Professional Papers

_______________________________________________________
Conservative Management of
Costovertebral Subluxation

Franklin Schoenholtz, DC, DABCO

Arcadia, California
Costovertebral lesions area frequent occurrence
seen often in practice. Not much has been written
on this clinical entity. The author has provided the
clinician with specific diagnostic tests to assess
abnormal joint movement of the costovertebral
subluxation. Two rib manipulations are presented
for consideration. Many variations of these maneu-
vers may be utilized to correct specific articular
lesions. This clinical paper attempts to provide the
busy practitioner with a short, clear, concise and
well illustrated article on the successful manage-
ment of this syndrome.
The author wishes to thank Tuan Tran, PhD, for his
editorial assistance in the preparation of this clini- movements which stress the lesion, such as shaking a pillow-
cal paper.
The chiropractic profession has referred to this syndrome
as costovertebral subluxation, posterior rib lesion and
costal sprain.
The disturbance is based on a structural and physiological
variation in the relationship between the rib articulation
and the thoracic vertebra.
This article will discuss the diagnosis, examination and
manipulative procedures to successfully manage this
syndrome.
Diagnosis
Pain in the thoracic spine is the most common
symptom. The pain may be felt centrally with lateral
radiation into the anterior chest wall. The patient will
usually recall that the pain had a sudden onset following
a faulty movement. The pain may be sharp and stabbing
and sometimes the intercostal nerves are involved caus-
ing the symptoms to be those of an intercostal neuralgia.
Dr Franklin Schoenholtz is a diplomate of the American Board of
Chiropractic Orthopedists. He maintains a private practice at 226-228
East Foothill Blvd. Arcadia, California. He taught diversified tech-
nique and undergraduate orthopedics at the Los Angeles College of
Chiropractic in Glendale, California, from 1964 to 1976. Presently,
Dr Schoenholtz is the secretary-treasurer of the Board of Regents at
LACC. He has written numerous articles on the manipulative man-
agement of various musculoskeletal conditions. The most recent,
“Conservative Management of Selected Shoulder Problems” appeared
in the October, 1979 issue of the ACA Journal.
A common complaint is of continuous soreness at
the costovertebral angle which may become aggravated by
certain unguarded movements such as coughing or sneezing.
Painful episodes may occur following exertion or
case out or attempting to open a window.
The costovertebral sprain must be differentiated from
rib fractures, cardiac pathology, bone pathology and respira-
tory syndromes.
Examination
The clinical signs obtained from palpation are invalu-
able. Palpatory findings will often reveal a resistance in the
area of complaint.
The clinical approach to the examination that the
author uses is to perform three tests to establish and confirm
the presence of a costovertebral sprain.
1. THE SPRING TEST
This test will provide the examiner with information
so that reflex muscle guarding may be able to be evaluated.
(Figure 1)
The test is performed with the patient in a prone
position. The doctor is at the head of the table and leans
forward so that the heel of each hand rests on the ribs and

ACA Journal of Chiropractic /July 1980

Copyright The Journal of the American Chiropractic Association

Copyright Dr Franklin Schoenholtz 2009
 Figure 1. THE SPRING TEST. The patient breathes deeply and during expiration the doctor applies more weight and
gently springs the ribs, the object being to create a separational stress at the costo-vertebral joints.
his fingers spread laterally across the scapula. The doctor must
keep his elbows fully extended. The patient is requested to
breathe deeply and during expiration the doctor applies more
weight and gently springs the ribs, the object being to create a
separational stress at the costovertebral joints.
Guarding occurs a moment after pressure is applied.
If it appears before springing, then the patient is apprehensive
and expecting the maneuver to hurt. When the contraction is
delayed, then the patient is attempting to create a false impres-
sion. If the contraction is sustained without variation during
the test, the clinician should be cognizant that either a severe
continuous deep pain is present or the patient is apprehensive
and is not relaxing enough for the test to be valid.
The springing test is a valuable and sensitive test.
If the doctor determines a disproportionate response to the
springing, such as excessive guarding, it should immediately
arouse his suspicion of pathological changes.
2. THE RIB MANEUVER TEST
This test is important and precise in locating the
involved rib. (Figure 2) It is performed with the patient placed
in a sitting position with the examiner standing behind the
patient. The patient is instructed to move his trunk in lateral
flexion away from the painful side and raise his arm on the
affected side over his head. The doctor then uses the tips of
his fingers to hook the lower border of the painful rib and pulls
upward. This maneuver can be reversed so that the doctor’s
thumb can be placed on the upper border of the painful rib and
a downward pressure can be exerted.
When a costal sprain is suspected one of these two
maneuvers will increase pain while the other is painless. This
sign exists only in cases of rib sprain. In the case of rib fracture
both maneuvers are equally painful. When the pain is primarily
muscular, it is not influenced by the rib maneuver.
3. THE RIB COMPRESSION TEST
This test is performed with the examiner standing
behind the patient and placing his arms around the patient’s
chest. (Figure 3) The examiner requests the patient to take a
deep breath while applying gentle pressure to the patient’s rib
cage. If the patient has a costal sprain the gentle compressive
force of the clinician will restrict rib expansion and the patient
will experience symptomatic relief. However, if the lesion is
present, unsupported chest expansion will create stress on the
hypomobile joint, causing the patient to experience pain at the
site of the lesion.
When performing this test on a female patient, the ex-
aminer may recommend that the patient flex both arms at the
elbows and bring them up in front of her chest to protect her
from excessive pressure being applied directly to the breast
area.
Treatment
Manipulation has proven to be the treatment of
choice.
Adjunctive physical therapy may be utilized to pro-
mote and maintain the normal physiological state.
Many techniques exist that may be used for the
successful management of this syndrome. The most com-
mon lesions are superior and inferior subluxations. The main
objective of manipulation is to correct the subluxation so that
freedom of movement at the costovertebral and costotrans-
verse joints can be restored.
 The author offers the following two techniques that he
has found valuable in the treatment of posterior rib lesions.

RIB TECHNIQUE FOR A SUPERIOR LEFT RIB SUBLUX-

ATION (Figure 4)

The patient lies on his right side, the doctor faces him
and grasps the patient’s left flexed elbow with his left arm
stretching the shoulder into full abduction and fixing the affected
rib in the mid-auxillary line with his right thumb and thenar emi-
nence. The thrust is inferior.

RIB TECHNIQUE FOR AN INFERIOR RIGHT RIB SUBLUX-

ATION (Figure 5)

The patient lies prone with both legs flexed upward, the
doctor grasps both ankles with his right hand. He then laterally
torques the patient’s legs toward him using his left knee as a
fulcrum. This maneuver opens the rib cage on the affected side.
The doctor then places the pisiform of his left hand on the inferior
border of the affected rib. He then thrusts in a superior direction.
When managing a patient with a costal sprain, it has
been the author’s clinical experience that fitting the patient with a
supportive rib belt enhances the patient’s recovery time. The rib
support helps reinforce, protect and stabilize the involved area.
The patient wears the support during waking hours throughout
the acute period.

Summary

It is understood that structure and function are reciprocal

and complimentary. The costal subluxation is a classical example
of an altered structure with resulting abnormal biomechanical
function.
Chiropractic manipulative management of this syndrome
is successful for the patient and gratifying for the doctor.

Figure 2. THE RIB MANEUVER TEST. This test is im-

portant to differentiate in what direction the subluxated
rib has moved. When a costal sprain is suspected, on of
these two maneuvers will increase pain the pain while
the other is painless.
Figure 3. THE RIB COMPRESSION TEST. The doctor com-
presses the rib cage while the patient takes a deep breath.
Restriction of rib expansion should provide the patient with
symptomatic relief.
Figure 5. RIB TECHNIQUE FOR AN INFERIOR RIGHT RIB
SUBLUXATION. The patient lies prone with the doctor grasping
his ankles. While using his left knee as a fulcrum the doctor uti-
lizes the left pisiform contact to thrust the inferior rib in a superior
direction.

Bibliography

1.Maigne: Orthopedic Medicine, 1976.

2.Maitland: Vertebral Manipulation, 1979.
3.Stoddard: Osteopathic Practice, 1969.
4.Stoddard: Manipulation of Osteopathic Technique, 1974.

Figure 4. RIB TECHNIQUE FOR A SUPERIOR LEFT

RIB SUBLUXATION. The patient lies on his right side,
the doctor faces him and grasps the patient’s left flexed
elbow with his left arm stretching the shoulder into full
abduction and fixing the affected rib in the mid-axillary
line with his right thumb and thenar eminence. The
thrust is inferior.

Copyright The Journal of the American Chiropractic Association

Copyright Dr Franklin Schoenholtz 2009