Valerie Phelps PT, ScD, OCS, FAAOMPT, & Jean-Michel Brismée, PT, ScD, OCS, FAAOMPT
QUESTION:
Does a dysfunction of the costotransverse joint induce a positional (biomechanical) disturbance that can be identified in clinical examination?
ANSWER:
It is unlikely that a stiffness purely at the costotransverse joint will manifest with an observable aberration in observation of trunk mobility. In clinical examination the spring test is used to provoke pain in the costotransverse joints and access end feel of the joints with dysfunction/pain in comparison to those ribs with normal mobility. This is primarily an end-feel and pain provocation test; it is likely that this is the best way to determine a dysfunction at the costotransverse joint.
QUESTION:
Is the costovertebral joint dysfunction solely responsible for rib malpositioning?
ANSWER:
1. We should be cautious in using the phrase that a rib is “out of place” or for that matter malpositioned. In conservative care clinics, most – if not all – the time, the rib will be positioned within the realm of its movement excursion; however, the soft tissue and joint capsule(s) can have restrictions that keep it from moving through its full excursion or that keep it from achieving (or returning to) its resting position. For example, in an ankle sprain; the ankle is not malpositioned if it has a plantar flexion limit and the person cannot push off effectively; we don’t say ‘your ankle is out of place’ – we simply make note of the stiffness and restore mobility for optimal function.
2. One joint being the sole cause of a movement dysfunction may be thinking too simply. There are so many structures from myofascial to joint that are within the immediate and adjacent environment that can be involved: cranial, caudal, dorsal and ventral. All tissues have to be involved to a certain degree; therefore, there is a need to think and treat in 3-dimensions. For example, an elevated rib will affect change in the intercostal muscles, costovertebral, costotransverse joints and the thoracic segment and all of the fascial and inert connections between these structures. The rib bone doesn’t “twist on itself”(certainly within the short expanse between verterbral body and the transverse process); the radiate ligament may be shortened at the costovertebral connection and the superior capsule of the costotransverse joint would be relatively shortened as well. Research shows us that in
immobilization, the myofascial structures are the first to adapt and tighten; so you can imagine that if there is a loss of mobility at the rib joints, that there is also loss of mobility of the surrounding myofascial structures. Do you ever notice in the clinical setting that you have to repeatedly mobilize a joint on an individual? The ribs are famous for that. In this instance, it is likely that the soft tissue structures, meaning all of the myofascial connections (and that’s a lot!) are not being mobilized sufficiently. If the various muscles that attach to any particular rib are not additionally ‘stretched’ (with any of a number of myofascial techniques), the ribs will likely ‘not stay in place.’In other words, the rib stiffness will return between treatment sessions because only a part of the ‘stiffness’ was optimally treated.
QUESTION:
Does treatment to the costotransverse joint only induce pain relief?
ANSWER:
1. No, this can be performed to break fatty bridges that can develop in states of immobility (when this is the goal, manipulation works well), and to stretch the joint capsule along with other connections between the rib and the transverse process. By mobilizing the costotransverse joint, a stretch will occur to the joint capsule, extra-capsular ligaments and all of the myofascial structures that are influenced during that particular maneuver.
2. Current literature validates that one of the primary effects of mobilization is neurophysiological, and this in turn is an important mechanism behind reduction in acute pain and inhibition of reflex muscle contractions. The achievement of neurophysiological effects requires movement at the joint, resulting in a hysteresis effect. Hysteresis involves inhibition of low threshold mechanoreceptors and inhibition of high threshold nociceptors, both of which result in a reduction of intraarticular pressure and peripheral afferent discharge.
QUESTION:
Is there differential testing for the costotransverse and costovertabral joint and a distinctive dysfunctional pattern that appears with testing?
ANSWER:
1. It can get rather theoretical to try to isolate one joint from the other when one wonders whether one really can affect change on one without the other.
2. One cannot differentiate which of the 2 joints (CV or CT) is problematic with any kind of specificity on manual testing; however, the need to do so could be purely academic, as clinically it seems to matter very little.
There are several clinical tests discussed in the two IAOM courses, 1) Thoracic Spine and Ribs and 2) Thoracic Outlet Syndrome and Cervicothoracic Junction, that emphasize one joint over the other, theoretically.
To test general rib dysfunction, the examiner can simply place the hands on the ventral aspect of the upper ribs and the lateral aspect of the lower ribs and ask the patient to breathe in and out deeply. Ribs 1 to 5 should move ventrally and ribs 6 to 10 laterally during a deep breath in; the examiner should also register a return to the resting position and beyond with deep exhalation. The spring test is applied to test the costotransverse (the more lateral) joints, and the position test is utilized to test the costovertebral joints.
QUESTION:
Is there a specific sequence to treat costotransverse or costovertabral joints?
ANSWER:
1. There are no specific research results that have evaluated the effect of costotransverse or costovertebral mobilization and the sequence of those on patient’s
improvements in mobility and pain.
2. The decision to mobilize costotransverse before costovertabral joint is more empirical; it seems to work better and be better tolerated by the patient. The IAOM
proposes starting with the more lateral or peripheral joint, the costotransverse, before trying to influence the costovertebral (a deeply medial) joint.
References
1. Edge-Hughes L. Canine thoracic costovertebral and costotransverse joints: three case reports of dysfunction and manual therapy guidelines for assessment and treatment of these structures.
Top Companion Anim Med. 2014 Mar;29(1):1-5.
Additional Resources
Diagnosis and Treatment of the Spine, Nonoperative Orthopaedic Medicine and Manual Therapy
Dos Winkel, Geert Aufdemkampe, Omer Mattthis, Onno G. Meijer, Valerie Phelps; Gaithersburg,
Maryland: Aspen, Publishers, 1996.
Sizer P, Phelps V, Azevedo E. Disc-related and non-disc related disorders of the thoracic spine. Pain Practice. 2001; 1,2: 136-149.
Brismée JM, Phelps V, Dedrick G, Sizer PS. (2006). Diagnosis-Specific Orthopedic Management of the Thoracic Spine and Ribs. Educational Resources from the International Academy of Orthopaedic Medicine-Orthopedic Physical Therapy Products, Minneapolis (#446 DVD).