Question
so history leading up to question:

6ish weeks ago i went hiking (part of this was an 70~80% grade for half a
mile so spent most of it on my left side inching my way down), i was caring a
tripod (.5~1lb) in a sling over my shoulder.

the next day i had an excruciating pain in my left shoulder (same shoulder i
carried the tripod in the majority of the trip, everything pain related will be
regarding my left side as its what hurts). I figured it was just a strain as even
though it was very painful I could stretch my neck and get minor relief. over
the next few days the pain got better... I also have been taking 2~3x 200mg
ibuprofen tablets as i feel i need it, which is usually about twice through out
the day.

however after about the first week the pain has remained less then the initial
onset but constant. the internet claims that it should have healed up in 4~6
weeks. The pain has been pretty severe, standing and sitting throughout the
day the pain gets better as weight is supported by my spinal column. however
transitioning to laying down is not fun. and laying down causing neck
muscles to be partially or totally engaged is very painful. this has led to 5
weeks of poor sleep and horribly painful mornings when i have to transition
back to standing. seeing as the pain from weeks 1+ since injury has been
the same and not improving I figured it was time to go my normal doctor.

Normal doctor listened to my symptoms and prescribed 2 weeks 3 times per
week visiting a physical therapist. he then poked each of the t1~t7ish
vertebra, and then poked at the area that i would describe as the center of
the pain. He then prescribed a muscle relaxant (alprozolam 1mg once per day
20~30min before bed). (which has been great! i have slept with out issue for
the last 5 days. i have been taking the muscle relaxant + ibuprofen) He
then told me if the pain does not get better after my time with the physical
therapist I should reschedule with him for a series of xrays to look into the
problem some more.

this last friday I visited the physical therapist for the first time. After there
exam, they gave me a deep tissue massage to try and loosen up the area.
they said that my first rib connecting to my t1 is dislocated, that it is sitting
in a higher position then it should be. they also said that the cvt (c7 t1) joint
was locked up and another t? joint was locked up much lower in my back.

the physical therapist then proceeded to pop each joint in my back from the
bottom of the thoracic to the cvt. they managed to pop or as they called it
"manipulate" each joint successfully, except for the left rib1 t1 joint. (they
were able to do the right rib1 t1 joint). The physical therapist then said that
hopefully as muscles relax and they work more in the coming two weeks they
will be able to reset the rib and everything will go back to normal. they are
confident that they will be able to fix it.

question:

If it is a dislocated rib1 t1 joint type thing, is physical therapy the right
solution, can they reset it? or should i go back to my doctor early and get a
xray/film set done to evaluate it?

i happened to fall asleep early last night and missed my muscle relaxant
retake time so woke up in lots of pain (about same as normal before i started
the muscle relaxant). so i took my dosage. for the most part when on the
muscle relaxant + ibuprofen, i can not gauge the actual amount of pain I
am experiencing.

thanks!

Answer
Dear Joseph,

Here is the first problem...although your physical therapist may be great, he/she is not licensed to diagnose anything, they are not doctors, they are therapists.  This is why they have to get a referral to treat you.  Although they have advanced education and training, it is not in primary diagnosis. So even if they are correct in their assessment, they are misrepresenting their licensure. For example, I have a great understanding of many surgical and pain management procedures, and actually know how to perform many them, but I am not a surgeon, I have not been formally trained that way and my license does not allow me to perform them.

Second:  That being said, many PT's have acquired extensive knowledge in the kinematics of the spine.  I have no doubt that your rib articulation is not functioning properly but I would not diagnose a dislocation in this case...especially without x-ray confirmation.  If your rib was dislocated, that would mean that the entire rib head was not articulating with the vertebra, and the joint capsule would have to tear for this to occur.  It is more likely that the rib is either fixated and not moving properly, or subluxated which is less than a dislocation.  

Third, your therapist used the word "manipulate" to cover their butt.  If they are "popping" your spine and rib cage, this is a problem.  The law specifically prohibits any fast movement of the joint space by a physical therapist because they do not have advanced education in spinal diagnosis, or spinal manipulative therapy (spinal adjustments). Chiropractic Physicians and Osteopaths are the only licensed health care professionals allowed by law to perform these procedures, which are specific to vertebral levels and there are numerous cases of physical therapists losing their license for doing this. Now, PT's are allowed to manipulate which is a slow deliberate movement which is not specific to individual spinal levels, but you did not describe that type of activity.  These conditions do respond to "re-setting the rib", but this should only be performed by a doctor.  Would you let the PT relocate your hip or shoulder joint if it was dislocated?  So be careful...do not let them try to adjust or "pop" your neck.  I would recommend that you see a chiropractor or osteopath for this type of care.  

Your PT can be very effective at helping though with resistive exercises, stretching protocols and stability exercises...this is what they are trained to do well and perform best!! I have worked with some great PT's, make sure that yours is doing what they are supposed to.

Hope this helps Joseph, Good Luck.

Respectfully,
Dr. J. Shawn Leatherman
www.suncoasthealthcare.net