Costochondritis Physical Therapy Exercises

costochondritis physical therapy exercises 1
graphic costochondritis physical therapy exercises 1

Costochondritis Physical Therapy Exercises

Chest and rib injuries have a high prevalence (26%) among female rowers.1–3 Pain which is localized to the costochondral or costosternal joints is typically associated with the diagnoses of costochondritis or Tietze’s syndrome. There is a higher prevalence in females both in general4,5 and athletic populations such as rowing.1 The diagnosis is usually based on clinical symptoms2 and imaging studies offer little value.6 These two conditions are relatively similar with the exception that costochondritis exists without swelling, heat, or erythema.2 Pain can be provoked with upper extremity movements, most commonly shoulder horizontal adduction.2 Symptoms may be recurrent5 and persist for months,7 but are thought to typically resolve within 1 year.4,8Costochondritis does not have an associated known etiology, but is thought to be due to inflammatory conditions, trauma, or insidious onset.2 Limited reports of proposed mechanisms of injury include pull of surrounding musculature,3 repetitive arm adduction,3 and hypomobility of posterior spinal structures.3,9,10 Costochondritis is thought of as a self-limiting condition2 allowing individuals to continue athletic participation as symptoms allow. Conservative management is usually symptomatic2,3,11 and includes reassurance,2 oral analgesics,2 and local injections.5,7 Cases in which symptoms do not dissipate with typical conservative management can present challenges for the patient and clinician. Patient reevaluation and attempts to further identify the underlying cause of symptoms may be necessary.Recent clinical suggestions12 and case reports have included the use of manual therapy interventions directed at the thoracic spine in the management of rib injuries.3,9,10 The rib and associated thoracic vertebral segment can be described as a fixed ring analogous to a hula hoop. Movement and stress applied at one portion can be transmitted through the entire ring. For example, during thoracic flexion the posterior rib rotates anteriorly (internal torsion) and elevates while the anterior portion of the rib translates inferiorly.13 Similar types of coupled motions occur with rotation and side-bending as well.13Unfortunately the potential mechanical explantation for the cause of costochondritis is limited.2,10 Altered thoracic spine and rib mobility may be a factor associated with the development of costochondritis and identification of the underlying cause of costochondritis is necessary for appropriate management. The purpose of this case report is to provide additional insight into the examination, evaluation, and treatment of persistent costochondritis in an elite athlete as well as propose an explanation for chronic dysfunction by examining rib and thoracic spine osteokinematics and arthrokinematics.
costochondritis physical therapy exercises 1

Costochondritis Physical Therapy Exercises

DiscussionTypically costochondritis is thought to be a self-limiting condition which spontaneously resolves with reassurance and relative rest.2 For the general population these measures may provide adequate relief of symptoms. For elite athletes, reassurance, relative rest from activity, formal rehabilitation program, and medical interventions such as joint injection may not resolve symptoms to allow an athlete to resume/continue competitive training. Identification of the underlying causative factors and impairments relative to chronic costochondritis is necessary to appropriately manage this condition.The rib and associated thoracic vertebral segment can be described as a segmented ring with mobile segments/articulations of the vertebrae, ribs, and sternum. Movement and stress applied at one portion can be transmitted through the entire ring. Thoracic flexion is coupled with posterior rib elevation and anterior rotation (internal torsion) which translates the anterior portion of the rib inferiorly.13 Thoracic rotation causes the contralateral rib to anteriorly rotate (internal torsion) and the ipsilateral rib to posteriorly rotate (external torsion).13 Lateral or side bending causes the lateral margin of the rib to approximate and the contralateral lateral margin to separate.13The individual in this case report performed repetitive thoracic flexion, left rotation, and side bending associated with rowing starboard side. The osteokinematics associated with this movement pattern include anterior rib movement in an inferior direction coupled with anterior rotation (internal torsion) and lateral rib approximation.13 This places additional stress on the anterior portion of the rib at the costosternal and costochondral joints which are attached to a relatively stable sternum.It is important for clinicians to recognize structures distant to the site of pain may contribute to dysfunction. It is common to examine distal and proximal joints in the extremities, but examination of distant structures associated with rib pathology is not as commonly described in the literature.9,10 This case report proposes a mechanistic rationale in which hypomobility and tightness of posterior spinal structures may place additional stresses at the anterior joints of the chest wall, which may manifest as hypermobility. Solely directing interventions at the site of pain and swelling may not fully abate symptoms related to costochondritis. Addressing hypomobility of posterior spinal structures and reinforcement of correction via postural reeducation and exercise can decrease loads placed on the joints of the anterior chest wall, which may have allowed for a more thorough recovery in this case study.Clinical examination findings included slight anterior prominence of the left third and fourth costosternal joints, restricted mobility of the third and fourth ribs with inferior displacement of the third rib on the fourth, hypomobility of the T3–4 facet joints into extension, and hypomobility of the third and fourth costovertebral joints on the left side. These findings are logical due to the repetitive pattern of the rowing stroke performed thousands of times each practice. We hypothesized that as the posterior thoracic facet joints and costovertebral joints became hypomobile, the relative motion was regained anteriorly, via hypermobility, at the costosternal joint. Pain and swelling at the costosternal joints were potentially related to repetitive tissue stress. Reducing stress on anterior tissues by restoring posterior thoracic mobility provides plausible rationale for intervention outcomes.The use upper thoracic mobilization and manipulation for the treatment of rib dysfunction is not a new concept. It has previously been described for the treatment of costochondritis in case report format as an adjunct therapy for a physiotherapist,10 a photographic processor10 and a volleyball player.9 The first report10 suggested the underlying cause was related to neurogenic inflammation whereas the other9 briefly discussed the potential contribution of hypomobile costovertebral and costotransverse joints. Thoracic and rib joint mobilization has also been utilized in the treatment of rowers with rib stress fracture.18,19 These reports also suggested that rib stress fracture symptoms may have been related to hypomobility of the thoracic spine and costovertebral joints. Based on the findings associated with this case report, as well as our clinic experience with the management of both costochondritis and rib stress fractures, we are in agreement with previous reports3,9,10 that hypomobility of the thoracic spine and costovertebral joints may contribute to anterior thoracic cage pathology.LimitationsResults of this case report should be approached with caution due to the nature the single subject design and limited reliability and validity of examination methods such as spinal joint mobility assessment.20,21 The timing of symptom resolution during the last month of her fourth year of collegiate rowing also made it difficult to determine if symptoms would have remained diminished should the patient have returned to her previous level of training and competition. Since the patient graduated from the university and was not a national team candidate, she concluded her rowing career. Thus, we were also unable to determine if pain would have returned upon resuming rowing during the following fall season. Finally, a causal relationship between interventions and symptom abatement cannot be made. It is possible that symptoms decreased as a result of natural progression of costochondritis.9,10 Further research is necessary to better determine the relationship between the thoracic spine and posterior and anterior rib articulations.
costochondritis physical therapy exercises 2

Costochondritis Physical Therapy Exercises

Costochondritis can affect children as well as adults. A study of chest pain in an outpatient adolescent clinic found that 31 percent of adolescents had musculoskeletal causes, with costochondritis accounting for 14 percent of adolescent patients with chest pain.5 In this series, no definite cause of chest pain was found in 39 percent of cases.5 In a prospective series of children three to 15 years of age presenting to an emergency department or cardiac clinic with chest pain, chest wall pain was the most common diagnosis, with respiratory and psychogenic conditions the next most common diagnoses.8Costochondritis is a common diagnosis in adults with acute chest pain. It is present in 13 to 36 percent of these patients, depending on the study and the patient setting.4,7,24 In a prospective study of adult patients presenting to an emergency department with chest pain, 30 percent had costochondritis. A prospective study of episodes of care for chest pain in a primary care office network found musculoskeletal causes in 20 percent of episodes of care, with costochondritis responsible for 13 percent.9 These data are similar to a study of patients with noncardiac chest pain that found reproducible chest wall tenderness (although not specifically defined as costochondritis) in 16 percent of patients.4 A European study found a higher prevalence of musculoskeletal diagnoses in patients with chest pain presenting in primary care settings compared with hospital settings (20 versus 6 percent, respectively).10Costochondritis usually affects the third, fourth and fifth costochondral joint and occurs more often in women. Whereas Tietze’s syndrome most commonly affects one joint, in particularly the second or third costal cartilage and both sexes are affected equally.57 Both diseases can start either acute or progressively at any age.
costochondritis physical therapy exercises 3

Costochondritis Physical Therapy Exercises

Costochondritis may be treated with physical therapy (including ultrasonic, TENS, with or without nerve stimulation) or with medication. Treatment may involve the use of nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or other pain relief medications (analgesics) such as acetaminophen. Severe cases of costochondritis may call for the use of opioid medications such as hydrocodone or oxycodone, tricyclic antidepressant medications such as amitriptyline for pain from chronic costochondritis, or anti-epileptic drugs such as gabapentin may be used. Oral or injected corticosteroids may be used for cases of costochondritis unresponsive to treatment by NSAIDs; however, this treatment has not been the subject of study by rigorous randomized controlled trials and its practice is currently based on clinical experience. Rest from stressful physical activity is often advised during the recovery period.

Costochondritis Physical Therapy Exercises

Costochondritis Physical Therapy Exercises
Costochondritis Physical Therapy Exercises
Costochondritis Physical Therapy Exercises

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