This patient was in her 40’s and had previously been fit and well, a regular Pilates class attendee and an occasional jogger.

Covid 19 knocked her flat. For several weeks she was bedridden, coughing constantly and feeling dreadful. Slowly over 4 weeks, the symptoms reduced and she was able to avoid the hospital. Just.

However, during the worst of the Covid 19 period, she developed pain in her left rib cage and spine which radiated around to the font under her heart. She had moments of worry that the stress was affecting her heart but as it was worse every time she coughed she decided it was unlikely.

However, as the coughing reduced the pain on deep breathing, cough, and to turn her trunk did not really change.

She found that even the increased depth of breathing associated with walking (Covid really left her unfit) produced pain in the back and ribs.

This lady’s husband suggested that she sought our help as we had successfully treated his ribs in the past as part of a car accident/seatbelt problem.

On examination, the lady had a very stiff trunk and rib cage and a very tender couple of ribs. Just alongside the spine. The ribs attach to the spine at two different small joints. They then attach in the front via cartilage to the sternum. They move up and down with your breathing like a bucket handle. Any dysfunction at these points of attachment can be very painful, especially to breathe deeply.

Typically this is caused by trauma – a fall or impact. Rugby is great for it! However, hard coughing fits can do the same thing.

Once they have become sore or strained or stuck the multiple muscles around the joints spasm and prevent normal motion from returning and thus everything stiffens up more and more.

There are nerves that come from these levels and travel around the chest – giving pain in the front.

Treatment was aimed at restoring the movement and function in the joint and breathing pattern.

The mainstay is manual therapy to release the tight soft tissues and muscles before then moving onto mobilisation of the rib itself and bringing in breathing to the movement. We have many manual techniques that work very well to restore normal function.

Happily, this lady felt better after the first session – if a little tender from getting these stuck areas moving. However, within 3 days she was able to breathe deeply normally again. we worked once more on the restoration of full function. This lady is now fully pain-free and build back into her Pilates and jogging as part of her recovery from this horrible virus.

Don’t let rib pains beat you! Let us help!

References

1. Research article into treatment methods 

If you have spent time in bed or hospital you will be much weaker and less fit than you were. You typically start to lose fitness after a few days of no activity so this has to be taken into consideration.

You will find everyday jobs tiring as you didn’t before. Simple things like stairs or just short walks will make you breathless and your legs ache.

The aim has to be to get back fit or even fitter again. You will at first feel more tired but this is part of the process.

Regular activity will make you feel better, will reduce the aches and pains in the joints, and start to rebuild your muscle strength.

Activity will help you sleep properly at night.

How do you do it?

• Start slowly and build over time.
• Listen to your body. If 10 minutes of walking makes you tired then start there but try to repeat 3 times a day and build through 12 to 15 minutes and onwards.
• A little and often is the key. Don’t be afraid to rest but equally, you need to push yourself to make progress.
• Don’t just sit through the rest of the time. Standing and walking on the spot is far better than just stagnating.
• Make a drink or do a small bit of housework – something is better than nothing.

What are my aims?

• Start with what you can do and don’t set too high a target. Make it attainable and you won’t lose heart.
• If 10 minutes walking is your limit then set a medium-term aim (say 2 weeks) of being up to 30 minutes walking. If you then add a minute or two each day you will get there.
• Try to repeat twice a day if you can.
• Once you reach 30 minutes you can either continue to build the distance if you are happy with your pace. Alternatively, you can add in a bit of pace.
  • You do this by, for example, a 10 stride ‘burst’ every minute. Or a burst between lamp posts or trees. Little gains all add up. Be imaginative.

Tips.

Pick a time of day that suits you – we each have better, more energetic times of the day.

Give it an hour after eating and take a drink along with you.

Use a walking pole or two for balance.

Walk with a partner or friend – at a distance – if you are worried about your balance.

Record your progress to give a sense of progress.

You will have days when you are not as perky but the record will show your overall, week by week, progress which is a much better gauge. You can use your phone health app or simply note in on pen a paper – how far and how long it took and how you felt. Athletes use this method to bring perspective to that bad run!

Rib pain

With persistent coughs, you can develop rib joint dysfunctions. We can help with this with an assessment of the specific issues, mobilisation of the dysfunction and breathing exercises, and rib self-help techniques.

Please read this before starting
Any exercise could lead to the risk of physical injury.
You should feel good when participating in an activity or exercise.
If you experience any extreme pain, shortness of breath, or dizziness, stop and seek advice.
Following this, activity and exercise advice, is at your own risk. You are agreeing to undertake these activities voluntarily and as such assume all risk of injury to yourself.
If you feel unwell before, during, or after, stop immediately and seek advice.

Details can be found here on the NHS website

If you are recovering from illness or struggling with breathlessness, or even fear, anxiety or panic, learning some simple breathing techniques can really help. It is essential to keep good lung function and breathing patterns to ventilate all the lung to reduce infection by mobilising and clearing the whole of the lung of fluids.

Your lungs sit within the protective cage of your ribs, with the diaphragm – the dome-shaped muscle, at the bottom. It is the diaphragm that plays a major role in breathing.

• As you take a breath in the diaphragm contracts and flattens, increasing the space in the chest, allowing air to rush into your lungs. The opposite then happens when you breathe out.
• Good diaphragm strength improves cough effectiveness and makes it harder for bugs to take hold – which is the difficulty people have with this virus.

When we get breathless or spend hours slumped on the sofa or over your laptop, we do not effectively use the diaphragm and we revert to breathing only with the top of the lungs, and the lower parts become stagnant. This then in turns reduces the oxygen uptake in the blood and leads to more feelings of breathlessness…..a vicious cycle.

• You can get control of this as well as exercise the lungs and clear the tubes more effectively by working on your breathing pattern.

Posture

Key start. Sit back in a chair and take the pressure off your tummy and allow space for diaphragm to move.

• If you can’t sit back, then lean forwards with your elbows on your knees to let your tummy space to expand.

Breathing Exercises

The active cycle of breathing techniques (ACBT) is an effective way to help clear sputum from your chest. ACBT is simply a set of exercises that helps loosen and remove secretions from deep in your lungs and airways.

1. Breathing Control

Breathing control is slow, controlled breathing, using as little effort as possible.

• Check your posture (as above).
  Relax your shoulders and think about breathing in with your tummy.
  • Place one hand on your tummy and one on the chest, feel the movement.
• Take a slow breath in through your nose, using your tummy
• As you breathe out purse your lips – this helps to open up the airways
• Gradually make the breaths slower and deeper

2. Deep Breathing

Deep breathing allows the lungs to fully expand, especially the lower parts.

• Take a long deep breath in through the nose, using your tummy to fully expand your lungs.
  • At the end of the breath in you might feel the ribs lifting, this is good. It should NOT be the first movement though.
  • What you DON’T want is your shoulders lifting up. Doing this leads to issues elsewhere – neck/shoulder tightness predominantly.
  • It can also be helpful to hold your breath for a couple of seconds at the end of the breath in, to really allow the air to get to the depths of your lungs.
• Breathe out gently and relaxed, as if you’re sighing.
• Repeat 3-5x

3. Huffing or Coughing

Huffing is brilliant at shifting reluctant materials from the depths of the lungs to the central tubes ready to be coughed out. Better than coughing and nicer on the throat. If when performing you hear a rattling sound, you are doing it right.

• Perform the huff on the breath out. You should have an open mouth, and imagine you are trying to steam up a mirror, rather than coughing. Use your tummy muscles to help you squeeze the air out.
  • This can either be a gentle, long huff or shorter, sharper huff.
• Repeat 3x
• Each cycle of huffing should be followed by breathing control.

If you have found this sequence of exercises has not completely cleared the chest it may then be worth performing a couple of coughs.

• At the end of the huffing, perform 1-2 short coughs, with chin to chest.
• The temptation is often to continuously and aggressively cough in the attempt to remove fluid, avoid this. It will cause irritation in the throat and will make you more breathless.

Working on these exercises several times a day will help enormously to ventilate the lungs and prepare you to better fight the worst effects of this virus.

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

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.

Thoughts.

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