Costochondritis Developed for OUCOM CORE By: Sheri Hull, D.O. Edited by Wayne Feister, D.O. and the CORE Osteopathic Principles and Practices Committee Series C – Session #7

Definition Inflammation of the junction of the upper ribs and the costal cartilage Localized chest pain aggravated by coughing, sneezing or deep breathing aka: Anterior Chest Wall Syndrome

Causes of Costochondritis Causes of costochondritis are not known and may involve several factors. Possible causes include heredity (genetic predisposition), viruses, and trauma (injury). Costochondritis can be an independent condition by itself or sometimes be a feature of a more widespread disorder. Examples of illnesses that can feature costochondritis include fibromyalgia, psoriatic arthritis, ankylosing spondylitis, reactive arthritis and inflammatory bowel disease, i.e. ulcerative colitis and Crohn’s disease.

Anatomy In this picture, you can see the costochondral joint. Netter, F. Atlas of Human Anatomy. 2nd Edition. 1997. East Hanover: Novartis

Anatomy This picture illustrates the complexity of the joints involved in costochondritis. Not only is the rib and costal cartilage involved, but this affects muscles in the thoracic wall, including the muscles of respiration. Netter, F. Atlas of Human Anatomy. 2nd Edition. 1997. East Hanover: Novartis

Very common in children and adults Symptoms Chest Pain Very common in children and adults Sharp chest pain with/without radiation to back 4th, 5th, 6th ribs most common Reproducible by palpating the costochondral joint

Cardiac Conditions Differential Diagnosis Tietze Syndrome - An inflammation of the costochondral cartilages of the upper front of the chest. Blood testing (Sedimentation Rate or C-Reactive Protein Rate) can show signs of inflammation in patients with Tietze syndrome, whereas patients with costochondritis alone typically have normal tests for inflammation. Costochondritis is often mistakenly called Tietze syndrome. Tietze syndrome is actually a separate entity, with a different location, cause, and presenting signs and symptoms.

Based on painful palpitation of the costochondral junction Diagnosis - Costochondritis Motion may be restricted – may be necessary to correct rib motion restrictions to make accurate diagnosis Based on painful palpitation of the costochondral junction Also dependent on exclusion of other causes (cardia, infections, etc.) It is very important that, if you are going to make a diagnosis of costochondritis, you have sufficiently ruled out any other (more serious or life threatening) causes of the chest pain.

Remember these people are in pain ! Treatment Direct Rib Release – Remember these people are in pain ! Anti-inflammatory medication and moist heat may also offer relief There are a number of rib treatments available, however, it is best to remember that these people are in pain. To correct the somatic dysfunction around the pain, a gentle technique is needed.

Treatment Direct Rib Release This technique, a balanced ligamentous tension technique, is very gentle, but very effective. Basically, you are floating the rib out of the joint slightly (allowing inflammation to decrease) and allowing the rib to replace itself in the correct position. Speece, C., et. al. Ligamentous Articular Strain: Osteopathic Manipulative Techniques for the Body. 2001. Seattle:Eastland Press.

Treatment Direct Rib Release The physician presses upward with the bottom hand while releasing pressure from the top hand. The physician holds this position for several seconds, after which the bottom hand releases pressure and the top hand exerts downward pressure. This technique, a balanced ligamentous tension technique, is very gentle, but very effective. Basically, you are floating the rib out of the joint slightly (allowing inflammation to decrease) and allowing the rib to replace itself in the correct position. Nicholas: Atlas of Osteopathic Techniques

Treatment Muscle Energy During exhalation the physician’s right hand exaggerates the exhalation motion of the dysfunctional rib. The patient inhales again (black arrow) as the physician’s right hand resists (white arrow) the inhalation motion of the dysfunctional rib. This technique, a balanced ligamentous tension technique, is very gentle, but very effective. Basically, you are floating the rib out of the joint slightly (allowing inflammation to decrease) and allowing the rib to replace itself in the correct position. Nicholas: Atlas of Osteopathic Techniques

Treatment Muscle Energy The patient exhales, and the physician exaggerates the exhalation motion (white arrow) of the dysfunctional rib. This technique, a balanced ligamentous tension technique, is very gentle, but very effective. Basically, you are floating the rib out of the joint slightly (allowing inflammation to decrease) and allowing the rib to replace itself in the correct position. Nicholas: Atlas of Osteopathic Techniques

Treatment HVLA The physician slightly rolls the patient toward the physician by gently pulling the left posterior shoulder girdle forward. The physician places the thenar eminence of the right hand posterior to the angle of the dysfunctional rib. The patient is rolled back over the physician’s hand, and the surface created by the patient’s crossed arms rests against the physician’s chest or abdomen. This technique, a balanced ligamentous tension technique, is very gentle, but very effective. Basically, you are floating the rib out of the joint slightly (allowing inflammation to decrease) and allowing the rib to replace itself in the correct position. Nicholas: Atlas of Osteopathic Techniques

Treatment HVLA Pressure is directed through the patient’s chest wall, localizing at the thenar eminence. The patient inhales and exhales, and at end exhalation a thrust impulse (white arrows) is delivered through the patient’s chest wall slightly cephalad to the thenar eminence. This technique, a balanced ligamentous tension technique, is very gentle, but very effective. Basically, you are floating the rib out of the joint slightly (allowing inflammation to decrease) and allowing the rib to replace itself in the correct position. Nicholas: Atlas of Osteopathic Techniques

References Downing, CH. Osteopathic Principles in Disease. 1935. AAO. DiGiovanna, E. & Schiowitz, S. An Osteopathic Approach to Diagnosis and Treatment. 1997. Philadelphia: Lippincott, Williams, and Wilkins. Kimberly, PE. Outline of Osteopathic Manipulative Procedures: The Kimberly Manual, Millennium Edition. 2000. Marceline: AOA. Foundations for Osteopathic Medicine. 1997. Baltimore: Williams and Wilkins. Nicholas, AS. Atlas of Osteopathic Techniques. 2008 Lippincot

References - continued Netter, F. Atlas of Human Anatomy. 2nd Edition. 1997. East Hanover: Novartis. Owens, C. An Endocrine Interpretation of Chapman’s Reflexes. 1937. AAO. Speece, C., et. al. Ligamentous Articular Strain: Osteopathic Manipulative Techniques for the Body. 2001. Seattle: Eastland Press. http://www.emedicinehealth.com/costochondritis/article_em.htm www.steadyhealth.com