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Occasionally, and typically following trauma, but not always, one can sustain an injury to the juncture between the ribs and the cartilage between the breast bone (the sternum) and the ribs. Alternatively, the irritation can arise between the sternum and the cartilage. I usually see these sorts of injuries after a motor vehicle accident where the seat belt coming across the rib cage creates the injury or when the chest is driven into the steering wheel is the cause. I have one recent case where the irritability was not traumatic at all, but came on after a case of severe and persistent coughing. Patients following open heart surgery often have to deal with this injury.
This is a difficult injury to manage because there is not much blood supply, and it is made more difficult to treat in hitting and throwing athletes because the rib cage needs to be able to rotate forcefully in those situations.
The pain is felt on the outer third of the chest wall, and is seemingly irritated with breathing deeply. Palpation of the joint line can illicit pain. The pain can be bilateral, but is most often unilateral.
The best treatment for this condition is a combination of aerobic exercise, even though it might hurt to breath at first, ice on the irritated chest wall, and a therapeutic dose of NSAID’s on board as tolerated. Physical therapy in the form of manual therapy is valuable to oscillate the joints to promote healing, but this is tricky and needs to be done very carefully. Also, mobilizing the thoracic spine through exercise is key. I really like the TRX as a tool here.
The bottom line is that this is an injury that takes a long time to heal, and is easily irritated again, so the return to sport must be managed on a gradient. For example, in the case of a baseball player returning to practice, I would suggest short toss until that was pain free, then gradually working their way to long toss before trying any hitting drills or throwing in form the outfield. As for hitting drills, swing next to a fence until that was pain free before hitting off a tee, before hitting any soft toss pitches, before hitting any regularly pitched balls, before throwing in from the outfield. In the case of tennis for example, ground strokes before overhead strokes and so on.
I'm female, 28, was an athlete, and have suffered from costo for almost 3 years. I've seen over 50 doctors with little success. Currently doing manual massage with a massage therapist. There isn't a shot, medication, or therapy I haven't tried. I've been very aggressive about trying to find treatment…I've quit my job to the pain and am struggling each minute with this. I've had a difficult time finding a physical therapist within 100 miles that knows how to treat this condition or to be honest, even knows what it is….I was curious about the mobilizing the spine through exercise? Will this help? I cannot even pick up a pen without pain. thanks in advance for any advice!!! Have you heard of the gastron technique? I'm thinking of trying that as well….thanks! I would be blessed by anything you can offer…also..is bed rest a good idea? I'm driving myself bonkers =)…Lauren Lucille nyctexangal@yahoo.com
Comment by Lauren Lucille — July 5, 2009 @ 2:55 pm
Lauren, I really feel for you. This is a very difficult injury for sure. Honestly, the real key to this is aerobic exercise. The gentle expansion of the rib cage as your breathing deepens is the best way to lubricate and feed the structures of the chest wall. As you inspire, the lower ribs spread and as the breathing deepens further, the upper ribs are lifted. This repetitive oscillation is key to the long term solution and ultimate resolution of your condition.
As for thoracic mobilizing exercises, try this one: On your hands and knees, place one hand behind your neck. Then very gently, bring the elbow toward the elbow of the arm stabilizing you on the floor. Try really hard to do this without pain. Then, bring your elbow away from the arm as you rotate the opposite direction as far as you can pain free. Do at least 8 of these three or four times with one minute between sets. Start with one set, and wait at least 3 hours before you try again because it might take that long for you to feel if you have overdone it. If you tolerate the exercise well, build up the tolerance until you can do three sets three times a day.
Let me know how this goes, then I can give you another exercise to try.
The Gastron Technique is really not suitable for this condition unfortunately since it is more of a soft tissue mobilizing strategy that actually works quite well when used in the musculature or over irritated tendons. But because this is really a bone to cartilage joint that is irritated, the methods I describe make more sense to me.
Bed rest, Lauren, is the worst possible idea! I prefer you get aerobic exercise even by swimming if you need to, but at least by walking, OK?
Neil
Comment by Neil Chasan, PT, MMT — July 5, 2009 @ 5:31 pm
Neil,
I will try this exercise for a few days and let you know how it goes. I was able to do 2 sets if I didn't put weight on the hand on the ground, I could feel the expansion the exercise was asking of me. Thank you very much for your time and reply. I really appreciate it, very generous.
I am currently walking about 45 min a day- I have wondered if this is a poor choice-it hurts, any and every light bouncing movement, but i will continue it lightly, and focus on the expansion of my rib cage.
I know bed rest seems nuts…it's just laying still as I can is the only thing that helps…I will quickly discard such crazy ideas. =)
Thank you again,
Lauren Lucille
Comment by Lauren Lucille — July 5, 2009 @ 9:25 pm
Lauren, try a stationary bike perhaps instead of walking if walking hurts. It is important to find a way to exercise pain free from my point of view. That walking hurts is interesting. It raises another question for me: Would you describe yourself as super flexible (hypermobile)?
Comment by Neil Chasan, PT, MMT — July 5, 2009 @ 10:14 pm
Yes, I would say before all of this I would have said I was extremely flexible. I did cheer leading for 6 years…Double jointed even in a couple places even. Now I stretch lightly every day. yet my flexibility is now out the window!
The bike is a wonderful idea as well…for some reason, the sitting position is very painful and even the slight exersion it takes to push the pedals is painful in my ribs…silly, huh? Drives me up the wall!
I've also tried the elliptical, swimming, tread climber, and the arc trainer…desperate to keep in some sort of shape…no dice as of yet.
I've also tried bands, light weights, even just body weight and they all feel like daggers through my chest…just lifting my arm is painful. I know, weird!
Currently when I do get my ribs lightly massaged (2 times a week), I've noticed that I can go about an hour that day able to breathe better, which has been a blessing. I'll take that hour.
…I have done the pt exercise you gave me again today twice- so far so good!
Thank you!
Lauren
Comment by Lauren Lucille — July 6, 2009 @ 8:55 am
I am a 27 year old male, and was playing soccer 10 days ago when I recieved a knee the area of my right false rib area. I was winded and the pain was excruciating, but I was sure it was not a fracuture. The symptoms I had were pain when coughing/laughing/sneezing, at the site of impact, but also in the right side of my back. Sleeping on my sides was very painful and moving from a supine to sitting position was painful at the front and back. I went to a physio and had a massage and micro current 3 days ago which sorted my back pain out, but the pain at the site of impact is still there. Also I have dark brusing on the right side just above my waist but no pain at all. I would say my condition is better now than it was a week ago however coughing and getting up from bed in the morning are still very painful.
Do you think this is serious? if not how long do you think it will take before I can get out of bed with no pain? Also are there exercises which you can recommend?
Many thanks
MH
Comment by insidealbania — July 6, 2009 @ 10:32 am
MH, it sounds like you have a deep bruise. Ice and heat (contrast therapy) will sort out the bruise. Use ice for a couple of minutes, then heat for a couple of minutes and so on for about a half hour a day. NSAID's will also help I am sure. Good luck.
Neil
Comment by Neil Chasan, PT, MMT — July 8, 2009 @ 10:31 am