Postgrad Med J (1992) 68, 655 - 659 C) The Fellowship of Postgraduate Medicine, 1992

Missed Diagnosis

Costovertebral joint dysfunction: another misdiagnosed

Summary: The diagnostic work-up of atypical chest pain frequently leads to invasive procedures.
However, this painful symptomatology can sometimes be of benign origin and respond to simple
therapeutic manoeuvres. A number of musculoskeletal conditions such as costovertebral joint dysfunc-
tions should be carefully considered. We report five cases in which patient discomfort and high costs could
have been avoided if awareness of these conditions had led to a correct diagnosis upon initial physical
examination.

Introduction
Atypical chest pain unrelated to a cardiac or this time located in the left basi-thoracic region.
pleuro-pulmonary cause is a common symptom Routine diagnostic work-up was unrevealing.
particularly in the emergency room.'4 However, Since the patient was in the postoperative period,
little attention has been drawn in the medical pulmonary embolism was suspected. She was
literature to musculoskeletal causes.2'5'6 This can anticoagulated with heparin. An isotopic vent-
lead to repeated, sometimes invasive and often ilation/perfusion lung scan indicated low pro-
costly medical investigations.7 Even though emo- bability for pulmonary embolism. Nonetheless, in
tional factors can play a role in such symptoms,",7'8 view of the high degree of clinical probability,
it seems important to identify specific local pulmonary angiography was performed, which
musculoskeletal causes of atypical chest pain, was normal. As the pain continued, the patient
which can be easily detected and treated.5'6"0 We underwent a complete physical examination by a
report five cases of atypical chest pain related to a rheumatologist. An exquisitely tender thoracic
characteristic cause of rib strain: costovertebral paravertebral region at the T7 level was identified,
joint dysfunction. whose palpation and rib mobilization precisely
reproduced the patient's symptoms. There was an
accompanying muscular contraction and cuta-
Case reports neous tenderness. The diagnosis was a T7 costo-
vertebral joint dysfunction. The pain disappeared
Case I after intercostal nerve block with lidocaine and the
patient was discharged from the hospital 48 hours
A 54 year old female patient underwent a right later.
artroscopic meniscectomy under general anaes-
thesia. In the recovery room, she experienced three Case 2
episodes of atypical precordial pain, independent
of respiratory movements. Clinical examination A 42 year old woman with a history of slight chest
and electrocardiogram (ECG) were normal. Nitro- contusion one month previously was admitted to
glycerin produced no relief, and the pain subsided the emergency room with a severe left basithoracic
after a few minutes. She was transferred to the pain, increased by breathing movements, and
ward. Twenty-four hours later, the pain recurred, accompanied by dyspnoea and tachycardia.
Physical examination and laboratory and blood
gas analyses were normal. The ECG revealed atrial
Correspondence: Jesus F. Arroyo, M.D., Medecin- fibrillation with a heart rate ranging from 120 to
Adjoint, H6pital Universitaire de Geriatrie, rte de 145/min, spontaneously reverting to a normal sinus
Mon-Idee, 1226 Thonex/Geneva, Switzerland. rhythm. Pulmonary embolism was suspected. The
Accepted: 30 March 1992 pulmonary scan yielded a low probability, promp-
656 J.F. ARROYO et al.

ting pulmonary angiography, which was normal. A at the T8 level. Palpation at that level reproduced
complete diagnostic work-up including echo- the patient's pain. After various dorsal musculo-
cardiographic examination, serological testing for skeletal physical examination procedures, the
viral infection, vertebral X-rays and isotopic bone patient described partial relief of his symptoms.
scan was normal. Upon re-examination, a left Costovertebral dysfunction was diagnosed, and a
paravertebral muscular contracture extending treatment of non-steroidal anti-inflammatory
from T4 to T7, with cutaneous hyperalgesia, was drugs and muscle relaxants started. The symptoms
discovered. There was exquisite tenderness of the disappeared within 48 hours, and the patient left
T6-T7 region as well as upon mobilization of the the hospital.
6th rib. These painful symptoms were identical to
those experienced by the patient during the Case S
previous days. A diagnosis of T6 costovertebral
joint dysfunction was made. Intercostal nerve A 70 year old female patient presented with sudden
block with lidocaine completely relieved the symp- left basithoracic pain, increased by breathing
toms. movements. She had been experiencing similar,
although less intense, symptoms for one month.
Case 3 The pain was usually deep, dull, and increased by
inspiration and anterior flexion of the torso. At
A 23 year old male patient was admitted to the times, she felt intensely dyspnoeic. The dyspnoea
emergency ward for acute dorsal and latero- was accompanied by palpitation and diaphoresis.
thoracic pain, with a probable diagnosis of peri- As with the other four patients, the initial
carditis. His history was free of recent 'flu-like emergency ward evaluation was inconclusive, but
symptoms, cough or chest pain. He complained of the symptoms were interpreted as possibly related
severe, burning pain, increased by breathing and to pulmonary embolism, and the patient was
movements of the torso, the latter producing left anticoagulated with heparin. An isotopic ven-
antero-lateral radiation. The initial diagnostic tilation/perfusion lung scan was normal. Anti-
work-up was inconclusive, and the patient was coagulation was stopped. Further evaluation
hospitalized. He described a similar episode one revealed left paravertebral muscular contracture at
year previously, for which he had also been hos- the T5-T7 levels. Skin-pinch testing caused
pitalized. No clue had been found as to the cause of dysaesthesia and local hyperalgesia, and palpation
the symptoms, which had spontaneously disap- of the posterior left 6th rib reproduced the pain
peared. He indicated that his present symptoms with its characteristic antero-lateral radiation.
had appeared after having spent a few hours Costovertebral dysfunction was diagnosed and the
studying in a prone position, followed by stretching symptoms were totally relieved by an intercostal
exercises. There was a paravertebral muscular nerve block at the T6 level, and the patient left the
contracture in the T5-T8 region. A skin-pinch test hospital after 48 hours.
produced localized dysaesthesia. Posterior palpa-
tion of the 6th left rib initiated sharp pain, radiating
anteriorly. Costovertebral dysfunction of the 6th
rib was diagnosed. An intercostal block with Discussion
lidocaine relieved the patient immediately. He left
the hospital after 48 hours, asymptomatic. We have reported five characteristic cases of
atypical chest pain due to a misdiagnosed mus-
Case 4 culoskeletal aetiology, which led to needless, and
sometimes invasive, investigations. Patients were
A 36 year old male patient presented with right hospitalized for a cumulative number of 26 days. A
latero-thoracic pain of acute onset. He had no past total of 14 ECGs, seven chest and spine X-rays,
cardio-respiratory problems. He described his pain four isotopic ventilation/perfusion lung scans, two
as mostly dull and deep, with occasional sharp, pulmonary angiographies, one cardiac echography
knife-like, characteristics. He was dyspnoeic. Dor- and one isotopic bone scan were performed.
sal or right lateral decubitus decreased the symp- All patients presented with atypical chest pain
toms. The emergency ward evaluation was that of a related to a poorly known aetiopathogenic cause:
possible pulmonary embolism. Anticoagulation costovertebral joint derangements.9' 4 This condi-
with heparin was started. However, an isotopic tion refers to an abnormal mobility and/or a
ventilation/perfusion lung scan was normal, and posterior subluxation of the rib producing a func-
heparin was thus discontinued. A physical re- tional disruption between the rib and its two
examination indicated that the pain appeared upon vertebral joints: costovertebral and costotransver-
inspiration and rotation of the torso. There was a sal articulations (the latter is nonexistent in the two
paravertebral muscular contracture and tenderness floating ribs). Both these joints are reinforced by a
 COSTOVERTEBRAL JOINTS/CHEST PAIN 657

strong ligamental apparatus and are under control Nevertheless, in some cases, a differential diag-
of certain muscles (especially ilio-costalis). nosis must be considered, with regards to other
Poorly recognized by physicians, costovertebral such musculoskeletal conditions: Firstly,
dysfunctions, as a particular posterior rib strain, intervertebral facet joint derangements can also be
are well described in manual medicine test- a potent source of local and referred pain, '0-1215 in
books'0-'2 and mentioned in some clinical observa- spite of minimal biomechanical strains in such
tions.9' 10"13"4 As reported in our patients, the failure small joints, particularly at the cervical and lumbar
to identify such lesions can lead to an erroneous levels. 1618 The vertebral segments involved elicit
diagnostic work-up. pain upon active mobilization. Positions that ease
As true diarthrodial synovial-lined joints, costo- the pain are common, as well as localized muscular
vertebral and costotransversal articulations are contractures which could introduce an additional
richly innervated by collateral branches of the source of nociceptive impulses as observed in
intercostal nerve. Excessive strain in such joints several myofascial pain syndromes.1" However, in
after trauma, effort or false movement, leads to an these cases the pain is not elicited by the mobiliza-
abnormal firing of nociceptive impulses from the tion of the rib and usually spreads into a few
deep musculoskeletal structures involved with, dermatomal areas, poorly defined and frequently
sometimes, longlasting local and referred pain.'0"14 distant. Secondly, interspinous ligament disrup-
Elements of relevance in atypical chest pain related tions can also trigger local and diffuse pain.10'19 A
to rib strains are reported in Table I. As observed prior history of trauma or sudden abrupt move-
by others,2'5'6"0 the clinical history as well as the ment is usually reported by the patient, who
description of the pain appear to be helpful diag- considers it causal. The pain is frequently persis-
nostic aids. Positional pain of a sharp and stabbing tent, and varies neither spontaneously nor with
nature, as well as the absence of any prior history of breathing. Local dermatomal skin hyperaesthesia
ischaemic heart disease, provide elements against is unusual and the mobilization of the rib does not
angina pectoris.2 In addition, a recent history of induce the symptoms, which are clearly reproduced
minor chest trauma or constraining postures, as by the palpation of the interspinous space, partic-
was the case in three of our five patients, are highly ularly during anterior flexion of the torso.'0
indicative of a musculoskeletal origin, and should Thirdly, costovertebral dysfunctions affecting the
prompt a very careful clinical examination. This inferior ribs can generate pain radiating anteriorly
frequently shows a characteristic increase in pain, in the upper abdominal wall.'0 However, clinical
radiating laterally to the trunk in a dermatomal examination allows differentiation with other con-
distribution, upon deep breathing and movements ditions such as the slipping rib syndrome20'2' and
of lateral flexion and rotation. Reproducing symp- the complete subluxation of a floating rib.22 Lastly,
toms by a careful mobilization of the rib, and the the protrusion of an intervertebral disc with true
search of a local segmental skin irritation radicular pain must also be considered, in spite of
(hyperalgesia and dysaesthesiae induced by a skin its very unusual occurrence at the dorsal level.23 In
pinch test)'0'2 are also essential diagnostic proce- such cases, the pain, of neurogenic quality, is not
dures. influenced by mobilization of the ribs. Also, a
specific dermatomal sensory deficit is usually pres-
ent, and is frequently associated with intense local
Table I Relevant elements of chest pain related to costo- hyperaesthesia. In addition, more than 70% of
vertebral joint dysfunctions these cases show neurological signs suggesting
medullar compression at the time of diagnosis.23 In
Prior history of pain with similar characteristics these cases, as well as in other local inflammatory
Quality of the pain (burning, sharp or stabbing) or tumoural processes, a satisfactory relief of the
Recent history of (minor) trauma or constraining symptoms cannot be obtained by simple antalgic
postures manoeuvres, and persistence of pain should lead to
Pain fluctuation with rotation of the torso (positional
pain) further diagnostic work-up.
Pain fluctuation with breathing movements In costovertebral dysfunctions, accompanying
Variable periods of spontaneous improvement neurovegetative signs such as nausea, mimicking a
Reproduction of symptoms by mobilizing/palpating the visceral origin to the complaints, can be present,
rib and could be related to the proximity of
Pain radiating into apparent radicular segmental the intercostal nerves to afferent sympathetic
distribution fibres.10'12 Patient 4 reported spontaneous relief
Localized skin hyperalgesia/dysaesthesia induced by skin after clinical examination which in our experience
pinch manoeuvre is not an unusual finding. It can also be reported by
Sudden improvement induced by clinical examination
('manipulation-like' effect) patients suffering from minimal facet joint
Total relief of symptoms after lidocaine block derangements. In the other four patients, radicular
nerve blockade (1O ml lidocaine, 1%) was per-
658 J.F. ARROYO et al.

formed as a diagnostic procedure, followed by the patients exhibit abnormal computed tomographic
permanent disappearance of symptoms. Different scan findings without experiencing any pain.27 The
techniques of intercostal nerve blocks have been value of invasive diagnostic and therapeutic
described and widely used in several clinical condi- measures by local injections into these facet joints
tions.24'25 However, it is not clearly established how remains highly controversial, and the subject of
nerve blockade procedures can produce long- much debate.28-30 The same questions can be put
lasting relief of pain in this as well as in other forward concerning costovertebral joints.
similar painful conditions.'6'20 A hypothetical ex- On the other hand, repeated X-rays in such
planation could be that a significant reduction in patients could also be an added source of diagnos-
pain by a local anaesthetic allows a normal tic error. Asymptomatic subjects can present a
mobility of disrupted joints which can finally exert localized hyperostosis of the posterior ribs, and
their normal biomechanical activity. This results in articulating transverse processes related to the
a reduction in the joints' strain and subsequent activity and insertions of iliocostalis muscle with-
abolition of local nociceptive impulses. A self- out any clinical translation.3' Nevertheless, any
perpetuating cycle of pain- spasm - pain is broken, mechanical manipulation must be avoided in such
with a considerable reduction in pain and, perhaps, patients in the absence of evidence for rib and
in local sympathetic overactivity when present. vertebral body integrity.
Beneficial effects of manipulations, when accurate- In conclusion, we have reported five characteris-
ly performed, emphasize such a biomechanical tic cases of atypical thoracic pain in which extensive
approach,10-12 although the precise analgesic medical investigations failed to make an accurate
effects of manipulations have not been clearly diagnosis. We emphasize that the lack of
established yet.26 knowledge of the existence of such costovertebral
An additional question could be addressed con- joint strains'0-14 and other musculoskeletal causes
cerning the potential interest of X-ray investigation of atypical thoracic pain,5'6 could be responsible for
in order to achieve a complete diagnostic work-up inappropriate, repetitive, potentially dangerous
in such cases, as has been proposed.13"4 In our and costly investigative procedures. This could in
experience, in the presence of characteristic history turn lead to a vicious cycle whereby patients'
and clinical examination (Table I) and no recur- anxiety, fuelled by recurring symptoms in the face
rence of symptoms after a significant clinical effect of negative examinations, will trigger additional
of lidocaine block, X-ray investigation can be diagnostic work-ups, thus further increasing risks
delayed. Indeed, as observed in other spinal pain and costs.'3'7'8 We suggest that further investiga-
disorders related to the facet joints, it must be tion of these painful conditions be pursued, in
pointed out that their minimal strain can be a order to improve physiopathological knowledge of
source of local and/or referred pain without any their causative mechanisms, and, most of all,
visible alteration 10,12,16-18 Conversely, some increase physicians' awareness of their existence.

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