Costovertebral Joint Dysfunction
What is the costovertebral joint?
The costovertebral joint is commonly known as the rib joint. This is the joint that articulates the ribs to the thoracic spine. Each rib head contacts two adjacent vertebral bodies, with T1 and T10-12 articulating only with 1 segment. The costovertebral joint allows for respiratory movement of the chest and functions as a structure for muscle attachment. Therefore the rib joint must allow for stability as well as flexibility. The costotransverse joints allow sliding or gliding of the rib. Costovertebral joint dysfunction can be caused by biomechanical changes that occur with injuries to the chest, interscapular region, or shoulder girdle.
Where do you feel costovertebral joint pain?
The costovertebral joint is a known pain generator for the thoracic spine, however, it is also a generator for atypical chest pain, and is often difficult to differentiate from myofascial pain syndrome. Pain is reported to being localized and is level specific with possible referral to the anterior chest. Asymmetrical rib function can be diagnosed as rib dysfunction if it can cause reproduction of the patient’s chief complaint. This can be examined while assessing for rib function during respiration, head flexion and extension, and thoracic range of motion.
How do the ribs move?
Typical rib function shows that flexion and extension is greater at the lower thorax with T1 having 4 degrees of motion, and 12 degrees at T12. Similar to this finding, rib joint stiffness to anterior-posterior loading is highest at T1 and lowest with superior-inferior loading at T10. Contrarily, rotation has an inverse relationship to flexion and extension, while the greatest amount of rotation occurring at T1 (9 degrees) and decreases towards T12 (2 degrees). Lateral flexion has shown little to no variability in terms of range of motion between segments (6-7 degrees at each segment). The axis of rotation of the upper ribs is in the medio-lateral position and allows rotation to produce elevation of the ribs (pump-handle). The axis of rotation for the lower ribs is oriented in the anterior-posterior direction to allow lateral rib movement (bucket-handle).
How does the costovertebral joint produce pain?
There are four identifiable areas of the costovertebral joint that can become pain generators, they are:
Synovial lining & tissues surrounding the joint
Axonal Bundles associated with the anterior capsule of the costovertebral joint
Free nerve endings at the anterior capsule of the costovertebral joint
Large intra-articular synovial meniscoids
The rib joint’s sympathetic innervation comes from the thoracic sympathetic trunk and has somatosensory innervation. The costovertebral joints also have innervation from the spinal nerves, each joint receiving innervation from the joint above and below as well. The 1st and 2nd costovertebral joints may additionally have arm pain that travels via Kuntz’s nerve (associated with the brachial plexus from the 1st or 2nd intercostal nerve).
Inflammation of c-afferent neurons can occur after an acute event which may sensitize nerve receptors (neurogenic inflammation). This can also affect mechanoreceptors that are located within the joint capsule. Sensitized mechanoreceptors have nociceptive qualities, which may cause reflexive muscular spasms, which can then cause mechanical loading or inflammation creating a feedback loop cycle (pain-spasm-pain cycle).
What are signs and symptoms of rib joint pain?
Upper thoracic rib dysfunction can be characterized by aggravation with overhead activities or loading of the shoulder. Mid and lower thoracic rib dysfunction is characterized with aggravation with lateral bending and rotation activities with paraspinal hypertonicity. This condition may also be associated with increased pain during deep inspiration, coughing, or sneezing, and the pain is usually unilateral. Provocative testing includes compression and loss of joint end-feel compliance. Adjacent vertebra may also be restricted and may exacerbate pain.
Who can diagnose costovertebral joint dysfunction?
You can go directly to an orthopedic physiotherapist or chiropractor for the assessment and diagnosis of costovertebral joint dysfunction. During your first appointment the clinician will be testing the rib joint sensitivity while also ruling out differential diagnosis. This is done using orthopedic tests, movement quality assessments and neurological tests. To book in with a Rehab Hero clinician click the button below:
What types of treatments are available for costovertebral joint dysfunction?
You can see your physiotherapist, chiropractor or massage therapist for manual therapy in the form of joint mobilizations to relieve rib joint pain. Joint mobilizations are grade 4 joint movements that require a certified therapist to guide a joint through gentle oscillations to reach it’s full physiological range. By doing so, passive range of motion of a joint can be restored which can help to break the pain-spasm-pain cycle.
Chiropractors can additionally provide spinal manipulation therapy to the costovertebral joints. Spinal manipulation is considered a grade 5 joint mobilization. A grade 5 joint mobilization takes a joint beyond it’s normal physiological range through a high velocity low amplitude manipulation. This manual therapy technique is considered safe and can provide pain relief and restoration of passive range of motion.
Massage therapy in the form of deep tissue massage, myofascial release, or sports massage can be used to break the pain-spasm-pain cycle by addressing myospasms of local tissues. By addressing secondary muscle spasms, massage therapy can be used to decrease the sequelae of rib joint irritation.
Osteopathy can also be provided by your osteopathic manual practitioner to restore joint range of motion and to reduce myospasm. By using muscle-energy techniques such as proprioceptive neuromuscular facilitation or post-isometric relaxation, your OMP can also reduce symptoms by reducing the pain-spasm-pain cycle of rib joint dysfunction.
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Which exercises help to relieve rib joint pain?
Since rib joint pain is due to dysfunctional arthrokinematics (joint movement) of the costovertebral joint and due to secondary myospasms in the spinal erectors, targeting both the muscles and joints of the thoracic spine with exercises can help to reduce symptoms. These types of exercises would be categorized as either flexibility (passive range of motion) or mobility (active range of motion) exercises and can be completed in the comfort of your own home.
An example of an exercise that can target the thoracic spinal erectors while also mobilizing the thoracic spine is the Foam Roller Extensions exercise:
Lay on a foam roller placed below your upper back. Keep the pelvis on the bench / floor as your extend your upper back over the foam roller and reach overhead with your arms. Aim to touch the back of your wrists to the ground if you are doing this on the floor.
An example of a costovertebral joint mobilization exercise is the Doorway Rib Lean exercise:
Start by placing the forearm of the target’s arm on a wall at roughly shoulder height. Place your opposite hand on your shoulder and press downwards to stabilize the shoulder joint. Lean forwards and use the shoulder blade to push the rib joints forwards. Oscillate gently back and forth to mobilize the costovertebral joints.
For additional exercises specific to your needs contact your local physiotherapist or sports chiropractor. For a full exercise program you can book in an appointment with a Rehab Hero therapist using the button below:
References
1. Triano J, Erwin M, Hansen D. Costovertebral and costotransverse joint pain: a commonly overlooked pain generator. Topics In Clinical Chiropractic [serial on the Internet]. (1999, Sep), [cited September 6, 2017]; 6(3): 79-102. Available from: CINAHL Plus with Full Text.
2. Scaringe J, Ketner C. Manual Methods for the Treatment of Rib Dysfunctions and Associated Functional Lesions. Topics In Clinical Chiropractic [serial on the Internet]. (1999, Sep), [cited September 6, 2017]; 6(3): 1. Available from: Alt HealthWatch.