costochondral pain/rib contusion

[puvoharvey]

Hey,

I have two questions:

Whats the best way to differentiate between the two, with trauma from landing on someone elses knee?

Whats the management plan?

I ask this because i had a pretty crap patient for the first part of my post grad musculoskeltal/manipulative therapy exam today. He wasnt actaully seeking treatment, he just knew one of the lecturers. So while all the other students i know got to work their way through peripheral joints (and i guess a few got spinals joints) i got this. I have never assessed one of these patients before, great to do something for the first time in an exam

So i cant find much on the internet, and certainly this WASNT covered in our course notes, or in my textbooks with any detail, and i have to present this patient and my mangement plan both short and long term in around 36 hours.

Im pretty annoyed that not one second of my MANY hours of study helped me in my exam, and i had to rely on logic, and my very basic anatomy

Alright, ill stop whinging now.

Any help greatly appreciated

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[alophysio]

Hi!

Tough timeframe - most people on this forum don't reply too often!

Put simply, a costochonral junction injury would have a step in it and a contusion won't - it will have a bump from the fluid trapped in the fascia. But I don't think that will be enough to pass your exam! :rollin !

I'll try help as best I can but I left my textbooks at work - "The Thorax" by Diane Lee (www.dianelee.ca) is excellent, even though a bit dry at times. One good thing I learnt from Diane and LJ Lee is that the thorax is like 12 little pelvis'! You think just the pelvis is hard! Try 12 individual thoracic assessments! There are up to 13 joints at each thoracic ring!

Bascially - is it a costochonral junction pain? It's not costosternal, costovertebral, costotransverse, etc but costochondral?

I ask because the joint mechanics of each of the above can affect the chostochondral junction. If this were my patient, I would first get his history, get where his pain is, assess the T/S vertebrae, clear the L/S and C/S, then check the ribs.

T/S - transverse processes - are they symmetrical or are some more posterior than others. In neutral, the coupled movements of the T/S vertebrae are rotation and contralateral sideflexion. So if the right lateral flexors are tight, you will see the vertebra rotate to the left. In flexion and extension, coupling is ipsilateral so tight right sideflexors mean lateral flexion and rotation to the right. Rx would be to clear the type I dysfunctions first (multilevel rotations to the same side in neutral) and then reassess for Type II (F/E dysfunctions).

Ribs - in flexion of the T/S, the ribs rotate inferiorly and anteriorly (??). In extension, they rotate posteriorly and superiorly (??). At ribs 7-10, they move ALI (anteriorly, Laterally and Inferiorly) and PMS (Posteriorly, Medially and superiorly). I am pretty sure that is right but i don't have my textbooks to be certain! Palpate the rib angles on the posterior chest wall to see if they are sticking out compared to the other side. The rib dysfunctions could be superior, inferior, AP, lateral compression joint fixations. You could then also get rib torsions which result from myofascial tightening of tissue around chronic problems - may not be the case in your guy - but then he may have had a chronic problem that got pushed over the edge with the accident!

As for the costochonral junction - it should feel symmetrical without any steps in it. Is there pain in breathing? Are the ribs splinted together by the intercostal muscles?

Don't forget the obliques and serratus extend over a significant portion of the anterior thorax and could also have an effect.

The Single-Arm Lift (LJ Lee) is like the Active SLR which is also good for helping to diagnose dysfunctions. If he finds his symptomatic side to be hard to lift, support the injured rib and get him to lift again - if it is easier, then he has a stability problem and motor control training would need to be done.

I would say that if everything comes up as fairly symmetrical in examination and joints are normal and muscles are negative, then he probably has a rib contusion and you would feel it on the rib.

Long term management would be restoration of ROM and arthrokinematics of the affected segments, stability training of the multifidus and rotatores progressing onto intergration with ADLs and global muscle use (think hodges, hides, richardson, jull, o'sullivan, commerford etc), etc.

Short term would be resotration of painfree ROM and isolating core stabilisers. Taping also works well.

I hope this helps!

[Physiobase]

Well a rib contusion might well lead to costochondral pain. That's the first comment i would have made. A contusion will cause a bruise that it pretty much going to be painful to direct touch and less likely than a costochonral issue to be painful with breathing.

In many cases supporting the rib cage against inhalation would reduce the pain of a costochondral problem. So to would some type of pressure supporting the joint more directly akin to something Mulligan would do.

It really was a pretty simple question and you had all the info to provide a simple answer. i.e. One was a direct trauma (assuming no joint involvement, and the other was a joint issue. Therefore one would have pain with movement of that joint and the other would most likely not.

Exams are funny things. For the most part examiners are not out to trick students, we just think they are. Often the simple explanation is the thing they are looking for. 8o

[alophysio]

Hi.

I read the OP as a future tense - "I will have to present this patient"! - which is why i went into so much detail! :rollin

[puvoharvey]

Yeah thanks to you both.

I have tried to reply about 4 times now to give more info and say thanks, and it just hasnt been working for me.

I do indeed appreciate the detail. I need to present this patient tomorrow, along with treatment paln etc and rationale for it.

Not out to trick us? Yeah thats what they say, then you go and get something that was never covered in the sourse or the notes, and not working with any sports teams in my limited career, i have never had to assess this area. And according to other physio's i have talked to as well, there is not much to do anyway, especially for this actual patient with no real breathing difficulty

So yeah, on this movement issue - fracture still hasnt been ruled out, so that will cause pain on deep breating at 8 days (which is when i saw him). Hes had a x-ray over a week ago, but no-one told him the outcome, so he assumes nothing has happened.

Deep Breathing is a issue with this patient, so its not a minor contusion. Normal breathing is ok. However, im unsure of what exactly can happen around the costrochondral area. It is a bit like a sheathed sword, but can a slight change in joint position occur, a slight subluxation if you will, and then resettle again? What happened was he fell on a knee, couldnt breath much for a couple of breaths, took a deep breath and felt something "pop back in" or "click back in" which made it easier to breathe, but not completely OK.

However, he is still very tender to light touch over this area, not moving the joint at all. Im sure there is a bit of both going on, but i cant find much information on what can happen around the costrochondral joint on short notice!!!!!

ANymore help would again be much appreciated.

[puvoharvey]

I forgot to say, this guy was no longer seeking treatment, and was able to play a few soccer games in a tournament with out much trouble. (on some anti inflamms) So he's relatively ok, so where i have limited things to present for him, i may need to go into detail for more serious injury.

However, i first of all want to get a diagnosis made.

Tx AROM - normal including side bend towards with a deeper breath, and side bend away with a deeper breath

Sternocostal A/P glides are clear also

Accesory glides of the Tx were all ok, same with the Costovertebral, so wasnt to worried about referred pain.

Deep breathing, laughing, lifting, lying on it, abdominal con
tractions for sitting up are all aggravating factors still.

My thoughts are my both contusion and some costrochondral issue are happening here, with some other differentails that i think i can rule out ok. However, i just dont have the knowledge on what can happen at this costrochondral joint. I mean, full dislocation with a step defomrity, but what about the pathomechanics of a lower grade injury???

Thanks again.

[Physiobase]

Well an Xray is not going to show any stress facture. It would rule out any major fracture or pheumothorax (which is impt to rule out if associated with a fracture). Quick tricks for looking for a fracture include a quick run of ultrasound over the boney region (pain might well indicate fracture). Obveoulsy you would not then continue with the U?S as a treatment! Also the vibration of a tuning fork held adjacent to a fracture that is close the the skins surface can indicate a fracture when pain is provoked (due to vibration in the bone).

Costochonral joints can indeed sublux or "pop out" and rather easily in competitive sport. You would compare obviously visually the right with the left in standing and perhaps in lying as a rotation through the rib cage would be more obvious.

You would still check the back itself as a constcondral subluxation probable has a disruption to the costovertebral region as well. Thus the Tx might need to be addressed with manual therapy in some way.

Supporting an inhalation to assess the best direction of force to help reduce the pain. You can then use this as a treatment either in sitting, supine or side-lying to help relocate the joint position if it appears on palpation to be out of place.

Address the trauma as you would a bruise. Supportive measures such as a bandage around the chest or taping can help if manual support has already proven to reduce the pain.

8o What course are you actually studying?

[puvoharvey]

Hey there, yeah i use ultrasound quite often to "diagnose" fractures, but usually for things like calcaneal fractures and tib/fib, dont know if i want to bring that up, because ill likely get asked to back that up from the literature!

I did a pretty thorough "observation", and there was no issue there, im thinking the seperation/subluxation happened initially, and has pretty much settled. What i mean here is no obvious defomity static, or dynamically, and nothing apparent on my admitedly rushed crap assesment under exam conditions......

Manual therapy to the Tx is definately in my treatment plan

Dont want to do much splinting or taping of the chest unless its for activity such as sport, all the atelectasis stuff and that.

The course im doing is postgrad musculoskeletal/manual therapy in New Zealand as a post grad diploma. This paper is the musculoskeletal aspect of it. Its a REALLY good paper, run by really good lecturers, we just didnt cover this type of patient. This is no worry for the physio;s in the course with ten/fifteen years experience whos seen X number of these, but with my 18 months part time experience, the only things that could throw me was this and maybe some sort of facial injury. Plus for 15/16 of those months, ive been working on my own, with only my own opinion!!!! Wheres that violin music coming from???............

Would have been happy to go through a foot, ankle, lower leg, knee, thigh, groin/hip, buttock, SIJ, Lx, Tx, Cx, shoulder, elbow, forearm, wrist or hand - the stuff we covered! - but it wasnt to be. They were stuggling for patients i think anyway.

A few years ago, they wouldnt have let me into the course, needed more experience, but now most Uni's are all about the money/bums on seats, but hey, what can you do other than just deal with it??

[Physiobase]

Well well done then on finding this forum as your questions have been very appropriate. Best of luck

[puvoharvey]

thanks again for the help, the presentation of the patient went better than i thought it would, but the compulsory pass cervical manips were another story!!!!!

Did it so bad on my mock paitient, i burst out laughing and eventually they had to send her from the room and get me to do it on the neck of the Head of the physiotherapy department.

But the pressure got to me, poorly locked up, too tense, weak manip, slippery hands - the works!!!

But hopefull they scraped through with c passes, they wrent dangerous or anything - all over if thats the case!!!!

[Physiobase]

Well done!