Letters to the Editor

Townsend Letter for Doctors and Patients,  July, 2001  

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Sternal-Costal (SC) and Vertebro-Costal (VC) Syndrome: A Typical Case History

Editor:

Peter had a sudden chest pain and as a result of the pain, he saw his family physician. He was told that the chest pain was not related to his heart and was given a diagnosis of a "pulled muscle." It was suggested he have a cardiac evaluation. He never did.

His initial pain went away but soon returned even more severely. He described it as being on one spot on his sternum. He said it worsened with non-movement and rest. The pain worried him and was aggravating, as well as interfering with his sleep. The pain increased with anxiety and tension.

In Peter's case, his primary care medical doctor was able to diagnose his condition as ribhead syndrome and referred him to me. My examination did, in fact, show an anterior (sternal) and posterior (vertebral) rib problem at the level of thoracic 5 and 6.

Patient was treated via chiropractic adjustments to the ribs at both the sternal and vertebral levels. Care started August 11, and patient was released pain free on October 13, 2000. Rib pain steadily decreased beginning with the fourth adjustment.

As is noted in the above case history (which is quite typical) pain is the most significant symptom in the SC (anterior sternal ribhead) and VC (posterior vertebral ribhead) syndrome. Also as demonstrated in this case, the subluxated rib can cause such pain that the patient fears he is having a heart attack. Many people have, in fact, checked into the emergency room because of the severity of the pain.

Let's look at some of the physiological and anatomical reasons for these fears related to the type of pain that occurs. In cases where the rib involvement is at the level of T1 and T2, the body can actually produce cardiac-type symptoms. This is because of the direct level of nerve supply from this vertebral level to the heart itself. [4] In addition, we also find direct sympathetic autonomic association between the heart and the first five vertebral rib segments.[1] At the same time, there is autonomic innervation from all seven cervical vertebral segments. [1] It is this nerve connection which will often cause a cervical torticollis when the first rib subluxation is to the anterior.

Almost without exception, the associated pain of a rib subluxation will follow the rib out along its lateral angle. It is this radiating pain that causes so much concern in the patient. In short, the pain is very atypical, not like any they may have ever had.

Because the rib is involved, the patient has severe exaggeration of pain when trying to get a deep breath. The physiologic mechanism involved is that the body's first reaction to stress associated with the flight/fight syndrome is a spasm of the intercostal muscles as the adrenergic system prepares for flight or fight.

The similarity of the symptom picture caused by the pain of the SC/VC syndrome and cardiac problems can be traced back to the fact that the heart and ribs develop from the same mesodermal layer of tissue in fetal life. Since they develop at the same time, they respond as a homologous type of reaction. [1-3] Furthermore, the sympathetic ganglia (which are located paravertebrally at the junction of the rib and vertebral body) migrate cells to the organs they will ultimately innervate. [1,2] These organs include the head, heart, lungs and pelvic viscera. Therefore, the perception of pain in the two conditions is almost identical and, in fact, no distinction can be drawn between them.

The differential diagnosis rests upon the fact that the patient will not show any positive cardiac test results when they check into the emergency room thinking they are having a heart attack because of the severity of pain associated with the SC/VC rib syndrome.

Muscle relaxants only partially resolve the patients' problems because they don't do anything to move the rib back into proper articular attitude. On the other hand, a proper adjustive correction of the rib complex will often give almost immediate relief. [4] Total relief and correction is usually complete within several weeks. In rare cases, it may be necessary to tape or place the patient in a rib belt along with adjusting, to achieve correction.

Gordon L. Townsend DC

Redmond Chiropractic Clinic

16148 NE Cleveland St. Redmond, Washington 98052 USA

425-881-7790

Fax 425-558-5676

References

(1.) Michael T. Haneline DC, FICR, Chest Pain in Chiropractic Practice, JNMS, Vol. 8, Number 3, Fall 2000.

(2.) Grant, A.P., The Syndromes of Chest Wall Pain, Int. Journal of Medical Science 1966; 6(489):367-374.

(3.) Johnson F.E., Some Observations on the use of Osteopathic Therapy in the Treatment of Patients with Cardiac Disease, Journal of the American Osteopathic Association 1976; 71(9):799-804.

(4.) Sterns, Wolf E., Costosternal Syndrome. Its frequency and importance in differential diagnosis of Coronary Heart Disease, Arch Inter Med. 1976; 136:189-191.

(5.) Dvorak J. and Dvorak V., Manual Medicine: Diagnostics, New York. Thieme Stratton, 1984; 38-39.