Chiropractic Management of Non-cardiac Chest Pain and Posterior Rib Misalignment: A Case Report
Chad M. Hagen, DC1, Julie A. Hartman, DC, MS, DICCP, CCRP2
1Instructor, Palmer College of Chiropractic, Davenport, Iowa
2Project Manager, Palmer Center for Chiropractic Research, Davenport, Iowa
Published: September 2017
Journal of the Academy of Chiropractic Orthopedists
September 2017, Volume 14, Issue 3
This is an Open Access article which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The article copyright belongs to the author and the Academy of Chiropractic Orthopedists and is available at: https://ianmmedicine.org. © 2017 Hagen/Hartman and the Academy of Chiropractic Orthopedists.
Objective: The purpose of this case report is to describe the resolution of non-cardiac related chest pain in a patient with costovertebral joint dysfunction using the sacro occipital technique.
Clinical Features: A 66 year-old Caucasian male presented with chest pain rated 8 of 10 on Numeric Rating Scale (NRS) and exacerbated with inspiration. Case history and physical examination were performed which revealed no indications of acute myocardial infarction (AMI). Sacro occipital technique trapezius fiber analysis and palpation were used to localize a left costovertebral joint fixation at T6 and associated trigger point superficial to the articulation.
Intervention and Outcome: The patient was treated using a modified anterior thoracic adjustment with the contact hand placed under the rib articulation as A to P thrust was administered. The patient reported pain rated 2 out of 10 on the NRS at post-evaluation the following day. Exam revealed restored motion to the T6 costovertebral articulation on inspiration and exhalation with a decrease in pain and tenderness of the trapezius fiber.
Conclusion: This case report describes the chiropractic management of a 66 year-old male with a complaint of non-cardiac chest pain resulting from a costovertebral joint misalignment.
Key Words (MeSH terms)
Chiropractic, chest pain, rib misalignment, sacro occipital technique
When a patient presents to any health care provider with a complaint of chest pain the priority is to rule out life-threatening conditions. In 2008, the Center for Disease Control reported that chest and abdominal pain were the most common reasons for emergency department (ED) visits for persons 15 years and older.1 Chest pain specifically is the second most common reason for ED visits (more than 4 million visits per year).2 Cardiac disease is the primary concern, but after a thorough history and examination (including temperature, heart rate, respiration, and bilateral blood pressure) about 50% of cases appear to be non-cardiac in nature.3;2 It is not surprising that nonspecific chest pain was also the most common reason for discharges from the ED in adults over age 45.4
The patients who have had acute myocardial infarction (AMI) ruled out often are discharged without a specific diagnosis. The term chest wall syndrome (CWS) has been used as a type of diagnosis by default, or when life-threatening conditions have been ruled out.5 Other terms that have been used to describe this type of chest pain include costochondritis, anterior chest wall syndrome, atypical chest pain, rib dysfunction, Tietze’s syndrome, painful rib syndrome and musculoskeletal chest pain.5;6 Even though these are relatively benign conditions, patients with these diagnoses experience impairment in daily activities, emotional distress and anxiety, and frequent contact with the health care system.5;7 The estimated cost in the Unites States for patients who are suspected of having AMI but instead are diagnosed with a benign condition is approximately $8 billion annually.8
Musculoskeletal conditions may represent an underdiagnosed etiology of non-cardiac chest pain.7 Segmental dysfunction of the lower cervical and upper thoracic spine (C4-T8) has been demonstrated to refer pain to portions of the anterior chest wall.9;10 Additionally, rib dysfunction is recognized as a source of chest wall pain as the ribs articulate posteriorly at the costovertebral articulations and anteriorly at costosternal articulations.6 Compared to the body of literature surrounding low back pain and neck pain, there is relatively little evidence to guide the management of musculoskeletal thoracic spine or chest wall pain.10
The purpose of this case report is to describe the resolution of non-cardiac chest pain in a patient with costovertebral joint dysfunction using the sacro occipital technique.
A 66 year-old Caucasian male presented to a private chiropractic clinic with a complaint of chest pain rated at 8 out of 10 on a numeric rating scale (NRS) and was exacerbated with inspiration. He was an established chiropractic patient that denied new trauma or illness prior to the onset of chest pain, which occurred one day prior to seeking evaluation. The patient was employed as a machinist for a local energy company, a physical job often necessitating body contortion to accommodate various welding jobs. He reported a past medical history of smoking 24 pack years, and a diagnosis of prostate cancer which was successfully treated and in remission for 1 year. The patient had no history of heart disease or other risk factors and maintained a healthy weight.
Upon examination the patient had blood pressure and pulse within normal limits and no shortness of breath was noted. Pain was exacerbated with full inspiration but not with increased activity. No other indications of acute myocardial infarction (AMI) were observed.
Palpatory examination revealed point tenderness and a palpable trigger point on the left 6th costosternal articulation and decreased motion of the 6th rib with inspiration and exhalation (Figure 1). Sacro occipital technique trapezius fiber analysis was also used to locate a posterior rib fixation via a nodule on Fiber 4 (Figure 2).
Treatment for this patient consisted of a modified anterior thoracic adjustment to mobilize the rib fixation at T6. The patient was instructed to use ice in the event of exacerbation. The patient returned the following day for re-evaluation. He reported diminished chest pain rated 2 out of 10 on the NRS with no pain upon inspiration and no further exacerbations. Point tenderness over the T6 costosternal joint was decreased and motion of the posterior rib was notably improved. Sacro occipital technique trapezius fiber analysis was performed with noted reduction in pain and size of nodule at Fiber 4 on the left. No additional manipulations were performed at follow up visit.
At the time of publication, 15 months had passed since the initial onset with no recurrence of chest pain or signs of costovertebral joint dysfunction. The patient was, and continues to be under regular chiropractic care with office visits averaging every 2 to 4 weeks.
As AMI can be life-threatening, it is paramount that a proper history and examination be performed to rule out cardiac causes of chest pain. Only then should musculoskeletal etiologies be explored. Galinski et al examined pain severity in patients with AMI. They found no relationship between pain severity and AMI in patients arriving at the ED with chest pain, indicating pain severity alone is not useful when ruling out cardiac causes of chest pain.11 Typically, protocols for ruling out AMI do not lead to a specific diagnosis, but suggest a musculoskeletal cause of pain. In another study that examined a diagnostic decision making process, the main indicators for musculoskeletal chest pain were absence of cardiac findings, items from case history and pain upon chest wall palpation.12 It is important to note that an earlier study found chest wall palpation was not a reliable diagnostic tool alone. However, when used in combination with case history and full examination, palpation was an additional component in making a diagnosis of musculoskeletal chest pain.13
Another type of palpation that was used in the diagnosis of this patient was sacro occipital technique trapezius fiber analysis. Major Bertrand DeJarnette, an engineer, osteopath, and chiropractor, discovered and developed sacro occipital technique. DeJarnette examined the body as a whole structure and created categories based on imbalance. Sacro occipital technique also uses a variety of diagnostic systems such as occipital fibers and trapezius fibers. The practitioner palpates these fibers for nodules which are theorized to correspond with areas of the body in dysfunction. While sacro occipital technique has various unique adjusting methods, it is not limited to any one specific ossesous correction.14 In this particular case, the chiropractor used sacro occipital technique trapezius fiber analysis in addition to joint motion palpation, physical examination, and patient history to make a diagnosis. Sacro occipital technique trapezius fiber analysis was also used as an outcome measure, in addition to NRS.
Treatment of rib dysfunction has also been documented by manual therapists in other health care professions. Germanovich and Ferrante described osteopathic treatment of rib dysfunction in a case series of 3 patients who presented with symptoms similar to those of the patient described in this case report. First they were treated with an ultrasound-guided intercostal nerve block at the level of dysfunction to prevent pain and guarding. Once the nerve block was administered, osteopathic manipulation was used for a manual reduction of the rib. The combination of treatments was more effective for long term relief than monotherapy.6
A 2015 systematic review of noninvasive musculoskeletal thoracic spine or chest wall pain management found evidence to support inclusion of chiropractic treatment in the management of MSK chest pain. Patients who received multimodal care (chiropractic treatment and patient education) were 40% more likely to report clinically important improvements in their chest pain.10 The authors concluded combined efforts from cardiology and chiropractic in a multidisciplinary approach could help to provide a better understanding of benign chest pain, improve patient outcomes, and lead to faster recovery.7;15 Cost analysis of chiropractic treatment of patients with non-cardiac chest pain illustrated lower overall hospital and healthcare services in the group that received chiropractic care compared with patients in the self-management group.16
The exact mechanism by which manipulative therapy may decrease non-cardiac chest pain is not entirely clear. 7;10 The authors suggest a misalignment at the costovertebral joint can cause biomechanical stress at the corresponding costosternal joint, which is perceived as chest wall pain by the patient. Future studies are needed to examine the potential for improved outcomes in patients discharged from EDs who are referred for chiropractic care and the impact of chiropractic management of CWS.
As this is a single case report, generalized conclusions cannot be drawn from this patient to others presenting with non-cardiac chest pain resulting from costovertebral joint dysfunction. Additionally, there has been no follow-up beyond 15 months and it remains unclear whether or when the patient’s pain might recur. A larger scale study would be needed to make determinations regarding efficacy, safety, or cost-effectiveness of the treatment described.
This case report describes the chiropractic treatment of a 66 year-old male with a complaint of non-cardiac chest pain resulting from costovertebral joint dysfunction. Once AMI was ruled out, chiropractic evaluation was utilized to find costovertebral fixation. Costovertebral fixation was found to correspond with the costosternal joint at which the patient had experienced chest pain. The patient experienced resolution of chest pain within 24 hours of costovertebral joint mobilization.
Written informed consent was obtained from the patient for publication of this case report. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
List of Abbreviations
AMI—Acute myocardial infarction
CWS—Chest wall syndrome
NRS—Numeric rating scale
The authors declare that they have no competing interests.
1. Bhuiya FA, Pitts SR, McCaig LF. Emergency Departmane Visits for Chest Pain and Abdominal Pain: United States, 1999-2008. 2010. U.S. Department of Health and Human Services.
2. Stochkendahl MJ, Christensen HW, Vach W, Hoilund-Carlsen PF, Haghfelt T, Hartvigsen J. Diagnosis and treatment of musculoskeletal chest pain: design of a multi-purpose trial. BMC Musculoskelet Disord 2008;9:40.
3. O’Shea L. Differential diagnosis of chest pain. PRACT NURSE 2010;40:13-18.
4. Weiss AJ, Wier LM, Stocks C, Blanchard J. Overview of Emergency Department Visits in the United States, 2011: Statistical Brief #174. 2006.
5. Verdon F, Burnand B, Herzig L, Junod M, Pecoud A, Favrat B. Chest wall syndrome among primary care patients: a cohort study. BMC Fam Pract 2007;8:51.
6. Germanovich A, Ferrante FM. Multi-Modal Treatment Approach to Painful Rib Syndrome: Case Series and Review of the Literature. Pain Physician 2016;19:E465-E471.
7. Stochkendahl MJ, Christensen HW, Vach W, Hoilund-Carlsen PF, Haghfelt T, Hartvigsen J. Chiropractic treatment vs self-management in patients with acute chest pain: a randomized controlled trial of patients without acute coronary syndrome. J Manipulative Physiol Ther 2012;35:7-17.
8. Kahn SE. The challenge of evaluating the patient with chest pain. Arch Pathol Lab Med 2000;124:1418-1419.
9. Dwyer A, Aprill C, Bogduk N. Cervical zygapophyseal joint pain patterns. I: A study in normal volunteers. Spine (Phila Pa 1976 ) 1990;15:453-457.
10. Southerst D, Marchand AA, Cote P et al. The effectiveness of noninvasive interventions for musculoskeletal thoracic spine and chest wall pain: a systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) collaboration. J Manipulative Physiol Ther 2015;38:521-531.
11. Galinski M, Saget D, Ruscev M et al. Chest pain in an out-of-hospital emergency setting: no relationship between pain severity and diagnosis of acute myocardial infarction. Pain Pract 2015;15:343-347.
12. Stochkendahl MJ, Vach W, Hartvigsen J, Hoilund-Carlsen PF, Haghfelt T, Christensen HW. Reconstruction of the decision-making process in assessing musculoskeletal chest pain: an exploratory study using recursive partitioning. J Manipulative Physiol Ther 2012;35:184-195.
13. Christensen HW, Vach W, Manniche C, Haghfelt T, Hartvigsen L, Hoilund-Carlsen PF. Palpation for muscular tenderness in the anterior chest wall: an observer reliability study. J Manipulative Physiol Ther 2003;26:469-475.
14. Blum CL. ChiroACCESS: Article, Chiropractic Technique Summary: Sacro Occipital Techique (SOT). 7-13-2011.
15. Stochkendahl MJ, Christensen HW, Vach W, Hoilund-Carlsen PF, Haghfelt T, Hartvigsen J. A randomized clinical trial of chiropractic treatment and self-management in patients with acute musculoskeletal chest pain: 1-year follow-up. J Manipulative Physiol Ther 2012;35:254-262.
16. Stochkendahl MJ, Sorensen J, Vach W, Christensen HW, Hoilund-Carlsen PF, Hartvigsen J. Cost-effectiveness of chiropractic care versus self-management in patients with musculoskeletal chest pain. Open Heart 2016;3:e000334.