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A Case Study on the Mal-Aligned Rib Cage

In this case study, a client presented a history of persistent back pain around the thoracic region caused by a mal-positioned rib leading to thoracic spinal stiffness and pain at the surrounding soft tissues.

In the past, the client had sought treatments which consisted of direct treatment to the thoracic region of the spine including mobilisation and manipulation of the thoracic spine. However, relief was temporary. Stiffness of the spinal joint and pain returned fairly quickly after each treatment session. Exercises and trigger point releases have not worked and only provided limited relief. This pointed to the presence of an underlying cause for thoracic spine stiffness and muscle tightness. It was determined that the rib cage was mal-aligned or more specifically a rib was mal-positioned. This affected the mobility of the associated thoracic vertebrae, causing thoracic spine stiffness and therefore pain around the upper back region.

In a case of maligned ribs, they may sit superiorly (held in inhalation), inferiorly (held in exhalation, anteriorly or posteriorly. This can be determined through palpation of the ribs and compared against the better side of the rib cage as the client takes deep breaths. Is the symptomatic side is not rising as high – stuck in exhalation or held inferiorly, or not falling as deeply – held in inhalation or held superiorly?

Next, we need to determine the cause of what is holding the ribs in inhalation or exhalation. Possible causes include strong scalenes from shallow breathing, weak external obliques, tense intercostal muscles holding the ribs in position for ribs held in inhalation or for ribs held in exhalation, the rib may be locked at the costovertebra junction. Generally, ribs are more often found to be held in inhalation than in exhalation.

Treatment consists of first determining the point of pain on the thoracic spine, then working to increase the rib mobility. Rib mobility can be increased through mobilisation, muscle-energy techniques, and soft-tissue mobilisation over the intercostal muscles and scalenes. We begin first increasing the mobility of the last rib stuck in inhalation before progressing onto the next rib above.

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