THE JOURNAL OF THE AMERICAN OSTEOPATHIC ASSOCIATION Manipulative body mechanics therapy: II. Upper dorsal lesion complex I. WILLARD JOHNSON, D.O.,° Minneapolis, panying upper dorsal intervertebral lesion will be Minnesota referred to as the "upper dorsal lesion complex." In children the presence of the upper dorsal lesion complex is the rule rather than the exception. Symptoms of pain are not often present during the The primary lesion in the upper dorsal region is a early years, but usually develop in one form or slip of the costovertebral joint. As with the sacro- another in later life. Somatovisceral reflexes origi- iliac joint, the lesion apparently involves a trau- nating in the area produce changes in autonomic matically produced abnormal relationship of the function ( visceral and circulatory) which are of articular surfaces which locks the joint against particular importance because of the segmental normal free motion. association of the upper dorsal region with vital Costovertebral maladjustment is typically en- functions. countered as a group lesion, involving the first and second dorsal costovertebral joints and producing a Symptoms characteristic pattern of abnormal mechanics in the upper dorsal region. The lesion is apparently pre- Symptoms commonly associated with the upper disposed by the normally restricted movement be- dorsal lesion complex include: tween the ribs and vertebrae in this area. 1. Pain and tension in the upper border of the Costovertebral maladjustment is intimately associ- trapezius muscle, extending from the suboccipital ated with varying degrees of muscle spasm, inflam- or mastoid regions down the side of the neck to the mation, fibrositis, and arthritis involving the inter- point of the shoulder. vertebral structures of the upper dorsal area. The 2. Pain and tension in the upper dorsal, cervical, lesion is identified by sensitiveness to pressure, and suboccipital regions, from mild tension to the stiffness upon applying springing pressure over the acute stiff neck. area, and frequently by a marked "hardness" pal- 3. Headache, from the occasional tension head- pated across the upper two or three dorsal trans- ache to the severe migraine. (While there are many verse processes and ribs. The chronic nature of the precipitating causes of headaches, costovertebral lesion, in most instances, suggests injury sustained maladjustment is found to be the usual primary, or at an early age. The pathologic changes develop predisposing, cause.) through succeeding years because of strain resulting 4. Symptoms commonly referred to by the patient from the costovertebral maladjustment and from as "sinus trouble" ( suboccipital and supraorbital the gradually developing restricted mobility in the tension and headache, eye strain, nasal congestion, area. In a spinal area in which movement is re- and postnasal discharge ). Dental pain may be stricted, inability to conform to normal function of greatly aggravated by costovertebral strain. the spine in body activity produces irritation and 5. Shoulder pain (referred pain, bursitis, brachial strain in the affected area. neuritis). Costovertebral maladjustment and the accom- 6. Numbness and tingling, rheumatic aches and pains, and arthritis in the fingers, hands, and arms. Part I, on the sacroiliac joints, appeared in the June issue of TUE JOURNAL. 7. Vertigo, usually in certain positions or on per- °Address, 2723 E. 38th St. forming certain movements. JOURNAL A.O.A., VOL. 60, JULY 1961 887 111111111111111111111111111111111111111111111111111,1111111111111111111111111111111111111111111110111111111111111111111111111111111111111111111111. develop gradually as a result of the strain caused by the slip and from the accompanying abnormal In children the presence of an mechanics. It is also noted that the pain or dis- comfort may disappear with no change in the upper dorsal lesion complex is the mechanical situation, and then reappear later. It is therefore important that treatment be given on rule rather than the exception. the basis of establishing mechanical normalcy rather than on the basis of symptom response. Symptoms of pain are not often Diagnosis of the present during the early years, but slipped costovertebral joint usually develop in one form or The diagnosis of slipped costovertebral joints is based on mechanical asymmetry, and upon tension another in later life and sensitiveness of irritated musculature. The following mechanical changes from normal sym- metry are noted: "111111111111111111111111111111111111111111111111111111111111111111.11111111111111111111111111111111111111111111111111111111111111111111111111111111a 1. With the patient sitting or standing, head and dorsal spine in forward flexion, the first ribs are 8. Ocular disturbances (refraction changes, er- palpated ( through intervening soft tissue struc- ratic visual disturbances). tures) from above downward, and somewhat medi- 9. Ringing or buzzing in the ears. ally, close to the base of the neck. The rib is ele- 10. Tension in the muscles of the throat (sensa- vated on one side (usually the left) and depressed tion of a "lump" in the throat). on the other. 11. Habit spasms, particularly in children. 2. The second ribs are palpated from above down- 12. Nervous tension and fatigue. ward, deeply, at a point about halfway between the These symptoms may be present singly or in any point of the shoulder and the base of the neck, and combination, and with recovery following treat- between the clavicle and the upper border of the ment a recurrence of the lesion may result in the trapezius muscle. The second rib is elevated on the same or a different combination of symptoms. same side and depressed on the other. In cases of migraine headache or epileptiform 3. There is a fullness or prominence over the attacks the upper dorsal lesion complex is usually transverse processes and ribs on the side upon found to be the determining etiologic factor. Occa- which the ribs are elevated, which reflects rotation sionally clinical experience suggests an additional of the upper dorsal vertebra toward this side. causative factor in the form of nerve damage which 4. Rotation of the upper dorsal vertebra carries sensitizes the patient to symptoms. It seems proba- the ribs forward on the side of the depressed ribs ble in these cases that the original injury occurred and backward on the other. With the patient in a at birth and involved minor nerve damage. dorsal position, the second and third ribs are In sprains and fractures involving the upper ex- prominent and sensitive and offer greater resistance tremities in which, for no apparent reason, pain to springing pressure on the side upon which they and swelling persist or arthritis develops, the cause are carried forward (usually the right). is usually to be found in circulatory interference The strain produced by slipped first and second resulting from costovertebral maladjustment and dorsal costovertebral joints results in palpatory find- strain. ings based upon soft tissue changes as follows: The failure of normal spontaneous recovery in 1. There is marked sensitiveness to pressure upon "whiplash" injuries is found to be caused by costo- palpating the ribs from above downward. vertebral maladjustment. The situation is frequently 2. The upper border of the trapezius muscle is complicated by the fact that the injury is super- tense and sensitive on the side upon which the ribs imposed upon existing upper dorsal strain in which are elevated. secondary arthritis has developed, and the injury 3. There is tension and sensitiveness in the mus- results in an acute flare-up of the previously chronic, cles over the costotransverse articulations and the and perhaps subsymptomatic, process. angles of the ribs. Somatovisceral reflexes originating in the upper While the costovertebral joints are usually slipped dorsal lesion complex are found to be a most im- with the bodies of the ribs elevated on the left side portant etiologic factor in thyroid hyperfunction, and depressed on the right, the reverse is occa- arterial hypertension, and gastrointestinal dysfunc- sionally encountered and must not be overlooked. tion. The importance of the upper dorsal lesion in coronary heart disease is becoming increasingly Costovertebral lesion mechanics apparent. As with the sacroiliac joint, a costovertebral slip In the study of upper dorsal costovertebral me- is seldom accompanied by symptoms of pain and chanics it is significant to note that the first ribs are discomfort at the time of its occurrence. Symptoms attached rigidly to the manubritun sterni (syn- 880 ehondroses ), so that the first ribs and manubrium move as a single unit. Upon complete inspiration there is slight elevation of the first ribs with corre- sponding movement at the costovertebral joints ("pump-handle" motion). The second ribs attach directly at the junction of the manubrium with the sternum, but the articulations are diarthrodial in type and permit slight motion. The second ribs thus move with the first ribs upon complete inspiration, and in addition perform restricted movement about an anteroposterior axis in which the bodies of the ribs are elevated ("bucket-bail" motion ). The relative rigidity of the first and second rib mechanism is conducive to slight maladjustment and locking of the costovertebral joints. The lesions occur with elevation of the bodies of the ribs on one side and depression of the bodies of the ribs on the other, and the vertebrae are rotated toward the side upon which the ribs are elevated. Since for the most part the upper two ribs do not normally Fig. I perform this "bucket-bail" type of motion, costo- vertebral slips occur, in which the head of the rib apparently slips downward in relation to the verte- point of his chin resting on a small pillow (pref- bra on the side upon which the rib is elevated and erably foam rubber). The head is in complete upward on the other. This movement of the rib extension. The arm on the side to be treated rests occurs around an axis which passes through the on the table at the patient's side. The operator stands costotransverse joint and the sternal attachment at the side of the joint to be treated (the side of of the rib.