Ribs don’t sublux. Ribs don’t “go out”. …so what’s going on?

Dr. Bahram Jam
The following insightful article was written by Dr. Bahram Jam, DScPT, MPhty, BScPT, CredMDT and is previously published (May 27, 2016) in the Clinical Library at aptei.com in PDF form. We are thankful to him for his permission to reproduce the article here. You can read more about Dr. Bahram Jam and the Advanced Physical Therapy Education Institute (APTEI) at http://aptei.com/

bahram Ribs don't go out 1The term “subluxation” is a medical term meaning a partial dislocation. A “rib subluxation” is, therefore, a partial dislocation of a rib usually described as occurring at the costo-vertebral (CV) and or the costo-transverse (CTr) joints. A number of textbooks and health care providers have described rib subluxations in detail and proclaim it as a common clinical occurrence found in patients with localized unilateral thoracic pain. Various methods of manual therapies to identify and treat torsioned or subluxed ribs have been described by osteopaths1, chiropractors2, physiotherapists3 and massage therapists4.

bahram Ribs don't go out - manipAlthough rib subluxations or ribs “going out” are claimed to be a common finding by various health care providers, the existence of this condition remains quite controversial. Despite the lack of any scientific evidence, some clinicians argue to have diagnosed hundreds of individuals with rib subluxations and to have successfully treated these patients by a course of rib manipulations (…or by “putting the ribs back in”). One simply has to Google “rib subluxations” to find dozens of websites describing in detail the diagnosis and the treatment of this painful condition.

The reason for the controversy over the existence of subluxing ribs is that, to date, there is a lack of radiological evidence supporting the notion that CV and CTr joints actually “come out”. In addition, there are no studies to date that support the notion that a rib subluxation can be reliably diagnosed by manual palpation or that manipulation of ribs can result in the ribs “going back to their place”.

bahram-ribs-fracturesIn fact, on a PubMed search for “rib subluxation” (as of October 2015) you will find only one paper discussing a very unique case study of a single patient post severe upper thoracic trauma that presented with a superior subluxation of the first rib as seen on a CT scan5. Considering how rampant rib subluxations are claimed to be, one would surely expect more than just one patient case study in all of medical research. A PubMed search on “rib dislocations” will also not show a single study demonstrating that a human rib dislocates. On the other hand a PubMed search on “rib fractures” will produce hundreds of papers on this condition with topics ranging from radiological findings6 to conservative management options7.

Some healthcare providers claim the only method of treating a subluxed rib is by performing rib manipulations to “reposition it back into place” or else the condition is unlikely to recover. The rationale behind this argument fails as there are thousands of patients post-traumatic rib fractures who fully recover without ever undergoing a rib manipulation procedure. In fact, rib manipulation is strongly contraindicated for anyone with a rib fracture, yet when the ribs radiologically heal, the painful condition also spontaneously resolves.

Some clinicians very confidently maintain that a rib subluxation can easily occur following a quick rotation of the spine, a pull to start a lawnmower or even after a sneeze. If these relatively benign traumatic events can cause a rib to sublux, surely major thoracic traumas must inevitably produce multiple rib subluxations. One would expect of the thousands of rib fracture cases described in the literature some of them would have mentioned a rib “going out” in addition to their fracture. If the forces were strong enough to fracture ribs, would one not think the force should have also caused torsions or subluxations?

Here is a sample study to demonstrate the point. The majority of blunt thoracic traumas seen in emergency departments are associated with motor vehicle collisions and account for almost 25% of all trauma-related deaths, second only to head injuries8. A comprehensive review study on CT scan imaging of patients post blunt thoracic traumas revealed an array of potential thoracic injuries diagnosed by radiologists such as pneumothorax, hemothorax, pulmonary contusion, tracheobronchial lacerations, rib fractures, sternal fractures and sternoclavicular dislocations.9 Considering the severity of the traumas described in this paper, not one patient was ever radiologically diagnosed as having a “displaced rib” or a “rib subluxation”.

So what could be the cause of this perceived rib being out?

bahram Ribs don't go out 1One explanation may be that the costo-transverse, inter-transverse and radiate (costovertebral) ligaments, being similar to all other supportive ligaments, can get sprained when stressed. A local ligament sprain following a major or a minor trauma (such as a sneeze or a sudden twist) can result in local inflammation and local protective muscle spasms of the relatively small local muscles such as the multifidi, rotatores and levator costalis that are simply attempting to stabilize sprained CV and CTr joints. This increased protective muscle tone may explain what is felt as a “bump” in the area of the pain and assumed to be a subluxed head of a rib. Perhaps, the various soft tissue techniques, mobilizations and manipulations have the effect of reducing the protective tone of these muscles. Once the muscle spasm and local inflammation are reduced, the perceived “bump” over the CV region is also reduced and the patient reports of reduced symptoms with thoracic rotation and breathing.

bahram Ribs don't go out - anatomyA technique with which I have anecdotally had success with in managing my patients with rib sprains is rib mobilization with movement (MWM) as proposed by Brian Mulligan10. With the patient in sitting, they are asked to rotate their trunk in the direction that produces their localized rib pain and return back to neutral. The range of motion (ROM) and pain level are evaluated.

A cranial glide is applied over the lateral aspect of the rib above the painful region. While sustaining this rib elevation/unloading, the patient is asked to rotate again while ROM and pain are once again evaluated. If there is no change, the technique is repeated on a rib above or below. If MWM on a rib at a specific level is found to reduce or eliminate the pain, it is repeated 10 times.

A home program of self-MWM may be provided although it is awkward for some patients to do on themselves.

I have also found the taping of ribs sometimes provides at least temporary relief. To decide on the location and direction of taping, apply a manual superior compression force through the postero-lateral aspect of the rib cage. Now ask the patient to take in a deep breath or rotate. If the patient notes a significant improvement in symptoms, then apply the tape at that level.

In conclusion, rib subluxations have been described, identified and treated for over a hundred years, yet there is still a lack of any scientific evidence supporting the existence of such a phenomenon. Perhaps as clinicians we should embrace evidence and not instill fear into patients by describing their ribs as having “gone out” or “subluxed”, but instead describe the same condition as ribs that have been simply sprained …this is likely closer to the truth, far more reassuring to a patient and inevitably better for their recovery which is the aim of all healthcare providers.

References:

1. Greenman’s principles of manual medicine. Lisa A DeStefano; Ph E Greenman English : 4th ed. Baltimore, MD : Lippincott Williams & Wilkins/Wollters Kluwer
2. Foundations of chiropractic : subluxation Meridel I Gatterman 2nd ed St. Louis, Missouri. : Elsevier Mosby
3. Spinal Manipulation Made Simple: A Manual of Soft Tissue Techniques Jeffrey Maitland North Atlantic Books, 2012
4. Textbook of remedial massage Sandra Grace; Mark Philip Deal Chatswood, 1st ed N.S.W. : Elsevier Australia
5. Kaczynski J1, Dillon M, Hilton J. Superior subluxation of an anterior end of the first rib in a trauma patient. BMJ Case Rep. 2012 May 30;2012.
6. Assi AA1, Nazal Y. Rib fracture: Different radiographic projections. Pol J Radiol. 2012 Oct;77(4):13-6.
7. Sclafani MP, Amin NH, Delehanty E, Figler R, Williams J. Rehabilitation following an acute traumatic first rib fracture in a collegiate football player: a case report and literature review. Int J Sports Phys Ther. 2014 Dec;9(7):1021-9.
8. Scaglione M, Pinto A, Pedrosa I, Sparano A, Romano L Multi-detector row computed tomography and blunt chest trauma. Eur J Radiol. 2008 Mar; 65(3):377-88.
9. Oikonomou A1, Prassopoulos P. CT imaging of blunt chest trauma. Insights Imaging. 2011 Jun;2(3):281-295. Epub 2011 Feb 11.
10. Mobilisation with Movement: The Art and the Science Bill Vicenzino, Wayne Hing, Darren Rivett Churchill Livingstone/Elsevier, 2011

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