Costovertebral joint sprain summary PDF

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Summary of costovertebral joint pathophysiology and other differentials to consider...

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Costovertebral joint sprain The costovertebral joint (CV) is made up of the radiate ligament which joins the rib heads to the intervertebral disc and two adjacent vertebral body demi facets for ribs 2-9. (1) The ligaments are rarely at rest as they assist with thoracic stabilization, load bearing, chest wall movement and respiration. (1) CV sprains are caused by compression and/or torsional forces that are greater than the joint can withstand. This includes sudden twisting, flexion, or hyperextension of the spine, which can inflict damage to the surrounding ligaments. Forceful coughing/sneezing, poor postures and degenerative conditions may also contribute to a sprain. (1) There are neuropeptides present along the CV ligaments that activate nociceptors and propagate an inflammatory cascade leading to acute inflammation and pain. (1) Which can result in muscle spasm and associated pain. Findings A costovertebral joint sprain will likely be unilateral and have pain with deep inspiration, coughing, sneezing or laughing, which may radiate to the scapular region or anterior chest wall along the associated rib. (1) The patient may also describe a “clicking” sensation in the joint during movement. (2) Assessment findings include reproduction of pain and/ or restriction at Tx vertebrae with AROM & PROM in flexion, ipsilateral SB, ROT. (2) Accessory PA ROM of rib segment is usually restricted (2). The hallmark finding is localised tenderness that is level specific over the CV joint. Other findings may include tenderness of the involved rib angle and costotransverse joint, increased muscle tension or spasm in paraspinal, rhomboid, trapezius and levator scapula muscles. CV joint may appear red and warm to the touch. (2) Other Ddx 1.Rib neck fracture: Posterior rib neck fractures are in close proximity to costovertebral joint. Case history may reveal trauma involving acceleration-deceleration injuries and blunt trauma to the chest. (3) The patient may have sudden onset of pain, intense pain with breathing, bruising and oedema. 2.Ankylosing spondylitis (AS): The costovertebral joint is susceptible to AS. The pain will present as a deep ache, stiff, unilateral, or bilateral and demonstrate restrictions in CV joint. In patients gait they may demonstrate a stooped posture. (2, 3) This may be ruled out as AS usually involves SIJ pain too. (2) AS symptoms typically appear in early adulthood, and it affects men more than women. 3. Osteoporotic vertebral compression fracture: To rule out this out we can assess the patient's risk factors in case hx. An increased thoracic kyphosis and lumbar lordosis may be observed, reduced height and severe back pain. Pain will likely be central, and palpation may reproduce pain over the fractured vertebral joint. Referral for imaging will help confirm an osteoporotic compression fracture. Special tests for Tx There is a lack of orthopaedic tests for the Tx spine and CV joints. There is little to no evidence on reliability of accessory motion testing at the CV joints. (2) Postural observation, palpation, active, passive and accessory ROM testing thoracic joint dysfunction was rated as poor to moderate for intra-rater reliability. Pain provocation with palpation or mobility testing is suggested to be used for the basis of clinical decision making. (2) Therefore, we are mostly relying on case history and osteopathic examination to make the working diagnosis. References 1. Saker E, Graham RA, Nicholas R, D'Antoni AV, Loukas M, Oskouian RJ, Tubbs RS. Ligaments of the Costovertebral Joints including Biomechanics, Innervations, and Clinical Applications: A Comprehensive Review with Application to Approaches to the Thoracic Spine. Cureus. 2016 Nov 11;8(11):e874. doi: 10.7759/cureus.874. PMID: 27994992; PMCID: PMC5154401. 2. Fruth SJ. Differential diagnosis and treatment in a patient with posterior upper thoracic pain. Phys Ther. [Internet]. 2006 Feb [cited 2021 Aug 19];86(2):254-68. Available from: https://pubmed.ncbi.nlm.nih.gov/16445339/. 3. Musculoskeletal Sports and Spine Disorders : A Comprehensive Guide, edited by Stuart B. Kahn, and Rachel Yinfei Xu, Springer International Publishing AG, 2018. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/rmit/detail.action?docID=5287210....