Case of the Week 5-14-12: It Hurts to Laugh! | Modern Manual Therapy Blog - Manual Therapy, Videos, Neurodynamics, Podcasts, Research Reviews

Case of the Week 5-14-12: It Hurts to Laugh!

I had a student recently who stated one of his left mid ribs was always "going out of place."

For those of you who do not believe in palpation for position, I would still read on, as the solution did not rely on palpation and manipulation.

History: 25 yo male DPT student who works out avidly. He c/o chronic left thoracic and rib pain of insidious onset. He was unable to laugh, lift, or press anything of moderate weight without one of his left mid ribs "going out" and causing pain. Where did it go? To instability-ville! Sx were worse with rotation left, reaching forward and overhead with left UE. The pain was intermittent and felt in mid thoracic spine radiating to around a rib.

For anyone who says you cannot reliably palpate a positional fault, maybe it is because as therapists, the inter-rater reliability of even agreeing on a spinal level is rather poor. However, other clinicians and students in the clinic could absolutely identify his painful rib, which was also quite posteriorly rotated.

Multisegmental Rotation

  • left: dysfunctional, painful, moderately limited
  • right: functional, non-painful
  • Breakouts revealed functional but painful trunk rotation in lumbar locked upper and lower trunk rotation to the left
  • incidentally, he also had limited hip IR and tibial IR bilaterally, but that is another story
Cervical Screen functional and non-painful in all planes

Shoulder IR and ER scratch tests, functional non-painful, bilaterally except left shoulder IR which was dysfunctional, non-painful showing excessive scapular dyskinesis

Myofascia: moderate restrictions along bony contours "of that rib" and left > right thoracic paraspinals in the mid thoracic area

Assessment: Signs and Sx consistent with thoracic derangement and scapular dyskinesis

Treatment: This occurred over several weeks as they were not formal sessions, since he was interning at our clinic!

  • first started with IASTM to the bony contours of the rib and thoracic spine, plus FR to the pec minor
  • thrust manipulation to the levels around the painful area
  • HEP was McKenzie thoracic "whips" in sitting (ballistic trunk rotation) to the painful side or left
    • he reported for 2-3 weeks that this was successful at "putting his rib back into place" each time "it went out"
    • for a few weeks, it still felt posteriorly rotated, but started to become less
  • the frequency of his "going out" did not change, despite his successful self management
  • seated thoracic rotation was now FN, but shoulder IR was still DN with dyskinesis
  • for the next 2-3 weeks I added mid trap strengthening with bands, scapular protraction and eventually progressed him to baby get-ups with a 20# kettlebell
  • the baby-get ups were progressed to bottoms up, requiring more stability
  • he was very compliant as I saw him performing these corrective exercises several times throughout the day
  • by the end of his internship, he said his rib "barely goes out," it no longer felt posteriorly rotated (and if it did, who cares), and he was able to work out and most importantly laugh without pain
Some food for thought
  • would the corrective exercises gotten him better without the initial manual work?
  • or vice versa, if we started with corrective exercises and stabilized the scapula first, would we have then needed to do the manual work?
These come from my MDT bias and giving as little exercises as possible for compliance reasons and following the derangement model. It may not have taken as many weeks if he were coming for regular sessions as opposed to "Hey how's the rib doing now?" when I thought of it.

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