CONSERVATIVE TREATMENT OF A FEMALE COLLEGIATEVOLLEYBALL PLAYER WITH COSTOCHONDRITIS
Donald Aspegren, DC,a Tom Hyde, DC,b and Matt Miller, MDc
Objective: This study was conducted to discuss the conservative care used to treat a female collegiate volleyball playerwith acute costochondritis.
Clinical Features: A 21-year-old collegiate volleyball player had right anterior chest pain and midthoracic stiffness of8 months duration.
Intervention and Outcome: High-velocity, low-amplitude manipulation was performed to the associatedhypokinetic costovertebral, costotransverse, and intervertebral zygapophyseal thoracic joints. Instrument-assisted softtissue mobilization was performed by using the Graston technique. Pain levels improved on numeric pain scale, as didfunctional status identified on Dallas Pain Questionnaire and Functional Rating Index.
Conclusion: This athlete seemed to respond positively to manipulation, soft tissue mobilization, and taping. (J Manipulative Physiol Ther 2007;30:321-325)
Key Indexing Terms: Manipulation; Spinal; Athletic Injuries; Tietze’s Syndrome; Chiropractic
The participation of women in sports has steadily therapeuticapproaccture,
mentation of Title IX.As participation increases,
so does physical stress placed on the musculoskeletal system
medications such as sulfasalazine.15 Symptoms may persist
of the female athlete. Chest wall pain is a common symptom
for several months to several years but most commonly
in athletes. Costochondritis typically presents as pain on the
anterior chest wall of the costochondral or nal joints.
We present a case study of a female collegiate volleyball
This condition is more common in associated
player with acute pain of the right fifth costocartilage, right
with physical stresses experienced in athleticon-
second through fifth chondrosternal joints, and stiffness of
dritis is typically a benign and self-limiting condition.
the midthoracic region. A literature search of the Ovid and
PubMed indices was performed. We present what we
ichia coli infecthe cartilage,intraabuse,
believe is the first published case of a collegiate volleyball
player with costochondritis managed conservatively. Treat-
to be an associated cause of symptoms.
ment included high-velocity, low-amplitude (HVLA)
As soon as serious causes of anterior chest pain, such as
manipulation, Graston technique (GT), and Kinesio taping
methods. The purpose of the article was to report the
diagnosis of a benign etiology of costochondritis has been
conservative treatment of costochondritis in a female
made, the management begins. The most commonly used
Private Practice, Director, Lakewood Spine and Sports Center,
A 21-year-old collegiate volleyball player presented with
b Private Practice, North Miami Beach, FL.
right anterior chest pain and midthoracic stiffness that had
c Private Practice, Director, Mile Hi Occupational Medicine.
been present for 8 months. She played year-round in the
No funding was received in the preparation of this paper.
United States and Europe and had begun this vigorous level
Submit requests for reprints to: Donald Aspegren, DC, 11220 W.
of activity in high school. The anterior chest pain was
constant and described by the patent as a sharp ache that
Paper submitted July 31, 2006; in revised form January 1, 2007;
worsened with volleyball and weightlifting. The weightlift-
ing activities that exacerbated her pain were bench presses,
bent flies, and power cleans. The patient denied respiratory or
Copyright D 2007 by National University of Health Sciences. doi:10.1016/j.jmpt.2007.03.003
cardiac problems, and the onset of chest pain was reported to
Journal of Manipulative and Physiological Therapeutics
Fig 1. High-velocity, low-amplitude manipulation being applied tothoracic region.
be insidious. Her quality of play had been adversely affectedbecause of the pain. The pain made it difficult for her to focus
Fig 2. Application of GT to costocartilage.
in the classroom and obtain restful sleep. When pain levelsincreased during play, it became difficult to bdigQ and bspikeQ
range of motion was within normal limits, but elevating the
balls. She had no prior treatments for this problem.
right arm through the range of motion reproduced symp-
She marked her Numeric Pain Scale at a 7 on a 10-point
toms in the chondrosternal and costocartilage areas and, to a
scale. A Dallas Pain Questionnaire strated
lesser degree, in the dorsal region. Motion palpation
moderate pain levels with activities, with highest pain levels
revealed dysfunctional motion from the fifth through ninth
noted during lifting and movements experienced during
costovertebral, costotransverse joints, and intervertebral
practicing and playing volleyball. The DPQ is a 16-item
segments. A bimanual spring test of the ribs yielded
visual analog tool developed for the purpose of evaluating a
patient’s cognition of how chronic pain affects 4 aspects of
A diagnostic ultrasound study was previously ordered by
their lives. These 4 categories are as follows: (1) daily
her primary care physician and offered an impression of
activities, including pain and intensity, personal care, lifting,
benign nodules in the rib region. Results of a plain film chest
walking, sitting, standing, and sleeping; (2) work and
radiograph were normal. A 3-phase bone scan ordered by the
leisure, including social life, traveling, and vocational; (3)
consulting orthopedic surgeon showed negative results.
anxiety-depression, including social life, traveling, and
The patient expressed a desire to avoid medications and/
vocational; (4) social interest, which include interpersonal
or injection therapy. Consequently, we approached the case
relationships, social support, and punishing responses.
using HVLA manipulation to the hypokinetic costoverte-
Initial DPQ scores were 60 for daily activities, 70 for
bral, costotransverse joints, tervertebral thoracic
work/leisure, 10 for anxiety/depression, and 0 for social
zygapophyseal (facet) joints (Audible cavitations,
activities. A Functional Rating Index (Ffound the
as described by Ross et could be heard when
patient reporting severe pain, with greatly disturbed sleep,
performing manipulation to the involved spinal segments.
and the ability to perform only 25% of her regular work/
Instrument-assisted soft tissue mobilization incorporating
sport activities. The FRI is a self-reporting instrument
GT was gently applied to the chondrosternal joint and fifth
consisting of 10 items, each with 5 possible responses that
costochondral segmenKinesio tape was applied in
express graduating levels of disability. Regarding clinical
2 strips. First, a vertical strip (an I strip) was applied over the
use of the FRI tool, the average time required to complete it
chondrosternal joints, and a second I strip was placed
is 78 seconds. A higher score suggests more pain and a
horizontally over the fifth costo). The patient
reduction in functional levels. Her initial FRI score was 22.
was initially treated twice a week for 2 weeks. After 2 weeks,
Acute pain was noted upon palpation and deep inspira-
she reported a subjective improvement in pain of b70%.Q
tion at the right fifth rib chondosternal joint and the
Sport participation was allowed to continue; however,
costochondral segment. Palpation tenderness in this region
weightlifting was initially suspended and reintroduced after
was graded 3 on a 4-point scale as per standforth by
several weeks. Pain stopped during volleyball play and
American College of Rheumatology in 1sternal
decreased during nonparticipation periods.
compression test was acutely positive and at both
High-velocity, low-amplitude spinal manipulation, GT,
the chondrosternal and costocartilage regior
and Kinesio taping were performed on a weekly basis
Journal of Manipulative and Physiological Therapeutics
we present, a significant history of breast cancer was in thefamily and of concern to this student-athlete.
Physical examination findings for costochondritis typi-
cally include anterior chest wall tenderness that is localized tothe costochondral junction of 1 oribs, but does notinclude swelling, heat, or erythThe second throughfifth costal cartilage areas are most commonly involved. Associated restriction of corresponding costovertebral andcostotransverse joints may be discovered on joint playassesssuch as by motion palpaMotionpalpation is a manual process of moving a joint into itsmaximal end range of motion, after which it is challengedwith a light springing movement. This end point of jointmovement forms the basis for determination of a normal orabnormal joint play. motion of the joint is considered
Fig 3. Kinesio taping over chondral-sternal joints and costocar-
fixated or hypokinetic.Hypokinetic motion of the second
and fifth costovertebral, costotransverse, and facet joints wasdetected in our patient. The loss of normal spinal movement
during the spring workouts to control pain and improve
and associated chest pain was recently described by Yell-
function of the previously described thoracic joints. We used
observed thoracic intervertebral dysfunction by
2 in Kinesio tape strips o tension or stretch applied to
using active movement and applying an intersegmental
the tape during The patient was treated a total
overpressure to the zygapophyseal joints. An examiner who
of 16 times. Pain scores at the end of treatment included an
was blinded to pertinent details identified intervertebral
FRI score of 5; her FRI score on initial presentation was 22.
dysfunction in only 25% of controls, whereas 79% of patients
Her Numeric Pain Scale score improved to 0.25 from a
with thoracic and associated chest pain were identified as
previous score of 7. Her DPQ improved; daily activities
having alterations in spinal intersegmental motion.
reduced from 60 to 6, work/leisure reduced from 70 to 10,
Plain film radiography is normally used in costochon-
anxiety/depression reduced from 10 to 0, social activities
dritis, mild soft tissue swelling may be present.
remained the same at 0. The athlete was able to continue
Ontell et cribe radiographic and computerized
participating as a volleyball player and fulfilled her athletic
tomography scan features of costochondritis that may
commitments to the university and her goals as a student-
include chondral enlargement or destruction, low attenuation
athlete. An extended treatment plan included care as needed
of the costal cartilage (observed on computerized tomog-
for control of any increased symptoms and a 60-day rest
raphy), and soft tissue swelling. Three-phase bone scan may
period from play and weightlifting during the summer. Six
offer a a costochondral junction that may be
months after discharge from care, the patient required no
asymptoming for the presented volleyball player
did not yield remarkable results. Most studies fail to describelaboratory findings; however, Disla et ed elevatedsedimentation rates in patients with costocondritis. Our
patient’s sedimentation rate was normal with no abnormal-
Costochondritis is 1 of several chest wall conditions
ities found in the complete blood count or differential.
commonly present to the emergency department. Disla et
The main theraapproaches involved in our case
reported that of the 122 consecutive patients presenting to an
reassurance,HVLA manipulation of costoverte-
emergency department with anterior chest wall pain, 36
(30%) had costochondritis. Of the 36, women accounted for
(facet) directly to the costal cartilage,
those diagnosed with costochondritis. Brown and
and Kinesio tapingthe fifth costal cartilage and along
137 adolescents presenting with chest pain and
the third through sixth chondrosternal joints. The subject’s
found that 82% were afraid their pain was cardiac in origin.
weightlifting workouts were altered, excluding bench
Of those who were concerned that a heart ailment was
pressing and flies. We allowed the athlete to continue
present, 29% continued to worry even after the diagnosis of
Rumball et ly described the mechanisms of
tively analyzed 100 adolescents with chest pain and found
rowing as a mechanical factor leading to the development of
that 56% believed their chest pain was due to a heart
costochondritis. They believe inflammation in the costo-
pathology. These authors further discuss that adolescents
chondral region is most likely caused by an increase in
begin to perceive themselves as adults, consequently viewing
pulling from adjoining muscles to the rib or a dysfunction at
themselves as vulnerable to adult diseases. In the case study
the costotransverse joint of the involved rib. In the
Journal of Manipulative and Physiological Therapeutics
passed over the area of pain at a 308 to 608 angle in thedirection of the beveled edge for 60 to 120 s. During thisapplication time, the clinician attempts to locate bgritty,gravelly, sandyQ types of sensations that are backto the clinician through the instrumenand Wthat the instruments are moved primarilyin longitudinal strokes over the involved musculotendinousstructures by using multidirectional strokes. Passing theinstruments over injured regions will produce an inflamma-tory se and result in the destruction of existing scartishas also been stated that many athletes develop
Fig 4. Stainless steel instruments used in GT.
excessive connective tissue fibrosis (scar tissue) or poorly
symptomatic rowers, arm adduction of the involved side,
organized scar tissue in and around muscles, tendons,
ligaments, joints, and myofascial planes as a result of acute
reproduced sympdescribed motion is descriptive
trauma, recurrent microtrauma, immobilization, or as a
of the follow-through motion of a volleyball player as they
spike the ball. Follow-through motion brings the arm across
During the initial application of GT to the symptomatic
the body while the head approximates the shoulder of the
costochondral region of the patient, a gritty sensation was
adducting arm. The volleyball player presented in this case
identified. As the patient improved, the amount of bgrittyQ
was right-handed and experienced right-sided costocondritis.
sensation decreased. Melham esized that the
The costotransverse joint dysfunction observed
use of the GT instruments break down existing scar tissue in
in with costochondritis was also found in our
patients with chronic pain and begins the formation of new
volleyball player. Whether this finding is a factor in
scar tissue activity with the fibroblast laying down new scar
causation ry manifestation is unclear. However,
tissue in parallel, as opposed to laying down of this tissue in
Erwin et luded that the costovertebral joint has
random. Gentle stretching is applied after treatment to assist
been considered a candidate for producing a chest pain
in the formation of new organized scar tissue. The formation
referred to as a bpseudoanginaQ that may be ameliorated by
of parallel connective tissue fiber formation might be
spinal manipulation. We did incorporate HVLA spinal
analogous to trabecular patterns of stress commonly
manipulation directed at hypokinetic costovertebral, costo-
transverse, and dysfunctional intersegmental zygapophyseal
Kinesio taping has recently been shown to improve upper-
extremity control and function in the acute pediatric
Many studies have been condthe effectiveness
rehabilitation setting. Motor skills and functional perform-
ance in the region where Kinesio taping was
been conducted using HVLA methods. During HVLA
e used Kinesio tape over the involved fifth costal
spinal manipulation, peak amplitude has been demonstrated
cartilage and over the second through fifth chondrostrernal
to range from 41 to 889 N. Applied forces rise quickly with
joints. The desired effect was to assist in local motor skill and
slopes ranging between 519 to 2907 use of these
functional improvement of activity to reduce irritation to the
forces with HVLA manipulation is commonly directed at a
cartilage. The application of the Kinesio tape seemed to
functional spinal lesion believed to exist (in our case) at
enhance proprioceptive function to reduce irritation during
costovertebral, costotransverse, and zygapophyseal joints.
activities. The athlete reported being more aware of the stress
The goal of using HVLA manipulation was to reestablish
she applied to the costocartilage while playing. Another
normal preinjury distribution of mechanical loads through
desired effect, as described in the Kinesio tape
the targeted spinal articular structures identified in this case,
to improve lymph flow from the injured area. In the physical
and to ameliorate irritation to associated costocartilage,
examination findings, a bogginess was noted over the
costochondral, and chondrosternal joints. By attempting to
patient’s costocartilage and chondrosternal regions. As also
reestablish normal motion, healing is promoted in nocicep-
described in the manual, pain will commonly decrease with
tive pain generators through a dissipation of pathologic
improvement in lymphatic flow from the injured region. The
stress and a return to normal activity.
patient noted improvement in pain and functional perform-
Also included in the treatment approach of this patient
ance levels during and after wearing the tape as shown in
was the incorporation of GT, an instrument-assisted soft-
. The patient wore the tape between visits to our
tissue technique using 6 patented stainless steel instruments
office. As she became less symptomatic, the benefits of
(These instruments are concave and convex with
Kinesio tape seemed to decrease. The benefits seemed most
single and double beveled edges. The concave and convex
pronounced while the patient was in the more acute stage of
surfaces allow for greater contact over irregular body parts.
her condition and the bogginess over the costocartilage and
In the application of the technique, the instruments are
chondrosternal joints was most pronounced.
Journal of Manipulative and Physiological Therapeutics
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Medical data is for informational purposes only. You should always consult your family physician, or one of our referral physicians prior to treatment . arterial circulation disorders, colitis, gum diseases, and assortedchildren's diseases. The First International Conference of Bio-oxidative Medicinewas held February 17-19, 1989 in Dallas/Ft. Worth, TX. Physicianspresented papers on the effi