Rib dislocation is a matter of debate. Most doctors will tell you that it is nearly impossible. For the population of patients who have Ehlers-Danlos Syndrome (EDS), I find the idea to be extremely likely.
There are 12 ribs with varying amounts of stability. The “true ribs” include ribs 1-7, as they are connected to the sternum, or breastbone. Ribs 8-10 are considered “false ribs”, in that they are connected only to the cartilage in the front. Ribs 11 and 12 are also called “floating ribs”, since they are only connected to the thoracic spine and then float in space. Most documented cases of “slipping rib syndrome” involve ribs 8-12. Since collagen makes up two-thirds of cartilage, it makes sense that the connection of the ribs in clients with EDS might be even more unstable than in the general population.
Another reason that the ribs can be a source of pain is due to the nature of their attachments to the spine. The head of the rib, attaches to two vertebral bodies, one above and one below. This is called the costovertebral joint and is reinforced by ligaments. It is a planar joint which means that it allows for sliding motion. There is a second attachment which is the tubercle of the rib attaching to the transverse process of the adjacent thoracic vertebra and this is called the costotransverse joint.
People with EDS are more likely to have rib subluxations because:
They might have spinal instability and have significantly more joint play at these attachment sites
They have decreased proprioception throughout the thoracic cage which results in uncoordinated movement of the ribcage and less effective breathing patterns
They have a higher prevalence of scoliosis and may be at a structural disadvantage
Rib subluxations mean that the rib slips out of place but does not fully dislocate; it maintains some contact with the joint. Rib dislocation would mean that the rib completely separates from the joint. They can both be very painful. The pain associated with subluxations and dislocations usually comes in the form of muscle spasm. True, because it is difficult to “diagnose” these rib injuries, most doctors will conclude that it is only a muscle spasm. The image below is one a patient of mine brought in. There was no evidence of a rib dislocation on the radiology report and the doctor had never mentioned it. She, however, noticed it on first glance and recognized it as a long-standing source of her pain.
If you’re suffering from what you believe to be rib subluxation or dislocation, there are a few things you can do to minimize your pain. These include slow, controlled breathing for pain management and relaxation, using heat to relax the muscle spasm, and/or gently massaging the area to try to relax the tissues and reduce the tone surrounding the joint. (You may need to employ a friend or family member in this area). Often times, hypermobile joints will slide in as easily as they slid out. If not, your physical therapist may be able to assist with muscle energy techniques, gentle joint mobilization, or taping techniques. Physical therapy would then follow with stabilization exercises aimed at preventing recurrence, as well as some training of the diaphragm for better, more effective breathing.
As I tell all my clients, it’s important to trust your instincts. No one can feel or understand your body the way that you do, even if your proprioception is impaired. ; )
Dr. Meg Mizrachi, DPT, OCS