Question
QUESTION: When I was 8 months pregnant, 3 years ago I suffered an injury to multiple ribs rolling over in bed - in the middle of the night I awoke with extreme pain and heard a ripping and a pop or break. During my pregnancy I was being treated by both a Chiropractor and Physical therapist for pain in my rib cage in that same area, even before the injury occurred. Prior to the injury I also had a severe cough so I believe the muscles were under a lot of stress. So three years later, after trying many things - chiro, PT, injections, massage, visit to orthopedist, bone scan (which showed three old fractures one year after injury), xrays, bone density test - I am at a loss on how to pursue help for my persisting chronic pain from this injury. Everybody just says there is no reason that I should still have pain from a rib fracture three years later. I should also note that the pain feels like it comes from under my rib cage, if I hook my fingers under my lower ribs and lift up I feel a bit of relief. Pressing on my lower right rib cage, the ribs feel loose, almost disconnected - they don't have the stiffness and strength of the left side and I also have a lot of clicking and grinding. There is also a penny size lump near the area of pain, about two inches from my spine and it seems to being getting larger slowly over time. The pain is constant and nothing seems to bring relief - it reminds me of nerve pain that I experienced years ago with thoracic outlet syndrome. I have been on the Fentanyl patch for two years now, having been told that this is the only treatment available, and not only does it barely help the pain, but I believe it has caused me to have paralysis of the stomach (gastroparesis) for the last year and a half - I have been so sick I have lost 60 pounds and am unable to eat much solid food and suffer with constant nausea. I am currently going to a Naturopath for acupuncture and he believes it is a dislocated rib (and that the bump is my rib protruding near my spine.) He has been gently manipulating the area and I have not noticed any change. He has suggested going to an osteopath. What kind of doctor should I see? I've been told an MRI would be a waste of money, but there is something obviously wrong. Who could help me figure out a way to heal the area so that I am not on nasty pain medication for the rest of my life? I am only 32 and the pain seems to be having a domino effect in my life in that it's causing other health issues, depression, family issues, financial difficulties, etc. I feel like I have exhausted all possibilities. I welcome any advice. Thank you.

ANSWER: Hello Erin,  sorry to hear of your severe and long term problem.

First, you are young,,, how did turning over in bed fracture three ribs?  How was, how is your underlying health, other then this rib pain?  Are you osteoporotic?  Do you have brittle bones for some reason?

"....bone scan (which showed three old fractures one year after injury), xrays, bone density test ...."  You injured your ribs 3 years ago,  how old are these tests? if over a year old, it could be time for some comparison tests.  You do not list an MRI; either a chest MRI and/or a chest CT scan which views the bones and organs could be helpful.  I would look for a chest MRI- view the organs and musculoskeletal system.  You could even ask the radiologist to place a marker upon you, near the point of pain, to help locate the area involved and assure proper scrutiny. When taking Xrays, sometimes a tiny BB is taped near the area of pain, perhaps something similar could be done with a chest MRI or chest CT, bring it to the radiologists attention if you do new imaging.  New imaging would be something I would recommend.

A naturopath is a pretty good starting point.  Your N.D. should be helping you with nutritional supplements, manipulation, massage, and acupuncture.  Naturopaths are licensed in some states, not licensed in others,  make sure your ND went to an accredited Naturopathic college, and if your state licenses NDs, make sure your ND is licensed.

From: http://en.wikipedia.org/wiki/Naturopathy
"""Naturopathic medicine (also known as naturopathy) is a complementary and alternative medicine which emphasizes the ability of the body to heal and maintain itself, which practitioners believe is innate. Naturopathic practice may include different modalities such as abstinence, acupuncture, colonic irrigation, counseling, chiropractic, diet, exercise, herbalism, homeopathy, hydrotherapy, environmental medicine, manual therapy, orthomolecular medicine and relaxation. Practitioners emphasize a holistic approach to patient care, and may recommend patients use conventional medicine alongside their treatments. Naturopathy has its origins in a variety of world medicine practices, including the Ayurveda of India and Nature Cure of Europe.[1] It is practiced in many countries but subject to different standards of regulation and levels of acceptance......"""

Perhaps helpful websites:
http://www.aanmc.org/

""""".....Educational Requirements Naturopathic medicine is one of the most regulated complementary health professions in North America. It is a licensed primary health profession in 11 U.S. states (and Puerto Rico) and 4 Canadian provinces.

In North America, graduates from five naturopathic medical schools are permitted to write the Naturopathic Physicians Licensing Examinations (NPLEX) to become licensed in the regulated jurisdictions.

The naturopathic program at these five schools is a four year, full-time graduate program that includes courses familiar to conventional medical practice, such as physical and clinical diagnosis, anatomy and pathology, as well as training in the naturopathic modalities.

The five naturopathic medical schools in North America are:

Bastyr University

National College of Naturopathic Medicine

South West College of Naturopathic Medicine and Health Sciences

University of Bridgeport

Canadian College of Naturopathic Medicine
............."  http://altmedicine.about.com/cs/naturopathicmed/a/Naturopathic.htm

If your ND does not feel comfortable with the manipulative portion of the treatment regimen, I would recommend a Doctor of Chiropractic with a DACBSP (sport injury specialty) or DACBO (orthopedic specialty)- Chiropractors are licensed in all 50 states and have specialties.  Your Naturopath may also have specialty training.

"....and it seems to being getting larger slowly over time. ...." Getting larger slowly?  Get additional imaging to explain this.  If after additional imaging the ND, DC or osteopath (DO) feels manipulation could help;  that manipulation may be supported by something called 'Kinesio taping' (http://www.kinesiotaping.com/).  If manipulation is the avenue decided upon, support it with kinesio taping, ask your doctor if they do this technique, it could be helpful.

I hope this helps.  Do not hesitate to ask a followup.  Please remember, my answers over the internet are for discussio , information, education only.  Only a treating health professional in person can properly evaluate, DX, TX, RX, PX a specific patient.

I wish you both good luck and good health naturally.

Dr. Victor Dolan, DC
http://drvictordolan.chiroweb.com  (email newsletter)
http://www.DocDolan.net
http://www.GoodHealthNaturally.info  













---------- FOLLOW-UP ----------

QUESTION: Thank you for your advice.  So, I've been told by other docs not to waste my money on an MRI, so I'm glad to hear from you that it would be helpful.  And after reading other postings on this website regarding rib injuries and pain and their answers from chiropractors it sounds like often their is cartilage or joint damage with rib injuries/dislocations?  Would an MRI or chest CT scan show this?  And if this were the case, is it fixable or does it remain a chronic condition?  Would an MRI or CT scan show a dislocated rib?  Also, regarding breaking ribs rolling over in bed (you asked about cause), my bone density test came back normal so it is assumed that the weight of the pregnancy was putting pressure on my rib cage and I turned just the right way and then crack!  Is it at all possible that because this injury occurred when I was 8 months pregnant, so the ribs would have been healing while I was still pregnant, that a rib or ribs healed in a malformed shape (to the shape of my pregnant body with an 8 lb. baby in my rib cage) and now that I am no longer pregnant the malformed ribs are not aligning correctly with one another, muscles, joints, vertebrae and possibly pinching nerves and causing a lot of muscle strain?  Would an MRI or CT scan show this?  And if it was a malformed rib, what would be the long term fix?  I've heard of bones being rebroken when they healed incorrectly.  Have you ever heard of that happening with ribs?
With all things considered what is best - an MRI or CT scan or both, and how do they differ?  So far I have had chest xrays, a bone scan, and bone density test (all 2 years ago), nothing seemed to provide useful information.
Thank you so much for answering my long, kind of complicated questions.  It's been going on so long and affecting many areas of my body and life and I haven't found anyone to help me, so it's hard to describe in a sentence or two.
Thank you again for your time and answering my questions.  It is a gift to hear some other options to explore.

Answer
Hello Again Erin,

You have certainly done a lot of research on your own.  

Yes, actually all that concentrated extra heavy pregnancy weight (8 months in), with the wrong maneuver, could possibly fracture/ dislocate a rib.  But when we break (fracture) a rib, it is usually not displaced, so it usually heals good as new in the correct spot.
Same with a dislocation; usually the dislocation is VERY uncomfortable, and we stretch, rotate, breathe deep, breathe out- and these movements will usually re-locate the rib to the correct position.  A fracture usually heals well, your prior tests would let you know if you had an fracture that did not heal.  The dislocation,,, is a different matter.  The dislocation can remain loose, slip in and out of proper alignment, causing inflammation and then pain.

Malformed rib, no I do not think that likely, but a "loose" rib prone to inflammation by being out  of alignment, more likely.

An MRI would probably be the better test, I think your bones will check out alright, but your sort tissue- joints or muscles may not.  The MRI would be a better test to evaluate that.  The MRI can also find inflammation, an also evaluate organs in the area.

Re-break your ribs,,, no I do not think that a good idea.

I do not remember if I discussed support for your ribs,,,, Ah yes, I see we discussed kinesio taping; look for a practitioner who will support your rib in place with this or something like it.

Hope this helps a little bit more.

Same disclaimer.

Good Luck and Good Health Naturally,

Dr. Victor Dolan, Staten Island Chiropractor
http://drvictordolan.chiroweb.com
http://www.DocDolan.net
Http://www.GoodHealthNaturally.info