Breast bone pain
(Keywords: TIETZES SYNDROME CaseFile, chest pain, rib pain treatment, heartburn, chiropractic books)
Five months ago a 26-year old man was referred to our Chiropractic Clinic by a cardiologist. The doctor, after extensive tests, could find nothing to explain his chest pains, and by default diagnosed Tietzes Syndrome. Pain in the breastbone and the breastbone-rib cartilages.
Normal chest X-ray:
What is Tietzes Syndrome?
Tietze syndrome is a benign inflammation of one or more of the costal cartilages. It was first described in 1921 by the German surgeon Alexander Tietze, 1864-1927.
In severe cases there may be swelling of the costal cartilages
but, in my experience, this is infrequent. Usually it's just pain, a
feeling of tightness, or pressure, in the chest, and
usually pain or discomfort in the middle of the back between the
shoulder blades. Only at a grade 4 is there a swollen lump.
In mild cases there's no pain over the breastbone, just in the midback, radiating between the ribs towards the mid axillary line. However, palpation of the costo sternal cartilage at the corresponding level is extremely painful. It's presumed that with time it may proceed to a full blown case, or pass over like many conditions that affect us humans; in his case it didn't.
The pain may be bilateral.
A 26 year old man presented at our clinic complaining of pain over his heart, hot stabs of pain with a tight, stretching feeling radiating from his mid back. He described a feeling of pressure in the chest with extreme sensitivity over the breastbone on the left side. A stabbing, hot electrical pain.
For five years he had been having difficulty with a hiatus hernia and heartburn, with his dinner often ending up back in his mouth, especially if ate too much or ate hot, spicy food.
The pain had been lurking for some months but had recently become much worse, with the tight feeling in the chest and the stabbing pain worsening.
His mother, also a doctor, concerned over a heart condition, especially as her son was a heavy smoker, referred him to a cardiologist.
No significant trauma was recalled.
The pain was aggravated by sitting in a cramped position at his computer. Stretching out his back was the only thing that relieved the pain.
Medicines; statins for high cholesterol.
ON EXAMINATION @ TIETZES SYNDROME CaseFile
A tall, slender young man, he stood with a level pelvis and no obvious leg length inequality. A minor S shaped scoliosis was evident with an apex in the high lumbars and another in the mid thoracic spine.
At this second apex there was mild tenderness, no pain on percussion over the spine, no abnormal lung or heart signs. Deep pressure over the seventh rib head on the left was extremely painful. Deep inhalation did not aggravate the pain.
Rotation of the thoracic spine provoked vague discomfort in the left midback. Anterior to posterior compression of the chest was painful, both in the midback and at the ribs anteriorally.
Motion palpation of the 5 to 7th ribs posteriorally revealed a fixation. The ribs 5 to 7 anteriorally were very tender on palpation, and fixated superiorally on exhalation; they did not descend in the normal manner, in comparison with the ribs on the right.
Motion palpation incidently, is a controversial examination procedure. Often after 35 years in practice, I'm still not sure about some fixations. Others stand out clear as day, and there is very detectable difference after manipulation.
What makes it more complicated is that a fixation with the spine say sitting, but change quite dramatically lying down.
But fixations at the costochondral joint are usually one of the clear as day sort, even to the extent you can detect whether it's on inspiration or expiration that it is fixated.
TREATMENT @ TIETZES SYNDROME CaseFile
Examination only. Copy of X-rays from the hospital requested.
Report of Findings:
CONSULT 3 @ TIETZES SYNDROME CaseFile:
Subjective: Slightly less pain.
Objective: No change.
Assessment: An immediate lessening of symptoms is heartening.
Plan: Treatment according to plan:
Gentle PA adjustment of the 7th rib on the left. Mobilisation of the 5-7th ribs. Deep soft tissue therapy along the length of the rib and the costo-chondral junction. Sitting anterior thoracic technique, specifically applied to the seventh rib.
S: Stabbing pain has reduced from an intensity of 9 to a 4.
O: Costo-chondral junction less tender. 7th rib far less fixated.
A: Satisfactory progress. Letter to cardiologist thanking her for the referral, and outlining findings and initial progress.
P: First hiatus hernia treatment. Continued chiropractic management of the fixated rib.
S: The hot stabs of chest pain have stopped completely.
O: Left rotation of the thoracic cage remains restricted and slightly painful in the midback. PA compression of the chest remains slightly painful.
A: Excellent progress.
P: As previously. Once only, I speak very directly to patients
about the dangers associated with smoking. Today. An anecdote about a
patient (tiny baby with infantile colic) this week whose father aged 37
died very suddenly of an MI three months after his third daughter was
COLIC CHIROPRACTIC ...
S: Much improved. Twice hot stabs of pain for a short period.
O: Tenderness of the whole rib much less.
A: Better than expected progress.
P: No change in treatment of rib cage. Add first adjustment of the pelvis and lumbar spine.
S: Occasional discomfort and sometimes pain of the 5-7th ribs, easily controlled with the ice treatment.
O: Right rotation and left lateral flexion of the thoracic cage provokes slight low thoracic pain at T12. Fixation of the right sacro-iliac joint no longer present. Subluxation of L5 still present.
A: Continued excellent progress.
P: Add anterior adjustment of T12. Outline of the hiatus hernia management protocol.
S: 60% less pain overall due rib and heartburn indigestion.
O: Left lateral flexion still slightly painful.
A: Very satisfactory progress.
P: Start of rehab next week.
CONSULT 9 @ TIETZES SYNDROME CaseFile:
S: Continued improvement. Much less regurgitation of food now.
O: The costo-sternal joints are still slightly tender on the
left, but no long painful, and no longer restricted movement on
P: Add in a thoracic spine "shot-put" exercise. Patient going on
holiday for a month. Recommendation that after his holiday he consider
Foods for lowering cholesterol as an alternative to Statins. Erectile
dysfunction is one of the side effects...
FOODS THAT LOWER CHOLESTEROL ...
CONSULT 10: (six weeks later)
S: Patient had a fantastic holiday with very little pain. Virtually no "spoegen" (after dinner regurgitation into the mouth).
O: Range of motion of the thoracic cage is now normal. He stinks far less of tobacco! Taking seriously the strong pressure from his mother, the cardiologist and myself. Trying to stop...
A: Great progress.
P: Occasional, regular treatment, increasing the interval as patient copes. Next consult 7 weeks. Give diaphragm exercise next.
HIATUS HERNIA @ TIETZES SYNDROME CaseFile
This Tietzes syndrome casefile is slightly unusual in that the patient has two allied yet separate conditions.
The diaphragm muscle separates the chest cavity from the abdoman having, as its attachment, the lower 6 ribs. The pain in his chest was directly due both to Tietzes and a hiatus hernia or ineffective valve that should prevent reflux, both allied to the ribs. This latter condition is known as GERD in medical jargon. Gastro esophageal reflux disease is it's name, and untreated often leads on to esophageal cancer.
In many cases of gerd it's greatly affected by what we eat and drink. In my own case, simply giving up beer at night completely cured very serious indigestion heartburn.
A weakness in the diaphragm muscle allows part of the stomach to bulge through into the chest cavity, a hiatus hernia, creating all the nasty symptoms of heartburn. I know of no research done concerning chiropractic and the hiatus hernia, but this patient is no longer troubled by heartburn. Simply an anecdote, and of no scientific value.
But, type the word antacid into wikiipedia, and see the sobering report on extreme dangers of taking tablets high in calcium and aluminium for heartburn. Those are not anecdotal.
Chiropractors use various techniques to treat the diagphragm, it is after just a muscle, albeit highly specialised. Certainly digestion and gerd are an integral part of a grade 4 Tietzes syndrome.
IMPORTANT CONSIDERATIONS @ TIETZES SYNDROME CaseFile
ANTICHOLINERGIC SIDE EFFECTS ... suffering from "mental fogginess"? 50% of Americans are taking these drugs.
FREE PAIN PILLS ...
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Many insurance companies now only pay for physical therapists to provide a chiropractic adjustment; that's in the face of powerful research proving that inclusion of DCs to perform their own technique would save them a good deal of money. One has to conclude that political medicine has gone off on another tack to contain our profession.
It's being successful with some doctors of chiropractic quitting. Others become involved in some dodgy practices, like demanding that patients sign up for a whole year of treatment in advance, in order to stay in business.
In recessionary times, the going is tough when the insurance won't pay.
Is the day approaching for a new Wilk versus the AMA and the insurance companies?
The chiropractic profession has tried hard to stay on the moral high ground; those who stoop to unscrupulous practices need to be exposed and disciplined if we are not to stoop to the low blows that medicine has often resorted to contain and eliminate us.
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