Ribs and Coccyx- The Great Imitators

These two bones with their adjacent articulations and soft tissue attachments are often neglected in clinical Chiropractic practice. They are important to include as they frequently mimic other conditions.

Costovertebral and costotransverse joints are rarely considered as sources of pain.(1) The Coccyx is regarded as a non-functional structure with little clinical relevance.(2)
The costovertebral complex has been shown to have innervation of the anterior joint capsule and synovial tissue, and large intraarticular synovial inclusions ("meniscoids") found in other spinal joints. (3) That is, the ability to cause the same type of pain as we see arising from spinal facet joints exits. The coccygeal area has a large and interesting innervation (4). The ganglion impar, located immediately anterior to the sacro-coccygeal joint, is the joining of the two sympathetic chains. It is interesting to speculate that coccygeal dysfunction may affect this structure, causing strange symptoms.
Symptoms arising from costovertebral joint dysfunctions include chest wall, upper back, shoulder, arm and neck pain (5,6). Intercostal neuralgia in pregnancy has been reported due to costovetebral and costochondral joint dysfunction. (7) An increase in chest expansion and blood oxygenation was found after HVLA dynamic thrusts were applied to the ribs (8), suggesting respiration may be affected by rib joint dysfunction. Chest wall pain, common to post-herpes zoster infection has been found to improve by treating myofascial trigger points in the intercostal muscles. (9)
In 21 years of practice, I have seen rib problems cause radiating pain in the chest, upper back pain, neck pain, shoulder pain, radiating arm pain mimicking a cervical disc protrusion, wrist pain mimicking carpal tunnel syndrome, neck and arm pain mimicking thoracic outlet syndrome, and sub-occipital headaches. All responded well to treatment of the ribs and their adjacent structures. There are very few manual practitioners who look for rib problems and know how to treat them effectively. There is some, though little information in the literature on treatment of rib joint dysfunction (5,10,11). The purpose of this lecture is to present what I have found to be an effective way to treat both rib and coccyx dysfunctions.
Symptoms attributed to coccygeal joint and surrounding soft tissue dysfunction are less prevalent in the literature. Low back pain and trunk flexion have been reported to improve after coccyx manipulation. (2) Abnormal EMG patterns of thoracolumbar spine, buttock, and thigh muscles were altered after therapeutic relaxation of the gluteal and pelvic floor muscles (12), suggesting treatment of the soft tissue structures adjacent to the coccyx may affect low back pain. Shortening of the pelvic floor muscles has been found clinically to cause asymmetrical movement in the sacro-iliac joints. (13)
Of the type -O disorders, urinary Incontinence in a 12 year old female was successfuly treated by cocccyx manipulation (14). In another interesting case study, external anal haemeroids were resolved upon sacro-coccygeal manipulation. (15)
Techniques for treating the sacro-coccygeal joint and coccyx dysfunction are found in the literature and include external coccygeal adjustments (16), internal coccygeal adjustments (17), Activator instrument adjustment (18), and soft tissue proceedures (12).
In my own experience, coccygeal dysfunction, of the sacro-coccygeal joint and surrounding soft tissue structures can also mimic the radiating pain of a lumbar disc herniation, as well as result in upper thoracic pain. It also seems to result in an anxious "irritated" personality type, where the patient with this problem is "edgy" and "agro". These lessen when the coccyx problem is resolved. I will talk of case studies later to illustrate this.
I find the most effective way to treat the coccyx is to work on trigger points in the affected muscles and ligaments. Coccyx adjustments are necessary but most of the pain is myo-fascial. Adjusting the joints has had limited success for me.