Elusive Rib Pain

[iwhitney]

For this last patient encounter reflection, I wanted to discuss a patient I have been seeing for a few months, but one that I’ve found myself reflecting often on due to the minimal progress we’ve made. The patient is an 89 y.o. Female who presented with L sided lower rib pain that began insidiously 3 months prior to our initial evaluation. Of note, she presents with moderate thoracolumbar scoliosis with a L sided convexity. Her pain was pretty significant and limited most of her daily activities, including prolonged standing, reaching OH, sleeping, and deep breathing. Previous treatment included chiropractic manipulation and 2 rounds of trigger point injections, all with no improvement. Going into the exam, I will admit I felt unsure of my differential list since the thoracic spine is so often an area of conjunct treatment rather than primary source of symptoms.
The patient’s pain was pretty pinpoint and localized to the angle of her L 12th rib with no radiating pain, numbness/tingling, or diffuse joint pain. I felt confident in my ability to rule out red flags based on her symptom description, history, MOI, and demographics. Reflecting back on that initial evaluation, I feel that I could’ve spent more time figuring out the source of her symptoms in her rib and whether they are coming from contractile vs non contractile structures. Although it is a basic skill we learn in PT school of following the ROM algorithm to determine if there is a true joint restriction or myofascial involvement, I find myself referring back to this often with many of the patient’s I have encountered over the last couple months, much to the credit of my mentor Laura. Understanding and being confident in where the patient’s impairments and symptoms are coming from can completely change the trajectory of our treatment plans and ultimately lead to increased efficiency and potentially shorter plans of care.
The initial HEP included many thoracic mobility exercises in quadruped, which backfired on me as she came back with a significant increase in contralateral neck and shoulder pain after trying to be in that CKC position. Our treatment sessions have therefore gone back and forth from treating her neck to treating her rib pain. Reflecting on this, I feel that my initial evaluation could’ve been more thorough in understanding what pre-existing areas of pain/limitation she had, and perhaps a neck/shoulder flare up could’ve been avoided. This is especially true for our older patients and I’ve found myself starting to think a lot more on what my home exercises should look like for geriatric patients based on their comorbidities, capability, and PLOF.
At this stage, the patient has seen minimal to no improvement in her L sided rib pain, even with more TPIs. She has started a trial of acupuncture as a method to relieve pain via central modulation. I feel more confident based on subsequent assessments that her pain is truly coming from the costotranverse joint although the pain is still elusive in that any improvements made in clinic are temporary. Her HEP has been adjusted to improve thoracic mobility in positions she can handle, but they don’t seem to be helping much either. Anyone have thoughts on how I could adjust my treatment or perhaps what I could shift my focus to? Let me know if you need any more information on her presentation.

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