by Bryn Zolty, PT
Rib flare refers to an altered ribcage position. This means the rib cage is tipped up/forward, flattened and wide, or both. Rib flare has many potential causes. For this article, we will focus on the postpartum individuals.
Ribs Tipped Up Flare
First, let's look at the rib cage position from the side to identify the ribs tipped up flare. Ideally, the rib cage would line up over the pelvis and the curve in your lower back is greatest in your lower back. You can feel the top of your hips and walk your hands around to your back, this is where your lower back curve should be located. See the arrow from her hips to her lower back.
The first picture (left) demonstrates fairly neutral (good) posture. Notice the horizontal arrow from the top of the hip bone to the low back showing the curve. Also, note the vertical line running through the middle of the shoulder, trunk, and hip. The line is fairly centered in these locations. The ribs below her bra line are tucked in the abdomen.
The second picture demonstrates the tipped up rib flare. Notice the curve in the spine compared to the first. The curve in the back is higher. It continues throughout the middle back and her shoulder blades sit further back. The ribs are tipped upwards and stick out further than her abdomen. Also, note the vertical line running through the shoulders, trunk, and hip. The trunk is more forward and not centered as in the first picture.
This rib tipped up position, the second picture, in a postpartum population is common. Later in pregnancy as the baby grows, the ribs tip up to make room. Women may lean back to maintain balance as their weight has increased forward. Next, women carry around a growing baby and continue to lean back. After standing in this position for months, your body begins to recognize this posture as straight.
Postpartum, the front abdominal muscles are stretched and weakened. The muscles in the lower back have been in a shortened position and can become painful and overworked as their counter parts in the front need time to regain strength. However, to do that, we need to restore posture. It is difficult to strengthen abs that are lengthened if the ribs stay tipped up! When this position is maintained for a long period of time, the back muscles can become tight and even maintain the tipped ribs when laying down.
Note in the picture the space between the floor and the back. The left rib cage here is sticking up. This individual will require some release work and stretching in addition to posture modifications.
Infrasternal Rib Flare
Another type of rib flare is seen in a front view. This is the infrasternal angle, the angle formed by the ribs coming together under the breastbone. A normal angle is 90 degrees. Place your thumbs together in this space and see if they form a 90 degree angle. When this angle is greater than 90 degrees, there is a rib flare.
Commonly with a rib flare, the internal oblique muscles tend to be dominant, creating muscle imbalance. The internal oblique muscles flare the ribs wide.
Here is the same individual lying flat looking at the front view to check for infrasternal rib flare. Now you can see the left rib is more pronounced and wider than the right. This angle is greater than 90, and is asymmetrical.
In the picture below, she was asked to start to curl up her shoulders off the ground. Note the ribs pulling wide and as her internal oblique muscles contract strongly demonstrating her muscle imbalance.
Rib flare does not get better on its own and needs individualized care to improve posture and muscle recruitment. So many functions in the body rely on the diaphragm and rib position. Dysfunction can alter digestion, create back pain, increase your sympathetic nervous system, and decrease pelvic floor muscle flexibility. Muscle imbalance can create compensatory patterns and resulting pain and/or weakness. Many women tell us they want their core back and their stomach to look pre-baby. Rib flare can prevent abdominal muscles from contracting well and even push(pooch) out the lower abdomen if muscle imbalances exist.
The key to treating rib flare is improving alignment and muscle balance. And not just muscle imbalance in your back and abdomen, but also shoulders, legs, feet, and pelvis. How you stand, sit, carry your kids, and exercise at the gym can all be part of improving rib flare.
At Connect PT we are happy to help evaluate and treat your posture, muscle coordination, and improve your strength!
If you are experiencing chronic pain, stiffness or discomfort, what is your body trying to tell you? Here is a short, fun practice to begin dialogue and partnership with your body.
This may seem awkward or strange at first; it may seem silly or even uncomfortable, but if you do this more and more, you shall receive the answers and your body begins to trust you and you begin to trust your body, thereby creating a partnership for health. Through practicing this over and over you may notice that the pain begins to subside and may eventually be gone.
You may choose to combine this with a very clear intention that it is your intention to 100% enjoy your body fully, and that your body enjoys you inside of it fully and completely. This supports your collaboration with your body for a maximum amount of enjoyment.
Although the pain may not leave immediately, recognize that the physical form takes longer to change, but the change starts once you make a connection and change your thoughts. It is new energy; it is new consciousness; it is new awareness. Your job now is to stay in a mode of receiving and know that you have started the process of feeling better, and while it might not be an overnight healing, it will be steadfast and continuous, and with ease and grace. We want this with ease and grace in the most gentle way for you.
According to Dr. John Sarno, in his book, Healing Back Pain, for a condition like chronic back pain, once you call out the emotion that your body is repressing, there is no longer any need for the pain and the body will no longer need to generate tension. (2)
All of us here at Connect Physical Therapy are here to support you to feel your best.
Beat those winter blues by getting up to stretch with Marzena Bard, PTA. When you can't get to the gym, these easy stretches are great to begin and end the day or to break up sitting all day at the computer.
Watch the video tutorial below.
by Michelle Dela Rosa, PT, DPT, PRPC
Kids and phone calls, cooking, and homeschooling...so where is the space to work from home? For some people, creating a proper work station at home has been challenging.
At Connect PT, we're seeing all kinds of issues from wrist pain to neck pain to low back pain and tailbone pain after making this transition. We cannot assume the table that we eat at is set up properly for zoom calls or studying. If you're still working from home, we want to help make the transition easier. Let's break it down:
Foye: I think that the biggest problem is that the vast majority of physicians unfortunately have a huge blind spot when it comes to understanding coccyx [tailbone] pain. We learned almost nothing about the coccyx in medical school. This leads to four main problems.
Dela Rosa: Your book Tailbone Pain Relief Now! describes the many reasons why people end up with tailbone pain. Are there 1 or 2 causes of tailbone pain that are more common than others?
Foye: Great question! By far the most common cause coccyx pain is when there is an unstable joint between the bones of the coccyx. Many medical textbooks and websites incorrectly state that the coccyx is a single fused bone. But that is rarely true. In the vast majority of humans, there are 3 to 5 individual coccygeal bones, with variability in whether there is fusion between any of those bones. Most people have at least a few coccygeal joints. And most people with coccyx pain have joint hypermobility (excessive movement) as the source of their pain.
The second most common cause of coccyx pain is a "bone spur"; extending from the lowest tip of the coccyx. When this happens at the bottom of the coccyx, there is thickening of the bone that projects backwards, often coming to a sharp focal point. It’s almost like a tiny icicle made of bone. This bone spur pinches the skin between the spur and the chair where the patient sits, and especially when they sit leaning partly backwards.
Dela Rosa: Thank you for clarifying the common causes of tailbone pain. In your book, you detail some of the seat cushions and medications that may help. People ask about injections for pain. As a pain management doctor, would injections be helpful for these causes and if so, could you describe how and what kind?
Foye: Sure it's a great question. Medications by mouth have a couple of big problems with them, which is why a lot of times medication given focally by a small local injection could be superior.
When medications are given by mouth, number one they go through multiple places throughout the body. If you're taking medication by mouth, they can cause side effects in the stomach, the intestines, the liver, and the kidneys, so the side effects can be quite limiting.
The second problem with medications by mouth is that because the medicine travels throughout the entire body, it gets diluted out. So only a minuscule amount of the medication actually makes it to the tailbone where the patient needs it the most. Many of these patients do respond to medication given locally at the site. Typically, that's done under fluoroscopic guidance. Fluoroscopy is like x-ray up on a computer screen, and using fluoroscopy we can target a specific location at the tailbone. I'm generally opposed to blind injections, which is where injections are done without any image guidance because 1) you can't guarantee where the medication is going to go and whether it's actually given at a place where it's going to be helpful, and 2) you also can get into problems if it's given in the wrong place - it can cause side effects.
So back to your question, which was about the diagnoses like hypermobility or a bone spur... Absolutely those can respond very, very well to placing medication locally at the spot under image guidance. Often that's a combination of steroid which helps to fight inflammation, and also local anesthetic which can be given as a nerve block and can be very helpful when there's hyperactivity or hyperirritability of the nerves.
Dela Rosa: How is the x-ray your center performs different than how many other facilities perform the test?
Foye: Here at the Coccyx Pain Center, the biggest difference is that we take coccyx x-rays while the patient is sitting down, since that is when tailbone pain hurts the most. I have trained the radiology technicians here regarding how to properly perform this technique, which was first developed in France. Very few places in the United States have ever heard of this approach and even fewer are experienced at doing these x-rays properly. We have evaluated and treated thousands of patients with tailbone pain, many of whom fly in from around the country and internationally. And it is extremely common that patients had previous imaging studies that were read as being normal. But then they come here and our seated x-rays show that when the person sits down and leans backwards (putting their body weight onto the coccyx) they often have very dramatic dislocations or other abnormalities that would be completely undetected if the x-rays had not been done while the patient was sitting. It is a huge relief for patients to finally have an answer as to what is causing their pain. Then, when we have identified a specific cause for their pain, we can provide treatments for that specific cause, which is much more likely to be helpful than generic treatments done blindly without a diagnosis.
Foye: A lot of this goes back to and starts with the general lack of awareness that physicians, radiologists and radiology technicians have about tailbone pain. Frequently, they lump it all in with low back pain. Lumbosacral pain is thousands of times more common than tailbone pain. A lot of the automatic checkoff boxes that people have on their radiology x-ray or MRI forms will have a box to check off for lumbar spine or lumbosacral spine, but they will not have a box to check off for the coccyx or tailbone just because it is thousands of times less common. So what happens is that the primary care doctor, or the orthopedic surgeon, or the pain management doctor, will check off the box and order lumbar or lumbosacral x-rays or MRI, and then that doesn't even include the tailbone at all.
The next problem then is that the study gets done and the patient is told that there's nothing wrong, and that there's no explanation for their pain when really the images did not even include the symptomatic area, or worse yet, it shows an incidental finding of the lumbar spine that may not be causing any symptoms at all. But now they start down the treatment path of epidural injections, and even spine surgery and other things for a part of the body that wasn't even causing the problem. So basically back to your question about what the patient can do: 1) look at the orders, look at the x-ray or MRI orders, make sure that the ordering physician has specifically explicitly requested imaging of the coccyx, and 2) when you go into the radiology center, make a point of talking to the radiology technician and being crystal clear with them that this is not your lumbar spine, that this is not up in the small of your back at the belt line, that the pain is specifically down at the coccyx, and make sure that the radiology technician is going to include that part of the anatomy within the study. It really does require a certain amount of self-advocacy by the patient unfortunately to fight this uphill battle against the ignorance that's out there.
Dela Rosa: I'm just curious, have people come to you from outside of the US? Or are you mostly seeing people domestically?
Foye: Most of my patients travel in from out-of-state and about a third of my patients fly in. It's maybe 5% or less that are international. Within the last six to 12 months, I've had patients from Japan, Sweden, Africa, the UK, New Zealand, and I think two from Australia. Which really just gets back to that there's this unmet need out there and patients who are not able to find local clinicians who will either take them seriously or that know the appropriate testing and treatments to provide.
Dela Rosa: How do you work with pelvic floor physical therapists in the treatment of tailbone pain?
Foye: As a physician specializing in Physical Medicine and Rehabilitation (PM&R), I'm a strong advocate for the role of physical therapists in treating patients who are suffering from painful musculoskeletal conditions. Historically, a big problem was that very few physical therapists were comfortable or experienced in treating pelvic floor problems. Fortunately, that has been improving in recent years.
The pelvic floor is often described as being like a muscular sling, or hammock, which supports and holds up the pelvic organs. The back end of that sling has attachments to the coccyx. Pelvic floor physical therapists and I often collaborate on figuring out the "chicken and the egg" phenomenon. By that I mean that we assess whether a patient is having tailbone pain due to pulling and tugging onto the tailbone caused by tightness and spasms of the muscles that attach to the coccyx. Or, sometimes it could be just the reverse: a painful condition at the coccyx itself might be causing reactive muscle spasm and guarding of the pelvic floor. If evaluation and treatment at one location is not providing adequate relief, then it often makes sense to collaborate and to consult each other, to help the patients find the answers and relief that they deserve.
By Bryn Zolty, PT
Its proposed treatments include a wide range of ailments, such as improving lymph drainage, improving blood flow, decreasing pain, and even drawing out infections.
Our therapists use one of the more gentle methods, gliding cupping, as a way of decompressing the soft tissues with lotion/oil to increase motion and decrease pain. A patient can feel gentle suction, stretching, or slow gliding of the cup. This is unlike the prolonged, static placement of the cups, as performed on some Olympic athletes. Our patients benefit by: increasing blood flow and removal of stagnant blood, softening/releasing scar tissue and adhesions, releasing trigger points and "muscle knots", improving tissue mobility/flexibility, and relaxing muscles. We have had success using cupping therapy with many conditions, like low back pain, pelvic pain, hip pain, stuck scars, constipation, and much more!