orthopaedic, neurological and chiropractic findings (and radiological, if X-rays have been taken. None in this instance)
- A short presentation on chiropractic philosophy, how chronic, unattended subluxations deprive the joint cartilage of nutrition causing Immobilisation Arthritis, and how toxic waste products in the joint, if not washed away, may lead to irritation of the nerve roots affecting general health.
- An explanation of the treatment. What the treatment will consist of, the scheduling, and what course of action will be followed if the patient does not respond as expected.
- Give the first chiropractic treatment.
Light prone drops T10-11 costo-transverse joint (right)Sitting mobilisation of the ribcage.No adjustment today.
IMMOBILISATION ARTHRITIS ...
VERTEBRAL SUBLUXATION COMPLEX ...
CONSULT 3 :
S: Definitely feeling a little better. O: Costotransverse joint still fixated and tender. A: No after-pain from the treatment. P: First chiropractic adjustment today. T11 (straight bilateral transverse pisiform technique), no release. Anterior thoracic techniques T11 (fist extension)Sitting mobilisation of thorax.
CONSULT 4 :
S: 50% less pain. Less of a wobbly, oscillating feeling when walking. Some slight lower back pain. O: Lateral flexion still restricted. A: Progress better than expected. P: Continued treatment of the ribs. First treatment of the pelvis today. Sacrum left / sacroiliac right prone drops. (No sideposture adjustment yet)Start treatment of the hip joint next consult.
CONSULT 5 :
S: Some rib pain after more forcible adjustment. O: Percussion negative, bruised rib. A: Avoid hard PA treatment. P: Continue with treatment of the ribcage and pelvis. Begin chiropractic mobilisation of the right hip. No PA rib-head treatment.
CONSULT 6 :
S: Still feeling it in the ribcage (anterior). Midback pain improving. O: No inspiration pain, tender on palpation. A: Iatrogenic illness ...doctor-caused disease. An overly robust chiropractic treatment has caused a temporary setback. P: Continue with mobilising treatment of ribcage, no PA adjustment. Sitting fist-extension treatment of the T11 ribhead. Prone drops on the pelvis. Next consult: Do proprioceptive test with a colleague to determine efficacy of a heel lift on the skew pelvis.
IATROGENIC ILLNESS ... includes bruised ribs from overly robust chiropratic treatment.
CONSULT 7 :
S: Still improving. Anterior rib much less tender. Amazing, the diarrhoea has abruptly stopped. No real change in the arthritic hip joint. O: Lateral flexion of the thorax is no longer painful. Proprioception testing indicates a 3mm lift in the left shoe would be most beneficial to level the pelvis, and reduce the scoliosis. A: Considering the set-back with the bruised rib, progress is most satisfactory. Patient happy. No improvement in the arthritic hip to be expected after after only two treatments. P: Chiropractic treatment as previously. 3mm heel lift.
LEG LENGTH INEQUALITY ...
At the next consult: Begin instruction on a home rehab programme. Discuss nutritional management of aging cartilage.
CONSULT 8 :
S: A very happy lady. She says her back is better than before the fall! No diarrhoea unless she eats out. Chinese did her in for 1 day. Hip also much looser. O: Complete free range of motion of the thoracic spine. No further pijn from the bruised rib, neither is it tender. A: Treatment phase nearly over. Now more rehab. Shot put exercise. Chiropractic mobilisation of hip. P: Begin a diet rich in fatty fish such as salmon, 1000mg omega-3 or codliver oil capsules. Chicken bones extract and flax seed. Start slowly in case it starts diarrhoea again.
COMMENT
- It's interesting that, whilst radiological research proves there is a higher incidence of hip and knee arthritis in persons with a short leg, that arthritis could be either on the short or the long leg. In Mrs T's case, the arthritic hip is on the side of the long leg.
- Frank cracked ribs do not happen often in the chiropractic practice (I admit to five in thirty years), but a bruised rib as happened in this case occurs periodically. The patient feels some rib discomfort for a week or two. Whilst Iatrogenic Illness (doctor-caused disease) does happen in the Chiropractic arena, it's a pale grey compared with that of medicine (over 200 000 deaths per year in the the USA alone).
- I wasn't prive to the examination of Mrs T six months ago, but I think the decision by her doctor not to X-ray was probably justified. There's no indication of a spinal fracture. Whilst I could find fault with his management once the 4-6 week period for a cracked rib were over, the fault is probably with us chiropractors for not properly informing our medical colleagues what chiropractic can mean for their patients.
- Certainly it was not his fault that she got diarrhoea for six months for his medication, it's simply one other instance of iatrogenic disease, and I'm in no position to point a finger!
- I'm expecting her arthritic hip to respond well to chiropractic management. It's not advanced, her weight is perfect, her attitude to fitness is very positive and, provided she takes the nutritional support needed seriously, I'm expecting a good result in the hip. X-rays may be necessary to define how advanced the arthritis is.
- Whilst there were fixations of the rib-breastbone joints, fortunately she never developed a concommitent Tietzes Syndrome. That causes severe breastbone pain...
TIETZES SYNDROME CaseFile ...
- It's difficult to explain how and why a six months diarrhoea, caused by drugs or possibly even by the subluxated rib(s) themselves, ceased after a few chiropractic treatments. Perhaps we underestimate the devastating effects that medicines and subluxations can have on general health.
NUTRITIONAL SUPPORT
Hyaline cartilage requires the correct environment to heal. Research done in the Netherlands on knee joint distraction clearly shows that unloading of joints and increasing cartilage perfusion lessens joint pain and disability and initiates joint cartilage healing. Furthermore many orthopaedists are now using Omega-3 oil as an anti-inflammatory, and its important affect on hyaline cartilage. Other research done at Harvard Medical School has shown the important effect of a chicken bones extract on arthritic joints.
KNEE JOINT DISTRACTION ...
CHICKEN BONES EXTRACT ...
SMOKED SALMON DIP RECIPE ... omega-3, vitamin D, calcium metabolism, anti-inflammatory effect.
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