12TH RIB SYNDROME & COSTOVERTEBRAL SUBLUXATION SYNDROMES

All 12 ribs articulate to the vertebral column with two gliding-type synovial joints; the costocentral and the costotransverse joint. The costocentral joint is located between the head of the rib and the lateral portion of the vertebral centrum, and the costotransverse is situated between the tubercle of the rib and the tip of the transverse process.

The costotransverse joints (CTJs) are anatomical structures that, together with the costovertebral joints, form the connection point between the rib cage and the thoracic vertebrae. The CTJs and costovertebral joints also contribute to the stability of the thoracic spine. 

In the group of thoracic spine pathologies, CTJs are no doubt less studied than the joints between the intervertebral facets and those between the vertebral bodies and fibrocartilaginous discs. CTJs can cause a particular form of “thoracic back pain,” which may be difficult to classify in clinical practice.

Costotransverse disorders are disorders affecting or involving the costotransverse and costovertebral joints and ligaments. 

Important considerations are:

• Often overlooked, it can be responsible for pain in the thoracic region or functional impairments of the thoracic spine.
• There are several reasons why people may experience this condition, such as physical injury, natural wear and tear of the body, growth of abnormal cells, physical deformities, or involuntary contractions of the muscles.
• A diagnosis is typically made through a clinical examination, and treatment may include mobilization, exercise therapy, injections, and/or fixation of unstable joints.
• The costotransverse  joint is known to be involved in patients with ankylosing spondylitis, which, combined with the involvement of the costovertebral, sternoclavicular, and sternomanubrial joints, would result in increased rigidity of the thorax and increased dorsal kyphosis. This does not result in decreased pulmonary function, which is possibly due to an increase in diaphragmatic breathing. 

Possible symptoms are:

• Pain localized to the posterior thorax.
• Pain may radiate to the anterior chest wall, along the rib, sometimes into the shoulder, and sometimes toward the upper limb.
• Unilateral symptoms.
• 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 the costotransverse joint and rib angle.
• Movement in adjacent thoracic vertebral and rib segments is usually restricted and may stimulate or exacerbate protective muscle spasms.
• Increased muscle tension in paraspinal muscles, rhomboid muscles, trapezius muscles, and levator scapula muscles.
• Neck pain, headache, 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.

“Twelfth rib syndrome, also known as rib tip syndrome, is a painful condition resulting from highly mobile floating ribs.

It commonly presents as pain that may be felt in the lower back or lower abdominal region due to the 11th or 12th mobile rib irritating the surrounding tissues and nervous systems. The condition is often labeled as slipping rib syndrome due to the unclear definitions of the conditions, with twelfth rib syndrome sometimes being referred to as a subtype of slipping rib syndrome.“

Twelfth rib syndrome is caused by irritation of the floating ribs'  intercostal nerve related to the hypermobility of the floating ribs' lack of bony attachments. 

Since its first description in 1962, twelfth rib syndrome has been an often-overlooked cause of chronic chest, back, abdominal, or flank pain. Pain from twelfth rib syndrome can be located more in the patient's back. Both are rare causes of chronic chest, back, abdominal, or flank pain that may commonly go undiagnosed or misdiagnosed, as many healthcare providers are unaware of such diagnoses. Various positions may exacerbate or elicit pain, including lateral trunk flexion, rising to a standing position, or trunk rotation. 

Postural physical therapy, such as Schroth method therapy, Nerve blocks, and surgical rib resection, can treat this syndrome. However, further evidence is required to evaluate them properly. Familiarity with this syndrome is crucial in reaching a proper diagnosis.