Expert: Scott F. Gillman, DC, DACBSP - 12/28/2006

Question
Thank you so much for your quick response. I found your answer very
informative.

Although, I do trust my DC and he has done extensive examinations
(including X-rays) in the past, he just resumed my previous therapy when I
came in with this recent flare up. I will be sure to address these concerns with
him on my visit next week.

I did follow up with my GP's office yesterday on some other concerns and they
informed me that my back pain may be a side effect of Zoloft treatment for
anxiety or a symptom of the anxiety, itself. I can understand the reasoning to
a point as the pain did resurface about the same time I started the medication
and, as I think about it further, I have had more back problems in the past
when I was on an SSRI. I have also noted that back pain is noted as a frequent
side effect of the drug, but have never put the two together.

I understand that stress and anxiety can contribute to the pain, but as I had a
herniated L5-S1 that I went through non-surgical therapy for ten months in
1990, and I actually felt that pop while throwing, I really feel like this is,
rather, injury related pain. Unless I can get a more definative answer from one
of my doctors, I hope to convince one of them to, at least, consider the
possibility.

Again, I thank you for your response. If you have any additional comments on
my follow-up I would really appreciate hearing them also, but unless you are
located in the Mid-West, it looks as if I am going to need to address some
things with my doctors-- or find new ones.

Thanks,
Scott
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The text above is a follow-up to ...

-----Question-----
I am a 41 year old male in pretty decent shape. Approximately 2-1/2 years
ago, while playing catch with a friend, I felt a pop in my upper back as I threw
the ball. The pain was sharp and severe and, although it was concentrated
between my shoulder blades, radiated throughout my entire rib cage.
Thinking I pulled a muscle, I iced up my shoulder and loaded up on
Ibuprophin. I was better in a few days but sore for a week or so after that.

At least a half a dozen times since then, however, the pain has returned to
some degree. I am not aware of a specific activity or event that brings the
pain back, although I am often carrying my infant son-- an activity that I have
only been involved with since his birth 17 months ago. The pain is, again,
concentrated between the shoulder blades, primarily on the left side. I also
have reffered pain in the muscle in my lower back, through my rib cage, into
the shoulder and up into my neck (all on the left side).

My primary physician said it is a strained muscle. I have seen a Chiropractor  
weekly for the last month who makes adjustments, performs massage
therapy and electrical stimulation. Sometimes it helps, other times I wake up
the next day feeling worse off than before therapy. He seems to believe the
problem stems from bad posture.

It seems as though each time the injury flares up, it is more severe and takes
longer to heal-- this last time has been over eight weeks.  In that time, I have
done a lot of research on the Web and ran across the term "subluxated rib".
Looking at my symptoms, it sounds as though this could be the cause of my
problem.

If that is the case, I am concerned because I have read that if the rib is not
repositioned quickly, it can cause scar tissue and take even longer to heal. If
this injury was actually caused over two years ago, has it caused irrepairable
damage? Should my Chiropractor have discovered this (if that is what it is)
and what should I be asking him? What kind of treatment is available that
would get me back to my active self?

Thank you for your time.
-----Answer-----
Scott,

After carefully reading your situation, what stands out the most is that your
problems started abruptly, when throwing a ball.  This is a clue that you
acutely strained, subluxed, or tore something.  Subluxated ribs are quite
common, causing many people to rush to the hospital thinking they're having
a heart attack.  There's also been a few papers describing "T4 Syndrome,"
where the joints in the upper thoracic spine (thoracic #4) acutely dysfunction,
become irritated, and cause referred pain into the ribs and chest or down an
arm.  Beyond speculation about what you have (including the erroneous
assumption it is a strained muscle), what is the evidence or data gathered to
this point?  If your chiropractor is thorough, he/she would isometrically test
all of the muscles in the region, including shoulder girdle muscles and
paraspinal extension and twisting muscles, for example.  Also, test the
pectoralis major (the sternal division) and note if it provokes your pain on the
left or if the left pec' is weak verses the right (also a sign of rib involvement;
your DC should be able to do this; if not, find a new DC).  Is there localized,
point tenderness?  In other words, can the doctor put his finger on a
"bullseye" that duplicates your pain?  Have your rib joints been palpated by
the DC?  Is there pain taking a deep breath (common with rib subluxation)
Have you had any xrays or MRI scans?  If you have scoliosis with significant
angulation in the thoracic spine, or have an underlying degenerative joint, or
have injured the middle back in the past, it is possible something else gave
way in that region, including a disc.  While uncommon (compared to the
cervical or lumbar spine), thoracic intervertebral discs can tear or protrude.  
Given that your condition is chronic and recurrent, a thoracic spine MRI may
be a good idea.  Make sure the doctor communicates your symptoms to the
radiologist so they can better understand what structures to look closely at.  
Scott, simple muscle strains resolve in days. Poor posture is not a cause for
what you're describing.   If you tore something, odds are it is a tendon or
ligament, or a disc, and not a muscle. And, odds are that whatever you did
may be close to the rib joints (at the spine).  You deserve a more thorough
work-up.  

Please keep me informed as to how you do.

'Hope this was helpful.

Dr. G
www.drgillman.com

Answer
Scott,

I'm glad you found my comments helpful.  I don't believe that your SSRI is the cause of your one-sided, acute-onset (with a pop) pain.  My additional thoughts on this beyond what I commented on previously is that you can also consider getting the opinion of an MD Physiatrist.  They may be able to do anesthetic injections or "blocks" to specific tissues in the mid back or ribs.  If such an injection immediately stops the pain, then that would identify the location of it's origin.  It can't hurt to get a consulation, but MRI is the first thing to do (I think).  

'Regards,

Dr. G