A bizarre issue. Pictures attached. Any help would be appreciated.

[physiobob]

Thanks Jason for the reply. I ask about discoloration to see if there might be any vascular issues such as a DVT in the veins of the arm (very uncommon but I have seen it before with people on a lot of pain meds and steriod users in the gym). I think if we forget all the recent treatment it sounds like is could be as simple as costovertebral joint perhaps in combination with a C4/C5 lateral disc bulge. I see this in combination a lot, especially as the local treatment of the painful rib area (usually close to the scapula on the rib cage as if it is a painful area) doesn't resolve until you treat the neck component. It can be in such cases that some manual therapy with guided neck retraction and extension +/- rotation can be really useful (although painful in the beginning as you try to reduce any lateral disc bulge). In terms of a +ve Roo's test (elevated arm stress test) this might also be positive when you are able to extend your thoacic cage fully so not sure it helps much in that case.

I think in relation to a possible scenario as I have mentioned above it is important to know that this is a very VERY common presentation and VERY normal. There is no real need to investigations other than manual movements of your spine and assessment of your symptom behaviour during and after mobilization of those areas. I would look maybe for a physiotherapist in your area who has skills in McKenzie 'Therapy' or his approach to the assessment of the neck and thoracic spine. This method has some very good self help exercises to administer at home once the physio has assessed what they believe to be the root cause of the problem.

If you were to have a further investigation at some stage and wanted to rule out any sinister pathology (as we call can get worries about such things from time to time) then a bone scan of the thoracic area would perhaps suffice as it would show any abnormal activity in the boney structures in that area.

Another very possible approach to this would be to get involved in some private (one-to-one) studio or 'Equipment' based pilates classes (not matwork classes) OR a private Gyrotonic class. I teach both and used them as a more natural way to restoring normal spinal movement and importantly 'breath' as well. Sometimes all it takes is 6-8 session to make a full recovery when the issues are more a mechanically restricted skeleton.

[Jasonm]

Hi Bob:

Thanks for the reply. I'm not worried about anything of sinister pathology. However, this has pretty dramatically affected my quality of life for over 2 years and I want to do everything and anything to tackle it. I've had about 40 sessions of PT and chiropractic with modest results. I probably should have included this in the original post since it was a large part of why I thought something atypical may be going on. When I was going to PT, they were unable to recreate the symptoms by bending my head in various positions and pushing down. He still tried manual and mechanical traction for about 5 sessions since he felt like a disc bulge was the most likely culprit. Unfortunately, it didn't do much. But hopefully I'm a little taller now . Another PT said I had the best feeling neck they'd dealt with in a long time. No one was ever able to "pop" me on the left side doing a thoracic thrust maneuver, although I'm not sure that's clinically relevant. On a side note, I seem to have very spasm prone muscles. For instance, I strained my piriformis wrestling with a girlfriend about 10 years ago and had nerve pain down my thigh and severe weakness of my leg to the point it had noticeably atrophied after 3 months. I rested for months hoping it would go away with no luck. It resolved with with just a few sessions of PT and some simple stretches. I'm hopeful this is a similar deal.

I took the the pictures to my physician yesterday and he speculated it could be a serratus posterior superior ("SPS") spasm because of the location of the elevated ribs. Although he noted he had limited training in musculoskeletal disorders. He referred me to a interventional radiologist for injections. I tend to believe physiotherapists have a lot better understanding of this stuff than most MDs, so I have a couple questions and will quit bugging you.

Is the SPS capable of causing that sort of rib elevation?

Could the rib compression impinge on the long thoracic nerve and cause the scapular winging?

Is there anyway to stretch the SPS or that general area? I can just look up the stretch if it has a common name.

I hope you're right about the pathology. I'm definitely going to look into your suggestions. I want to sincerely thank you for taking the time to answer my questions regarding these issues. It's unbelievably refreshing to see someone who has some genuine interest in helping people rather than profiteering. I'm sure it's not really worth your time at your current price but it's greatly appreciated. I'm glad I stumble across your forum and you've been an enormous help. If I end up having more questions down the line, I'd be happy to compensate you more adequately for your time. Thanks again!