Back, rib & shoulder pain

This case study involves a 28 year old lady (Ms P) who had a 7 year history of right sided pain half way up her back and under the right shoulder blade.  The pain was not becoming worse or improving but she recently realised that she was fed up with it and wanted to see if anything could be done.

She described 2 pains:

Pain 1 was a diffuse ache, present most of the time under the shoulder blade.  It was aggravated by sustained postures, i.e. sitting or standing for any length of time.  Keeping moving or lying down would ease it.

Pain 2 was an intermittent sharp pain approximately 1 inch to the right of her spine.  It was a brief pain brought on by twisting, reaching up or lifting.

These pains started 7 years previously after seeing a therapist (not a Physiotherapist) for a lower back problem.  That Practitioner had manipulated her spine all the way up quite forcefully and the pain occurred at this point.  She had not gone back for a follow up visit.

Ms P was naturally concerned that no such manipulations be performed this time.  She was reassured that this would not happen and that I would seek her consent to any treatment after fully explaining the nature and purpose of the treatment.

Past Medical History: nothing relevant.

Medication: only anti-inflammatory tablets as required.

Social History: Teacher. No children. Swims 3 times a week and uses a gym once a week.

Initial Thoughts

Due to the cause (being a forceful manipulation) the location, and nature (description) the sharp pain was likely to be from joint dysfunction.  This is where, for any reason, a joint is not operating as it should.  In this instance, it was likely to be a spinal facet joint or a costovertebral joint (where the ribs join the spine).

The ache was likely to be muscular or referred pain from the spinal joint.

Initial Examination

This showed no observable scoliosis or other spinal deformities.  The muscles to the right of the spine were tenser than they should be and there were a few tender places in them.

Movement testing showed no restrictions in the cervical (neck) and lumbar (lower back) spine movements.  Thoracic spine (mid back) movements were painful, especially backward bending, twisting right and side-bending either left or right.  The most restricted movement was twisting to the left.

Arm movements caused both pains when nearing full elevation. A deep breath in caused pain 1.


Treatment initially was to relax the muscles on the right side of her back.  This eased the ache and allowed a more thorough spinal assessment.  The further findings were that accessory movements of the 4th, 5th and 6th thoracic vertebrae (T4-6) and the right 5th rib gave pain.  Also, T5 was stuck in a right rotated position.

Ms P. was informed of the findings but the vertebra was not directly treated in this first visit due to her previously mentioned concerns.  Instead, she was taught 2 exercises to try to address the problem.  1 of these was to begin to twist that area to the left.

2nd Visit, 4 Days later.

Ms P. reported an improvement in the ache for a few days after treatment but it had started to come back.  The sharp pain hadn’t changed.

On examination: the muscles were again tight on the right side.  Once these were relaxed off it was clear that the T5 problem hadn’t changed.

Commonly this is an area that responds well to more forceful manipulative treatments but due to Ms P’s past experience, it was decided to use a Muscle Energy Technique (MET) to realign her spine.  This is a more gentle technique that uses the patient’s own muscle contractions as the force and usually feels more like a good stretch.  The technique was used 3 times, each time allowing a greater degree of left rotation.

A new home exercise was given to increase the amount of stretch incorporating left rotation, side flexion and forward flexion.  We discussed the impact of her daily activities and it was discovered that 2 things were probably not helping: sitting on the settee with feet up and looking to the right every evening; and that she also turned to the right at the end of each length when swimming.  We agreed that she should avoid these for a short while.

3rd Visit, 1 Week Later.

Ms P was delighted with her progress and both pains were 60-70% better.  There was no pain on breathing or reaching up anymore and she described her back as “much freer”.  She actually came in requesting the same manipulation that we did last time!  After examining the area it was clear that this was still the appropriate treatment but the muscle treatment did not need doing – it had stayed relaxed for the week.  The left rotation range was ¾ of what it should be (a good increase from where it had been).

The MET was repeated and left rotation then was equal to that right.  Her home exercise was checked to ensure she was doing it correctly.

4th Visit, 1 Week Later.

Ms P reported being “95% or more” better with no ache and had only felt a few hints of pain near the spine.  The treatment was repeated a further time and she was checked to make sure no other problems were present.  We did not book a further appointment because I expected the remaining discomfort to disappear over the following 2 weeks.  She was to rebook if any symptoms remained but have not needed to.


I feel that there is often too much acceptance of being in pain.  This can be due to fear of treatment as in this case.  Sometimes people believe they will not get better but they have not explored all the options. However, the research says, ‘Thoracic manual therapy accelerated recovery and reduced pain and disability immediately’ Ref 1. 

There are usually a few treatment options for any given condition.

As Physiotherapists we feel it is important:

-to look at muscles as well as joints

-to think about the patient’s everyday activities and postures

-to try and include them in the treatment process

The combined approach is shown to be the best route for rib and shoulder pain.

Keith Allen-Shirtcliffe