Introduction
At each level of the thoracic spine (the upper back), the ribs are attached to the corresponding vertebrae on the right side and left side with small joints. The rib joints from the second to the tenth vertebrae in the upper back comprise costotransverse and costovertebral joints that are located in the back of the vertebrae. These joints provide stability to the upper back and chest wall. The joints are supported by ligaments, which add strength to the junction of bones and limit the motion of the joints in the upper back.
Causes
Costovertebral joint injuries usually occur after a sudden movement involving twisting, bending or over-extending (arching) the spine. They may occasionally occur due to repetitive twisting or bending motions.
Compressive and torsional forces are applied to the joint when we move. If these forces are greater than the joint can withstand, then damage may occur to either the ligaments, cartilage or both. In some cases, the head of the rib may even dislocate from the joint.
Rib dysfunction syndromes may cause one or a combination of the following symptoms:
upper back pain, arm pain, pain between the ribs, and/or generalized upper back area discomfort.
Pain with deep inspiration, coughing/sneezing/laughing
Increased pain with passive or active thoracolumbar flexion, rotation and ipsilateral side bending, lifting or twisting movements
Hypomobility of the costotransverse and costovertebral joint
Palpable tenderness and pain at costotransverse joint and rib angle
Movement in adjacent thoracic vertebral and rib segments is usually restricted and may stimulate or exacerbate protective muscle spasm
Increased muscle tension in paraspinal muscles, rhomboid muscles, trapezius muscles and levator scapula muscles
Neck pain, head ache or both
The sensation of having a useless or heavy limb
Referred pain originating from under the scapula and worsens with coughing, sneezing or deep breathing
Acute, atypical chest pain
Possible musculoskeletal sources of thoracic pain are:
Muscle strain (erector spinae, lower and middle trapezius, rhomboideus, latissimus dorsi, levator scapulae and intercostal muscles)
Vertebral or rib fracture
Zygapophyseal joint arthropathy
Active trigger points
Spinal stenosis
Intervertebral disc protrusion or herniation
Diffuse idiopathic skeletal hyperostosis (DISH)
Intercostal neuralgia: > often follows injury or thoracic surgery
focal tenderness over affected intercost.
burning pain and paresthesias in thorax or abdomen that usualsly follow the nerve path
T4 syndrome
Ankylosing spondylitis
Costovertebral and costotransverse joint dysfunction
Thoracic radiculopathy
Fractures
Patients with upper back pain and the above symptoms may be candidates for a costotransverse or costovertebral joint injection to both help diagnose the condition and provide pain relief. It is important to note that these injections should not be considered a cure for upper back pain: rather, the goal is to help patients get enough pain relief in order to be able to progress with their rehabilitation program.
Costotransverse and costovertebral joint injections both involve carefully injecting medication into the small joints where the ribs join with the spine in the upper back. These injections are types of pain blocks and may also be referred to as a costovertebral block or a costotransverse block.
Costotransverse and costovertebral joint injections are used to both confirm a diagnosis that these joints are the source of the patient's upper back pain as well as to provide pain relief.
Diagnostic goals: by placing numbing medicine into the joint, the amount of immediate pain relief that the patient experiences will help confirm or deny the joint as a source of the upper back pain. If complete pain relief is achieved while the joints are numb it means that these joints are likely the source of patient’s upper back pain and other symptoms, and if not, then there is likely another pain generator. If partial pain relief is obtained, then the joints may be part of the problem.
Pain relief function: along with the numbing medication, time release cortisone is also injected into these joints. The cortisone helps reduce any inflammation, which usually surrounds the painful joints in the upper back. Reducing inflammation in the upper back area can often provide long term pain relief.
Treatment
Most costovertebral joint sprains heal on their own in time. The following may help to speed up the process:
Rest from ANY activity which causes pain.
A doctor may prescribe anti-inflammatory medication to ease pain and inflammation.
Icing the area may be helpful to ease pain and inflammation. 15 minutes 3-4 times a day should be sufficient.
Once pain free, start mobility exercises such as gentle twists and side bends to get the joint moving again and prevent stiffness.
A professional will be able to recommend exercises to strengthen the back muscles.
They may also use treatments such as electrotherapy, mobilisation, soft tissue therapy and dry needling (acupuncture)
Injection
