Question
Dear Dr. Leatherman,

I appreciate your detailed and timely response. However, it prompted a few more questions. I am far from "large breasted" (ha ha), and I consider my posture to be pretty good. I had another visit to my chiropractor today, of course, it was very painful.  He tried a new therapy today, it was what he called "spinal traction". It was a table type device which had "rollers" that moved up and down the spine. It was definitely not a comfortable experience to say the least. Of course, I am right back in the same discomfort again. I am going to get my CT films from the hospital tomorrow. My chiro requested me to do so.  He feels that maybe there may be a vertebrae, or few that are rotated. He said that most ER docs don't look for the things you guys would look for, they focus on the pathological problems, ie: fractures. I tried palpating my sternum, I did not feel any bumps. My pain is mostly contained to the spine, from the bra line to the base of the neck, and at times, the side of the rib cage. It is painful for deep inspiration still. I am not going to give up, I am just hopeful for some new insight, or information that may help to remedy the problem.  Again, I thank you very much for your repsonse.
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Followup To

Question -
I am a 27 y.o. female and I have been dealing with what at times can be, excruciating upper back pain. During these episodes of terrible pain, it is difficult to inhale deeply. I went to the ER over 2 weeks ago in the middle of the night, when the pain first became terrible. I had a CT scan, with IV contrast, PE protocol. The CT was negative for any lung defect, but noted that I had "displaced ribs". I was prescribed a mild analgesic and muscle relaxers. Well, a week later and I am still experiencing this horrible pain. I made an appointment with my chiropractor. He adjusted me, set me up with ice and electrical stim for 15 minutes. I felt relief after this inital visit, but only for a short time.  By evening, the pain was right back to where it had been.  I could actually feel that my back/ribs had again slipped out of alignment. I have been seeing my chiropractor daily since then and I continue to experience the same pain, only getting relief briefly after adjustment. The chiro has even said that he cannot believe how everything that he had "put back into place, had slipped right back out again." He also said (several times) "WOW! Did you feel that?  Every single bone in your back moved!". I apologize for such a lenghty explanation, but I am very frustrated at this point.  I am not sleeping, as it is very uncomfortable to lay flat, or on my side for sleep. I would just like to have an answer, or suggestion.  I would appreciate any advice or information you could offer me.

Thanking you in advance,

Lisa M. Webb

Answer -
Dear Lisa,

When the articulations between the ribs and the vertebra of the upper back become "misaligned" there is usually a chronic underlying condition to blame for it. Rib problems are intensely painful because of the normal movements associated with breathing.  These movements create increased inflammation around the joint capsule of the rib/vertebra when the joint is not articulating properly. The fact that you do get relief from the adjustment is a testament that the problem is definitely biomechanical, but you need to address the underlying cause of the problem.  There are a multitude of things to look at such as new activities, work resposibilities, daily repetitive activites, work out routines, etc...  Do you have proper form, are you hunched in poor positions throughout the day, are you a grad student with poosr study posture?

Your chiropractic physician needs to examine the articulation of the ribs to the sternum as well.  When you adjust a rib problem, often you need to adjust it over and over.  I have had patients come to the office twice daily for a week in these circumstances, and they get adjusted on both visits (2nd visit no charge).  This helps to relieve the tension on the joint capsule as well as reduce the inflammation.  When I do this, many times I need to adjust the rib on the front near the sternum to have any lasting effects.  This can be very tender for the patient, and you should always use ice afterward.  You can actually check your own sternum by running your fingerss down the front of the sternum and checking for any protruding areas "bumps", they will most likely be very tender to lighte pressure.  This is an indication that the rib needs to be addressed from the front, not the back.

Some other things to address:  
Are you large breasted?  If so, you need to wear a bra that gives good overall support without a small clasp...many women wear lacey, sexy types of bras that do not support the breast tissue adequately, and they wear them all day. The result is abnormal stress on the upper back above the bra stap with increased compression under the bra strap.  These bras may be appropriate for evening wear, but not for all day work environments.  I find that a good sports bra with large coverage across the back helps to lessen the pain and constriction because of the increased surface area.  Especially in women with desk jobs.

How is your posture?  Are your shoulders rounded forward?  Does your head protrude forward from your torso?  These are common posture problems that lead to chronic upper back, neck and rib problems.  It also creates abnormal muscle shortening & tightening in the front of the body with abnormal muscle lengthening & tension in the back.  This poor posture leads to longterm problems as well as short term problems and needs to be addressed on a daily basis with exercises to prevent and rehab the area.  

Lisa, I would ask your chiropractor to address all of these issues.  He should be able to help you effectively create an exercise program to combat these issues.  In addition after you get adjusted in the office it may be of benefit to wear a constrictive bandage around the chest/ribs to help keep them in place after.  This is harder to accomplish in women than men, with men you just wrap them in an ACE bandage.  JC Penny actually has a few good posture braces for women with a bra built in that will help to support the breast, pull the shoulders back, and support the upper back musculature.  I would recommend that you purchase one.

Concerning your sleep, it is advisable that you try to lay on your back as much as possible and avoid sleeping on your side.  Side sleeping places increased stress on the neck and upper back due to rotation of the shoulder and arm on the down side, with added weight of the shoulder and arm on the up side.  When you lay flat on your back, the spine is more properly aligned with less pressure on the joint capsules, and the weight differential from side to side is minimized.

You may need to lay in a more upright position to help with the pain, but do not prop up your shoulders with pillows.  Instead you should actually prop up the mattress, or the bed underneath the frame at the top. This is easier than you think, a plywood wedge, (approx. 15 degree angle and full width of bed), placed between the box spring and the mattress will do the trick, and can be made simply with little cost and a few pieces of wood.  

Don't give up Lisa, rib problems are difficult, but they can be addressed.  It may take a little longer than you expect, but look for the source of the problem, and make the necessary changes to allow your body to heal.

Respectfully,
Dr. J. Shawn Leatherman  

Answer
Dear Lisa,

Well, it sounds as though posture is okay, and support is not an issue.  Lets look into some more avenues.

The "traction table" that you spoke of is called an intersegmental traction unit.  Most patients actually like the table because of the rolling nature as well as the pressure placed on the paraspinal muscles.  It sounds like the chiropractor you are seeing may have just had it set too high for your comfort.  Realize that this is considered to be a non-therapeutic treatment modality, and many chiropractors do not even charge for it anymore.  

If you were my patient with the information you have given me, I would be using interferrential electrical current for pain relief and lymphatic system stimulation, along with ice packs to lower the amount of inflammation,(you cannot have pain without inflammation), in addition to adjustments.  Also, if muscle spasms are associated, massage therapy should be utilized to allow the muscular system to relax enough that it will reduce the stress on the associated vertebral levels so that the adjustment will be more effective.  Lastly, it is improtant to be doing some active rehabiliatation in the area.  Rhomboid exercises, levator scapulae stretches, and possible trapezius exercises.  Ask your chiropractor for some instuction on proper form as well as repetitions etc...

Please keep in touch with progress.  Also I doubt that there will be any significant findings on the CT.  I agree with your chiropractor that radiologists do not look for subtle changes on imaging as we do, but A CT scan is taken while lying down.  An upright x-ray of the spine would be more appropriate for biomechanical analysis of the spine.  We are moving in a gravity controlled environment every day with all of our duties and activites...when radiographic techniques are utilized lying down it changes the appearance of the spinal configuration and it is inappropriate to analyze them as such.

Respectfully,
Dr. J. Shawn Leatherman