By Bernard Preston


by SJ

lateral. All these x-rays were taken erect

lateral. All these x-rays were taken erect

lateral. All these x-rays were taken erect
anterior-posterior. Not sure if L is actually on the left side; look for a heart shadow
oblique 1
oblique 2

Dear Dr. Lewis,

Apologies for an unsolicited e-mail, but I am baffled and apparently my chiropractor is too.

For about 2.5 years I have had pain at the base of my neck when my neck is in extension or extension + rotation, and sometimes on neck flexion. Sometimes I have had radiculopathy on either or both arms, to my little fingers or (more recently) to my pointer finger and thumb. Raising my arms over my head has no effect, but with Spurling's test I usually feel moderate pain on one or both sides. A few times recently I have had pain between my shoulder blades. Infrequently I have pain in the vicinity of the costochondral junction near rib 5 (left side), usually short-lived (a few hours or less), except last winter when I had a cough and my rib was sore for more than 1 week (ice reduced the pain but did not eliminate it). After reading your website I checked my sternum and found a tender spot on the left side about halfway down.

Almost 2 years ago I had cervical x-rays taken; mostly for the neck pain but also because I had a lump-behind-my-throat feeling. The lump feeling went away after about 1 month, but the neck pain remains.

My chiro has looked over my x-rays and thinks they look great; he sees no obvious problem that could be causing my pain.

I looked at my x-rays and measured:
First rib height difference 3.7 mm
First rib angle difference 3.7 degrees
First rib length difference 0.1 mm
Clavicle height difference 4.7 mm
Scapula height difference 4.1 mm (the higher clavicle and higher scapula are on opposite sides)

Are any of these differences indicative of an issue that could be causing my neck pain? My chiro did not check my measurements, but thinks the differences are not large enough to cause pain. I saw a few journal articles that might suggest otherwise (Helgadottir, H. et al. 2011. Altered alignment of the shoulder girdle and cervical spine in patients with insidious onset neck pain and whiplash-associated disorder. Journal of applied biomechanics 27(3): 181-191; Helgadottir, H. et al. 2010. Altered scapular orientation during arm elevation in patients with insidious onset neck pain and whiplash-associated disorder. The Journal of orthopaedic and sports physical therapy 40(12): 784-791).

I am also suspicious of costochondritis because of the rib and sternal issues. I mentioned this to my chiro but he thinks that costochondritis would not affect my neck; that costochondritis would be localized near my sternum. Some pages on chiropractic-help seem to differ (e.g. Tietzes Syndrome - left chest and arm pain). I also frequently feel like I am hungry very soon after eating a full meal.

I uploaded x-rays and hopefully they come through OK. Most of the issues I mentioned are apparent on the anterior-posterior but I can send the others if you need them. I am later 30’s and active (hiking, cycling, running); about 1 year ago I had a herniated disc at L5-S1 with radiculopathy (~70% better).

I am very grateful for any insights you can offer.

Thank you so much.

Dear SJ,
Firstly the x-rays. Indeed they aren't bad but

1. There is definitely a small osteophyte at the base of C5 seen on the lateral protruding posteriorally and again seen on the AP view in R joint of Luschka, often called the paravertebral joints. They are not yet seen on the obliques which are patent. There is likely irritation of the C6 nerve root there explaining the effect on the thumb and pointer finger.

2. T1 is notoriously difficult to read on plain x-rays; if you have a scan that would be an area to focus on.

3. There is the faint suggestion of cervical ribs, possibly quite large on the right; they are often mainly cartilage and not well visualised on plain x-ray.

The key to a nasty Spurling's test is that radiates down the arm, and not only neck pain. I wonder if the upper limb tension test, found at yields any information, but more difficult to interpret as you are having symptoms in both arms.

A cervical rib can be a bugger if large; it's very close to the brachial plexus and the interscalene triangle. Use the Search function here to find it.

Adson's test, very subjective, will give an indication as to whether the subclavian artery is affected in the thoracic outlet. The characteristic symptom is the arm tiring very quickly when working above your head.

It sounds like you do have a costochondritis; my only insight on this is that a heavy midback AP manipulation will aggravate it, and the 'anterior thoracic' technique is the adjustment of choice.

Clearly somewhere in your history you've had a whiplash, probably five or more years ago, and it's left its mark on you.

You don't sleep on your tum?

Get help with your computer setup. Support for the mouse arm at the elbow is important and I prefer a keyboard on shelf below the desk so your wrists point downwards.

I hope this contributes in some way. An MRI sometime would yield a lot more information, focusing on T1 and whether there is indeed a cervical rib, and how large it is.

Dr B

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Nov 19, 2017
Re: Costochondritis
by: SJ

Thank you very much for your response.

I had not noticed the osteophyte on caudal C5, but I wondered if there is a lesion on the cranial side of C5. Also if some of the upper ribs and clavicle are dislocated, or if they only appear such as an artifact of the angle of the x-ray.

Another thing that has baffled me is why my neck pain and radiculopathy went away completely when both my ears plugged up last spring (a sinus issue, I suspect), and returned when they unplugged.

What role might inflammation be playing?

Thank you for your insights.

Hello SJ,
Yes, both sides of the C5-C6 joint; there appears to be a small osteophyte complex growing there. Old whiplash?

Immobilisation arthritis occurs when a joint is not moving freely; synovial fluid that sloshes about in the cavity is not able to fully supply the need of cartilage for oxygen and nutrients; lots of research on it. Degenerative changes begin.

The secret is to keep moving, and to keep those fixated joints mobile. An occasional but probably not too frequent adjustment at C5 is necessary.

It's not researched but simply my opinion that too much manipulation of the injured joint is probably not healthy either.

I suspect those rib measurements are not significant, but open to correction; not sure. Clinical examination is probably more important.

Diet has an important influence on every part of our existence, from our mood, intelligence, mental decay, to cancer and arthritis and a host of other things. You'll find I've written quite a lot about the anti-inflammatory diet at

Make a start with fatty fish and freshly ground flaxseeds for their omega-3 several times a week; I prefer getting it from our food to capsules.

It's a very complex subject with new research coming out weekly; as one surgeon said, get back to the foods that your grandmother set on the table, and not what you learned from your mother.

Good luck, SJ, necks and ribs can be a bugger.

Dr B

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