- January 2001
Clinical Corner:
When Patients With Chest Pain Need Chiropractic Care
By Al Ueda, D.C. and Gregg Carb, D.C.
A
thirty-two year old male in good general health sought chiropractic
evaluation for complaints of left-sided chest pains of a throbbing and
achy quality. He had a history of rapid onset chest pains about two
weeks after driving cross-country. He had previously seen four
successive medical physicians at the County General Hospital. Diagnostic
procedures undertaken over a six-month period included physical
examination, blood analysis, chest x-ray, EKG, treadmill test, and
echocardiogram. The last physician he saw diagnosed costochondritis.
Treatment prescribed was anti-inflammatory medication.
On chiropractic examination he was found to have a palpable lump
and specific tenderness at the left fifth rib costochondral joint, and
mid-thoracic spine costovertebral fixation as well. Posturally, he had
anterior head translation and forward rounded shoulders with internal
arm rotation. He was treated on a chiropractic basis with axial spine
adjustments and instructions for stretching in extension with the arms
externally rotated. He was seen on six occasions over a period of four
weeks and released with minimal/occasional residual discomfort.
Background
Costochondritis is a common, but poorly understood condition
among patients with chest wall pain.1 Various musculoskeletal structures
of the thoracic wall and the neck can be a source of chest pain. Pain
arising from these musculoskeletal structures is often mistaken for
angina pectoris, pleurisy or other serious disorders.2 The more common
causes are costochondritis, traumatic muscle pain, trauma to the chest
wall, “fibrositis” syndrome, referred pain, psychogenic regional
pain syndrome, and arthritis involving articulations of the sternum,
ribs and thoracic spine.3
The costochondral joint is that junction between the rib and the
chondral cartilage in the anterior ribcage. The chondral cartilage, not
the bony rib itself, is what actually contacts the sternum. The chondral
cartilage of the first rib is rather short, so the first costochondral
joint is close to the sternum. Proceeding inferiorly, the chondral
cartilages become longer, such that the lower costochondral joints are
further lateral from the sternum. The forth costochondral joint
approximately underlies the nipple. In costochondritis, a definite and
markedly tender “lump” can be palpated at the involved costochondral
joint, whereas adjacent uninvolved costochondral joints are non-lumpy
and much less tender.
Since patients with costochondritis present with chest pain, a
differentiation must be made from disorders that represent potential
medical emergencies. Angina Pectoris, a condition caused by myocardial
ischemia, is characterized by episodes of substernal pain or pressure,
typically precipitated by exertion and relieved by rest. The discomfort
of angina pectoris may radiate to the left shoulder and down the inside
of the left arm, even to the fingers. It may radiate straight through to
the back, into the throat, the jaws, the teeth, and occasionally even
down the right arm. During an attack, the heart rate usually rises and
blood pressure is frequently elevated. Myocardial Infarction is caused
by an abrupt reduction in coronary blood flow to the heart muscles,
resulting in ischemic myocardial necrosis. The pain is similar in
character to that of angina pectoris, but not relieved by rest, and
usually accompanied by arrhythmia, apprehension, restlessness, and
palor.4 Therefore, in patients presenting with deep chest pain, with or
without radiation, brought on by exertion and relieved by rest, or
accompanied by signs of shock, cardiac disease should first be ruled out
by medical referral.
Studies
Disla1 et al prospectively analyzed patients presenting to the
emergency department with chest pain, not due to trauma, fever, or
malignancy. Of 122 consecutive patients studied, 36 had costochondritis
(30%). Women made up 69% of the costochondritis patients. Only three
patients (8%) with costochondritis met the American College of
Rheumatology criteria for fibromyalgia. Rheumatoid arthritis and
osteoarthritis were diagnosed in only five costochondritis cases. One
year later, 11 (55%) of 21 patients with costochondritis were still
suffering from chest pain, but only one third still had definite
costochondritis.
Klinkman5 et al established a primary care research network to
prospectively collect detailed information on episodes of care for chest
pain. Over a 12-month period, clinicians prospectively collected
demographic, clinical, and clinician decision-making information for all
patients seen in their offices with the complaint of chest pain. Three
hundred ninety-nine complete episodes were collected and used for
analysis. Episodes were well distributed among urban, rural, academic,
and private sites. Musculoskeletal chest pain accounted for 20.4% of all
diagnoses, followed by reflux esophagitis (13.4%) and costochondritis
(13.1%). Stable angina pectoris was the primary diagnosis in only 10.3%
of episodes, unstable angina or possible myocardial infarction in 1.5%.
The authors of the research concluded that resource use (i.e. $) during
episodes of chest pain in primary care are directed toward exclusion of
cardiac disease, despite the surprisingly low frequency of cardiac
diagnoses.
Peyton6 studied the records of patients seen in a two-year period
in a private gynecologic practice, and a one-year period in the
emergency department of a general hospital, prompted by the incidence of
chest wall pain diagnosed as costochondral pain. The study revealed 76
women in the former practice and 156 men and women in the latter with
this condition. The author urged physicians to understand this symptom
complex and be aware of the frequency of its occurrence in patients
presenting with chest pain and fearing breast cancer or cardiac disease.
It was again noted that costly, intensive investigation can be avoided
with proper evaluation, in particular, when careful, deep palpation of
the costochondral junction discloses pain traversing the rib under the
breast, leading to a diagnosis of idiopathic costochondral pain.
Treatment
Hearon7 describes an adjustment for the costochondral
articulation whereby the doctor’s stabilizing hand (Figure One) is
placed with one finger above and below of the involved rib cartilage
with a tissue pull maintained towards the sternum. The doctor’s
contact hand (Figure Two) is placed at the involved costochondral
interval with tissue pull away from the sternum. The doctor’s contact
point used may be the index finger or the ulnar edge of the hand. A
quick thrust is made along the plane of the rib (not into the rib) and
longitudinal with the rib slope on both inspiration and expiration to
pull apart the costochondral articulation and allow the rib sheath to
align the segments.
It is not uncommon for rib pain patients to also have
characteristic postural abnormalities that place greater strain on the
rib articulations. Those abnormalities include translations of the head
on the thorax, shoulder distortions (glenohumeral anterior
translation/rotation and scapular protraction), and internal thoracic
cage distortions such as hyperkyphosis. Those contributory factors
should be managed with CBP®¨ mirror-image¨ based8 adjustments and
exercise/ stretch instructions. Chiropractic management of well-selected
chest pain patients can save a great deal of time, money and anguish for
what may otherwise become a waste of medical resources on a simple
musculoskeletal patient.
References
1.
Disla E, Rhim HR, Reddy A, Karten I, Taranta A. Costochondritis.
A prospective analysis in an emergency department setting. Arch Intern
Med 1994 Nov 14; 154(21):2466-9.
2.
Fam AG. Approach to musculoskeletal chest wall pain. Prim Care,
1988 Dec; 15(4):767-82. Review.
3.
Fam AG, Smythe HA. Musculoskeletal chest wall pain. CMAJ. 1985
Sep 1; 133(5):379-89.
4.
Merck Manual of Diagnosis and Therapy. Merck & Co, Inc.
Rahway, NJ. 1982.
5.
Klinkman MS, Stevens D, Gorenflo DW. Episodes of care for chest
pain: a preliminary report from MIRNET. Michigan Research Network. J Fam
Pract 1994 Apr; 38(4):345-52.
6.
Peyton FW. Unexpected frequency of idiopathic costochondral pain.
Obstet Gynecol. 1983 Nov; 62(5):605-8.
7.
Hearon KG. What You Should Know About Extremity Adjusting - 8th
edition, 1990. P.O. Box 1887, Boise, ID 83701.
8.
D. Harrison. Chiropractic: The Physics of Spinal Correction. CBP®¨
Technique, 1994.
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