Assessment and management of medically unexplained symptoms
BMJ 2008; 336 doi: https://doi.org/10.1136/bmj.39554.592014.BE (Published 15 May 2008) Cite this as: BMJ 2008;336:1124
All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
The influence of chest shape on posture, health and ageing in relation to the spino-sternal triangle
In previous essays to BMJ I have discussed the cause of postural abnormalities and their effects on health.
One of the many things which I noticed was that some individuals would maintain an upright posture throughout life, whereas others would tend to develop a more significant stoop as they aged, so I became curious to know why, and would now like to discuss that aspect.
As mentioned before, in the process of determining an explanation I observed people sitting at bus stops, but also in theatres and restaurants, where it was apparent that, in some cases, they would be aware of the importance of good posture and how to establish it, but in most cases they were just sitting in their own natural way, either upright, or slouched to varying degrees, without knowing that they were different.
It was evidence that posture was the result of the shape of the spine, it’s arrangement of vertebral bones, and the relative length of connecting tissues and ligaments which determined if they sat upright, or slumped partially, or completely, like a puppet which is made to change position by the arrangement of it’s string attachments.
I had also concluded that people who sat upright would not be as likely to develop health problems when leaning forward to read, as those with a forward curve in the upper spine which tends to compress internal anatomy.
I then noticed that such individuals as television newsreaders and top businessmen most commonly sat upright.
However, I also noticed the influence of an additional factor, namely the shape of their chest, in particular that they tended to have a forward angled sternum, which indicated that they had a deep chest with plenty of room to house their internal anatomy, which could consequently function in an unimpaired manner.
Furthermore, I noticed that when viewed from the side their chest had a roughly triangular shape, which would present all of the advantages of a building constructed and reinforced by triangular beams, and would naturally dispose to maintaining the upright posture.
By contrast, someone with a vertical sternum which was somewhat parallel to the spine, would present with a side view of the chest that was roughly rectangular, and which would be much more prone to collapsing forward and compressing the internal anatomy, particularly in the midriff (between the chest and abdomen), to potentially cause discomfort or pain during such activities.
I also concluded that the triangular shape would tend to be maintained throughout life, whereas any slight stoop with the rectangular shape would tend to increase as the person aged.
I compared that aspect to a tall rectangular block, and a triangular block on a table, where hitting each at the top from the side would cause the rectangular block to topple over, whereas the triangular block would tend to slide forward or fall back to it’s original base.
After noticing the triangular shape from the side view, I began to readily notice the forward angle of the upper chest when viewed from the front, where it was much less obvious.
In that regard, I had often been curious about how such individuals as Walter Matthau, who had a very significant stoop in his upper spine, could be an actor, when that vocation would involve a lot of time spent reading television and movie scripts, but I eventually noticed some photos which showed the somewhat forward angle of his upper chest.
By way of conclusion the round shouldered curve in some young people progresses to an extreme curve often seen in the elderly, such as the extreme C-curve, the upper spinal curve, and the upper spinal hump.
However, I also noticed that some elderly individuals have maintained their upright posture, and concluded that it was because of their triangular chest, which braced their spine and stopped it from bending forward, but in other cases, at the top of their thoracic spine, their neck angles sharply forward, so I concluded that it was because of the weight of the head, and the fact that there was nothing to stop it from tilting when they leaned forward.
The latter individuals therefore sit or walk with their spine upright and their neck and head stooped.
Many other factors would explain why postural problems are more common in the elderly, such as the long term accumulating affects of multiple factors which contribute to spinal curvature.
For example, it can be seen in some women who wear high heel shoes for many years which regularly lift the hips and tilt the lower spine into a forward arch, and results in a corresponding forward curve in the upper spine, and it sometimes occurs in, and remains after pregnancy, particularly multiple pregnancies, or in women who have had twins or triplets, where the weight of the enlarging womb drags the lower spine forwards for months at a time, and in other cases it would be due to the general deterioration of eyesight with age which requires the individual to lean progressively further forward to read.
The deterioration is evident when contrasting examples from the posture of young people with that of the elderly, but the multiple, small incremental changes between those age groups occur so slowly that they otherwise go unnoticed.
Such knowledge is useful in the prevention of postural deterioration and the related health problems.
Competing interests: No competing interests
In previous comments in BMJ I have described how I drew the conclusion that lower left sided chest pain was due to postural displacement of the eighth rib (and/or by implication the 9th or 10th rib).
I also explained how I began studying the topic in 1975 with the observation that various symptoms were, on some occasions, induced by leaning forward, and later that postural factors were also involved.
During that time I was looking for independent evidence when I found a book by Paul Wood from 1956 which contained a chapter on some of the symptoms with his finding that the chest pain was relieved by the intramuscular injection of local anaesthetic, whereas cutaneous or subcutaneous injections had no effect.
I saw that as evidence of a physical cause and the pains precise location.
He then suggested possible causes which included lifting a heavy weight, cranking a car engine, faulty posture, or psychological factors.
Anxiety, for example, affects the breathing rate, so he suggested that the pain may be due to strain on the attachments between the respiratory muscles and the chest wall.
He then suggested that many patients had been timid children whose kindly mothers and doctors had protected them from the hazards of football, swimming, and gymnastics, and that they therefore grew up with a fear of exercise and sport.
However, I had played a lot of sport as a teenager, including swimming and gymnastics, so as the years went by I noted that some prominent sportsmen also had problems with similar symptoms.
I began describing my ideas in the BMJ late last year, and early this year presented some information about the chest pain when L.Sam Lewis suggested that I read a research paper about the slipping rib syndrome by Leon G. Robb.
It was a narrow area of research which I had not previously been aware of where it was reported that in most cases the cause was unknown, but I was then able to determine that it was due to postural displacement of the eighth rib.
During that process I looked at other research papers which reported that SRS was not mentioned in modern medical text books, and that most physicians were not aware of it, or the little known diagnostic method called the hooking manoeuvre, or that the pain could be cured by surgery.
They also reported cases where it occurred many months or years after chest injuries in sports such as soccer or football (McBeath &.Keene, 1975) or, in one case, immediately after an injury in cricket (Meuwly et al, 2002), and that the patients were usually assessed by many doctors using various diagnostic methods to rule out broken ribs, and pleuritic pain, and referred pain from abdominal disorders such as gastric ulcers, gall stones, or appendicitis, with nothing evident.
Since then I have found another paper by Uderman et.al. who reflect those comments and adds that the typical symptoms included intermittent sharp stabbing pains followed by a dull achy sensation, which are often aggravated by “activities such as bending, coughing, deep breathing, lifting, reaching, rising from a chair, stretching, and turning in bed”.
He then presents the case of a 22 year old competitive swimmer who was “jumping up and down and gently swinging her arms” as part of her warm up exercises, when she felt moderate diffuse pain in her lower left chest followed by discomfort during the race, which recurred episodically for more than eight months afterwards.
During that period she was examined by an athletic trainer, two physicians, and a chiropractor, had three x-rays and a bone scan, and treatment included activity modification, hot packs, anti-inflammatory medication, ultrasound, twelve sessions of spinal manipulation and electric stimulation, and ten sessions of physiotherapy which produced some temporary relief but no long term affect.
She was paradoxically “most comfortable in the slouched position”, but initial investigations with Valsalva’s manoeuvre and sit-up tests elicited the pain, and eight months later, when she eventually consulted a thoracic surgeon he suspected the slipping rib syndrome and applied “the hooking manoeuvre” which reproduced the pain to confirm the diagnosis, and then she underwent surgery for “resection of the abnormal cartilaginous attachment of ribs 11 to 10, as well as the resection of a portion of the rib 12”, which relieved the pain.
Six months of restricted activity followed, and then, after a program of gradually increasing levels of exercise, she competed in the national swimming competitions successfully.
Udermann also mentioned that many trainers and physicians were ‘relatively unfamiliar’ with the SRS which was ““often misdiagnosed or undiagnosed”, and therefore recommended that they become familiar with it’s symptoms, and the hooking manoeuvre so that diagnosis and treatment can be applied early to “avoid many months or even years of unnecessary pain and discomfort”.
He also recommends “the avoidance of movements or postures that exacerbate symptoms”.
By way of summary I conclude that the cause of SRS has remained obscure because of the delayed response to postural factors and injury, often for months or years, and because cases of injury which are followed immediately by pain are relatively uncommon, and the fact that it is not evident on standard widely known and used diagnostic tests.
Furthermore, after the rib has become loose the type of movements which cause them to slip are usually so casual and ordinary that they most often go unnoticed.
In the case of the swimmer, the pain was first noticed when she was just jumping up and down, and gently moving her arms in a warm up before a race, but the ribs were probably loosened by another incident long before that.
References:
1. Paul Wood, 1956, Diseases of the Heart and Circulation, 2nd revised edition, Eyre & Spottiswoode, London, p.937-947.
2. Brian E. Udermann et al, 2005 (April - June) Slipping Rib Syndrome in a Collegiate Swimmer: A Case Report, Journal of Athletic Training, 40(2): p.120-122. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1150226/
3. LSam Lewis, 2014, (April 28th), Re: Assessment and managementy of medically unexplained symptoms, BMJ 2008;336:1124, Actual page http://www.bmj.com/content/336/7653/1124/rr/695943
4. Leon G.Robb et al, 2014 (July 21st), The Slipping Rib Syndrome: An Overlooked Cause of Abdominal Pain, Practical Pain Management.com, http://www.practicalpainmanagement.com/pain/other/abdominal-pelvis/slipp...
5. A.A.McBeath & J.S.Keene, 1975 (September), The Rib Tip Syndrome, The Journal of Bone and Joint Surgery, Vol.57-A, No.6, p.795-797.
6. Jean-Yves Meuwly et al, 2002 (March 1st), Slipping Rib Syndrome, A Place for Sonongraphy in the Diagnosis of a Frequently Overlooked Cause of Abdominal or Low Thoracic Pain, Journal of Ultrasound in Medicine, Vol 23, no.3, p.339-343.
7. M.A. Banfield, 2014 (March 30th), The Posture Theory as an explanation for many previously unexplainable symptoms, The British Medical Journal (Online Rapid Responses), BMJ 2008;336:1124 Actual page of response http://www.bmj.com/content/336/7653/1124/rr/692354
8. M.A. Banfield, 2014 (May 6th),The postural and bio-mechanical causes of nerve pain in previously unexplainable chest pains, The British Medical Journal (Online Rapid Responses), BMJ 2008;336:1124, Actual page of response http://www.bmj.com/content/336/7653/1124/rr/696832
9. M.A. Banfield, 2014 (May 11th), An example of injury to rib attachments as a cause of previously unexplainable chest pains, The British Medical Journal (Online Rapid Responses), BMJ 2008;336:1124, Actual page of response http://www.bmj.com/content/336/7653/1124/rr/697563
10. M.A. Banfield, 2014 (July 13th), The Banfield explanation for anterior displacement of the eighth rib and the cause of previously unexplainable chest pain, The British Medical Journal (Online Rapid Responses), BMJ 2008;336:1124, http://www.bmj.com/content/336/7653/1124/rr/760594
11. M.A. Banfield, 2014 (July 30th), Four more examples to clarify the cause and effect of displacement of the ribs and chest pains, The British Medical Journal (Online Rapid Responses), BMJ 2008;336:1124, Actual page http://www.bmj.com/content/336/7653/1124/rr/761779
Competing interests: No competing interests
In previous discussions in BMJ I have presented evidence that postural abnormalities are the cause of various previously unexplainable health problems.
At one stage, when considering those aspects, I noticed that the fictional hunchback character Quasimodo was described as being born with a severe spinal deformity, and was usually portrayed as having a breathy and raspy or hoarse voice.
I had previously noticed the fact that forward curvature of the upper spine places the head and shoulders forward where the weight is then transferred downwards onto the lungs, which would affect breathing, and would also alter the angle and compress the throat and affect the voice.
I was also told about the Alexander Technique, which was named after the Tasmanian recitalist, Frederick Matthias Alexander, who developed a way of improving his posture to cure a voice problem.
When I read his biographies I found that his poor posture was attributed to a bad habit in the way he stood, but I also noted that he stood in an odd way as a child, so I concluded that his postural problems may have been due to a genetic or acquired foot or spinal deformity.
He stated that he stood with his toes contracted and bent downwards so that his feet were unduly arched, which affected his balance.
He then noticed that when he altered the position of his head it affected his throat, and also resulted in the lifting of his chest, the shortening of his stature, and the arching of his lower back, and the narrowing of his back, which I suggest is characteristic of a spinal abnormality.
As part of his solution he noted that when he moved his head forward and down, or back and down, it compressed his throat, so he eventually determined that the best thing to do was to move it forward and up, which lengthened his stature, took the pressure of his throat, and restored his voice.
He also reported that after he developed the method of improving his posture he stopped getting the respiratory illnesses which occurred frequently when he was young, presumably due to the removal of postural pressure from his lungs.
His methods of improving posture became known internationally, and are still used nowadays by many radio announcers, singers, and actors, where a good voice is required.
In a related manner, I also noticed that opera singers such as Luciano Pavarotti, Dame Nellie Melba, and Dame Joan Sutherland had very deep chests which would give them large lungs which are an advantage in producing a powerful voice.
While looking for more evidence I found that Hippocrates mentioned that people with a spinal deformity above the waist tended to get chest diseases and have a hoarse voice, and deformity below the waist was associated with abdominal disorders.
I also found a comment by John Bulwer, in 1650, who suggested that women who go to extremes to narrow their waist and chests by tightening the laces of their corsets and stays “open the door to Consumptions, and a withering rottenness”. (consumption is now called tuberculosis).
The evidence indicates that any compression of the chest impairs either the upward, downward, or outward expansion of the lungs and restricts their ventilation, which produces congestion, and makes it more likely that disease or infection will eventuate.
By way of conclusion posture and chest size and shape have a significant influence on the health of the lungs and the quality of the voice, and a knowledge of those aspects is useful in prevention and treatment.
1. Hippocrates, 460 B.C. to 377 B.C., On Joints, XL1 - XL11.
2. Bulwer, John, 1650, Anthropometamorphosis, p.338-339.
2. Withington, E.T., 1927, Hippocrates with an English Translation, Volume 3, p.281, William Heinemann, London.
4. Maisel E., 1990, (1974), The Alexander Technique: The Essential Writings of F. Matthias Alexander, Thomas and Hudson, London.
5. Banfield M.A. 2014 (March 30th), The Posture Theory as an explanation for many previously unexplainable symptoms, BMJ 2008;336:1124
Actual page of response http://www.bmj.com/content/336/7653/1124/rr/692354
7. Banfield M.A. 2014 (April 20th), The cause of poor posture and previously unexplainable symptoms, BMJ 2008;336:1124, Actual page of response is http://www.bmj.com/content/336/7653/1124/rr/695127
8. Banfield M.A. 2014 (August 10th), The causes of poor posture with evidence from history, BMJ 2008;336:1124, Actual page http://www.bmj.com/content/336/7653/1124/rr/762433
Competing interests: No competing interests
The purpose of the following comments is to show the relationship between posture, leaning forward, pressure on the anterior chest wall, the slipping rib syndrome, and symptoms due to the impaction of intercostal nerves, by using kidney aches as an example.
When I was in my early twenties I noticed that when I leaned toward a desk I would feel a vague ache in my left kidney area, and when I leaned back it would stop.
On some occasions where the ache persisted it was accompanied by a sense of nausea, and although nothing was evident at the time it was later followed by the diagnosis and treatment of a kidney stone.
Soon after that I noticed that leaning forward caused upper abdominal pain, and then on another day it caused breathlessness, and an hour later faintness, and I became curious about why.
I eventually began studying medicine and later concluded that all of those pains were related to the shape of my spine, which was curved forward, and was placing downward pressure on my chest and abdomen.
I later considered that there were various ways of leaning forward which may account for the different symptoms.
For example, it is possible to read by bending the neck to face the pages on a desk, or to bend the spine into a C-shaped curve to bring the head and eyes closer to the page, or to bend from the hips while keeping the back straight.
I also considered the possibility that as the person leans forwards, the back muscles also move forwards, so, for example, the kidney could be compressed from behind, and that presented the additional possibility that the ache could be from strain on the loin muscles.
However, the association of the ache with kidney stones and nausea made it more likely to be due to pressure on the kidney.
About twelve years later I found information which led me to conclude that postural pressure on internal organs such as the stomach, or the kidneys might be pushing them out of shape and position.
In some cases it might be bending or kinking the tubes leading in or out of those structures to cause partial blockage and congestion of the kidneys, and for example, to cause salts in fluids to deposit out as a kidney stone.
I have discussed some of those ideas in my recent comments in BMJ, and also described the postural cause of lower left sided chest pains.
L.Sam Lewis then suggested that I look at an August 2013 research paper by Leon G.Robb et al on the topic of the slipping rib syndrome.
Robb described how slippage of the eighth, ninth, or tenth ribs could cause unilateral subcostal pains in the upper abdominal quadrant by impinging an intercostal nerve.
He also presented the case of a 34 year old woman who had right upper quadrant pain for four months where there was no history of chest injury, and where the subcostal abdominal pain was associated with nausea without vomiting.
Soon after that I found a research paper from May/June 2013, by Rajender Kumar, who described a 32 year old woman who had been experiencing intermittent right loin pain for the previous two years.
She reported that the sitting, and leaning forward was likely to produce the symptom, particularly when she was sitting at a “swing machine” (which I presume is a misspelling of “sewing machine”).
Investigation and treatment by various specialists were not effective, and when examined by Kumar it was found that manipulation of the twelfth rib reproduced the exact pain which was ultimately cured by a series of nerve blocks.
He then presented the case of a 40 year old woman who had intermittent right loin pain for ten months which was made worse by the rotation of her trunk, and similar tenderness of the twelfth rib was found and treated effectively.
His third case was a 22 year old female who developed sudden and acute pain in her left loin when she bent forward or lifted heavy items.
The tenderness of the twelfth rib and treatment were similar to the other examples.
He reported that it was a common problem, and that the pain sometimes occurred on both sides of the back, but was usually unilateral and related to movement or manipulation of the 10th, 11th, or 12th rib tips.
He also mentioned that it was sometimes related to a previous chest injury, but that in many cases no such incident occurred, so he attributed the problem to the irritation of intercostal nerves by the hypermobility of the rib cartilages and advised patients to avoid the type of activity which induced the episodes of pain.
By way of summary I note the evidence that kyphosis moves the head and shoulders forward where the weight is directed down along the anterior rib cage and strains and stretches all of the sternal and rib attachments and disposes to the slippage and impingement of nerves to produce the various symptoms related to the focus of pressure, which explains why they often occur separately in response to the same movement.
1. 1980, June, Banfield M.A., The Matter of Framework, Australasian Nurses Journal, p.27-28.
2. 2014 (February 9th), Banfield M.A., Kyphosis as a cause of the chronic fatigue syndrome, The British Medical Journal, BMJ 2013;347:f5731, http://www.bmj.com/content/347/bmj.f5731/rr/685825
(more detail about the kidney ache).
3. 2104 (April 28th), L.Sam Lewis, Response to the article on “Assessment of management of medically unexplained symptoms, The British Medical Journal, BMJ 2008;336:1124, Actual page http://www.bmj.com/content/336/7653/1124/rr/695943
4. 2014 (March 30th), Banfield M.A., The Posture Theory as an explanation for many previously unexplainable symptoms, The British Medical Journal, BMJ 2008;336:1124, Actual page of response for 30-3-14 is http://www.bmj.com/content/336/7653/1124/rr/692354
5. 2014 (May 6th),Banfield M.A., The postural and bio-mechanical causes of nerve pain in previously unexplainable chest pains, The British Medical, BMJ 2008;336:1124, Actual page of response is http://www.bmj.com/content/336/7653/1124/rr/696832
6. August 3rd. 2013, Leon G. Robb et al, The Slipping Rib Syndrome: An Overlooked Cause of Abdominal Pain, Practical Pain Management.com
7. 2013 (May/June), Rajender Kumar et al,, The painful rib syndrome, Indian Journal of Anaesthesia, Vol. 57, Issue 3, p.311-313.
Competing interests: No competing interests
The cause of poor posture is generally attributed to laziness, lack of self respect, or misery, and I suppose I may have also held that opinion if it was not for the fact that I had a very poor posture myself ever since I was very young, when I was confident, and was not lazy or miserable.
Many years later, at the age of 25, I began studying the subject and writing about it in various publications where I determined that measles at the age five, and hepatitis at age six, and carrying a heavy kit bag to and from school each day contributed to the weakness and stretching of my spinal ligaments and bones to produce kyphosis and scoliosis.
I then tried to find evidence to confirm those conclusions and was eventually able to do so by comparing examples from history.
I have recently discussed some of my findings in BMJ on 30-4-14, and would now like to present the additional evidence.
Alexander Pope once wrote . . . “Just as the twig is bent the trees inclined”, which is a general observation based on the fact that a small tree has a pliable trunk, and as it reaches maturity the trunk will harden and remain in a fixed position.
Consequently if it is allowed to grow straight it will do so, but if it is roped and staked into a curved position it will grow in a curve, and remain in that shape even when the rope is removed.
A good example of natural events causing the curvature is a tourist attraction in Holdfast Bay, South Australia, called The Old Gum Tree, which is curved into an arch from ground to ground.
In 1993 I found an illustration of the internal anatomy of a nineteenth century woman who had worn a narrow waisted corset, and her rib cage had been changed from broad based to v-shaped.
I then found the concept of the “training corset”, where mothers placed their children, as young as four years old, into corsets for most hours of the day and night, and kept them clothed in corsets as they grew, for the deliberate purpose of developing that permanent body shape in adulthood.
I then found an illustration of several different corset shapes from the eighteenth century drawn for comparison.
Some were designed to produce a backward angle in the spine, others to produce an abnormal arch in the lower spine, and a third type combined it with an abnormal forward curve in the upper spine.
Other sources presented designs which pushed the breasts forwards, or the buttocks backwards.
I then found illustrations of seventeenth corsets which produced the V-shaped torso to create the broad shouldered and narrow lower waisted appearance.
I also found that some women strapped their shoulders to produce the round shouldered appearance which was considered to be attractive, and some tribesmen strapped their shoulders to deliberately create the hunchback appearance.
I also found examples where people used similar methods to permanently alter the shape of other parts of their bodies, such as the flat head indians who placed their babies in a type of basket which they carried on their backs during the day.
The top of the basket included a flat board which was roped over the babies head, to train it to become permanently flat.
Other people altered their head shape to become round, oval, pointed, or square.
There were also examples of tribesmen who pierced their ears and hung weights from them, and gradually increased the weight until the ear lobes reached their shoulders.
I also found that some authors referred to Alexander Pope as the hunchback poet so I read a biography about him which reported that at the age of three he was knocked over and trampled by a wild cow which also injured his throat with it’s horns, so there are two possible causes emanating from that injury.
The first is that the cow broke some of his spinal bones and they healed bent, and the second is that the cow had bovine tuberculosis which can be transferred to humans by blood contact, where it then typically travels through the blood stream to infect the spinal bones which collapse into a permanent bend.
When the upper spine curves forwards the body would tend to fall forwards, except for the fact that reflexes counteract that tendency by producing a corresponding arch in the lower back, and Alexander Pope was described as having both structural changes.
There are other examples where the enlarging womb of pregnancy places weight forward and drags the lower spine forward, and can cause changes in the shape of the spine, as can long term obesity where the abdomen is large and heavy.
Some people who are involved in occupations where they maintain the same posture all the time may develop changes for that reason.
I also found that Vitamin D deficiency can weaken the bones and cause postural changes in children, and Osteoporosis can cause such changes in the elderly.
In summary the main causes of poor posture are changes in the shape of the spine due to poor nutrition, infections, and long term or repetitive mechanical or biomechanical factors, and in most cases it can be prevented and treated by good education about the process.
References . . .
1. 1650, John Bulwer, Anthropometamorphosis, London, U.K. (European corsets and native tribal fashions).
2. 1753, William Hogarth, The Analysis of Beauty (for the 7 part corset diagram).
3. 1874, Luke Limner, Madre Natura Versus the Moloch of Fashion, Chatto and Windus, Piccadilly, London, U.K. (corsets).
4. 1930, Edith Sitwell, Alexander Pope, re-published in 1948 by Penguin Books, Hammondsworth, Middlesex, London, p.28.
5. 1974, D. Holloway, Lewis and Clark and the Crossing of North America, Wiedenfield & Nicolson, London. (The flat head indians).
6. 2014 (March 30th), M.A. Banfield, The Posture Theory as an explanation for many previously unexplainable symptoms, The British Medical Journal (Online Rapid Responses), BMJ 2008;336:1124
http://www.bmj.com/content/336/7653/1124/rr/692354
7. Banfield M.A. 2014 (April 20th), The cause of poor posture and previously unexplainable symptoms, The British Medical Journal (Online Rapid Responses), BMJ 2008; 336 doi: http://dx.doi.org/10.1136/bmj.39554.592014.BE (Published 15 May 2008), BMJ 2008;336:1124, Actual page of response is http://www.bmj.com/content/336/7653/1124/rr/695127
Competing interests: No competing interests
I would like to thank the editors of BMJ for publishing my comments of 11-5-14 in which I described an incident where pressure from my fist on my chest was followed several months later by a chest pain.
I would now like to describe some comparable injuries which involved delayed reactions to clarify that particular link between cause and effect.
Firstly, in 1975 A.A.McBeath & J.S.Keene described a case where . . . “A nineteen-year old woman was kicked in the anterior part of the right side of the thorax during a soccer game.”
“She stated that the right second and third ribs had been fractured”, and that her chest had been taped, and that “the pain soon subsided”.
However a year later “she complained of episodic soreness and a popping sensation with deep breathing at the anterior margin of the right tenth rib of six month duration”.
The authors then presented a similar case of a 22 year old woman who was injured in the anterior ribs during a game of football five years earlier, and another example of a 34 year old woman who had been experiencing episodic chest pain since she bruised her ribs seven years earlier in a snowmobile accident, and the aggravating factors included deep breathing, vomiting, abducting the right arm, and laying on the side.
In 2002 J. Meuwly et al provided an example of a 20 year old cricketer who was admitted to the emergency department with acute pain in the upper right abdomen occurring abruptly after the over stretching of the abdominal wall during a game of cricket, and on clinical examination the inferior anterior border of the thoracic wall was also painful.
Various diagnostic methods were used to determine that the injury stretched the attachments between two ribs and made one of them loose, and in some cases it caused immediate pain, and in others it didn’t have any effect until several months or years later when a relatively minor incident resulted in it slipping over another and impinging an intercostal nerve to cause the pain.
In relation to my more recent suggestions of 13-7-14, such injuries would be more likely to result in chest pains in people who already had kyphosis and vertical sternums and would, in combination, shed light on the causes in other cases.
References:
1. 2014 (May 11th), Banfield M.A. An example of injury to rib attachments as a cause of previously unexplainable chest pains, The British Medical Journal (Online Rapid Responses), BMJ 2008;336:1124, Actual page of response is http://www.bmj.com/content/336/7653/1124/rr/697563
2. 2014 (July 13th), Banfield M.A. The Banfield explanation for anterior displacement of the eighth rib and the cause of previously unexplainable chest pain, The British Medical Journal (Online Rapid Responses), BMJ 2008;336:1124. http://www.bmj.com/content/336/7653/1124/rapid-responses
3. 1975 (September), A.A.McBeath & J.S.Keene, The Rib Tip Syndrome, The Journal of Bone and Joint Surgery, Vol.57-A, No.6, p.795-797.
4. 2002 (March 1st), Jean-Yves Meuwly et al, Slipping Rib Syndrome, A Place for Sonongraphy in the Diagnosis of a Frequently Overlooked Cause of Abdominal or Low Thoracic Pain, Journal of Ultrasound in Medicine, Vol 23, no.3, p.339-343.
Competing interests: No competing interests
In previous discussions in BMJ I have presented evidence that kyphosis and scoliosis contributes to lower left sided chest pains and L. Sam Lewis responded by recommending a research paper by Leon G. Robb et al about the Slipping rib syndrome.
Robb mentioned that in 1941 J.F.Holmes, and later in 1975 A.A.McBeath and J.S.Keene studied the problem and found that in some cases the eighth to 10th ribs, which are not directly attached to the sternum, had their ends curled up, and if they were fragile and their attachments were incised they became locked one behind the other.
Holme’s concluded that the cause was recurrent irritation of the intercostal nerves which may be direct or indirect and sometimes completely covert.
I subsequently found an SRS sonography study by Jean-Ives Meuwly et al, in 2002, who concluded that it is related to minor trauma, constrained posture, or prior abdominal surgery, but added that the cause remains unclear because many patients could not recall any preceding event.
Some time after reading those reports I was standing up and placed my hand on the left side of my chest and moved it down from the clavicle along the slight undulations created by the ribs and intercostal spaces until I came to an obstruction.
On closer observation it was the eighth rib which was projected in the anterior direction to the extent of almost it’s entire diameter, creating an L-shaped bend between the anterior surface of the seventh rib, and the upper surface of the eighth rib.
I then moved my hand over that rib and the next was projected slightly more forward, and then I moved it over and around and to the left, and the tenth rib continued slightly further forward, and the 11th and 12th were then roughly vertically aligned, and then my hand moved over, around, and back toward the abdominal wall.
The same feature was evident as I ran my hand down the right ribcage.
Later that day I was laying on my back and I tried the same process where the eighth ribs onwards were projected upwards in a similar manner.
By way of explanation I could describe my rib cage, when upright, as having the structure of a vertical seven ribbed wall with a narrow downward 5 ribbed verandah below, which extends immediately forward and then somewhat slightly follows the forward curvature of the muscular abdominal wall, which is all hidden behind a layer of skin.
I.e. the eighth ribs jut out about 1cm, and then the 9th to12th proceed out for a total of another 2cm as they taper to the side of the lower chest.
I then considered how and why that structural feature developed.
In that regard I have previously explained how kyphosis projects the weight of the head and shoulders forward and down over the chest wall, and that the normal chest and sternum are angled forward, and that mine is vertical, and that when I lean forward my sternum tilts slightly backwards.
Consequently any kyphotic pressure down the top ribs is likely to displace one of the next ribs forwards, and in my case it was the eighth rib, and any more downward pressure is likely to make the seventh rib slip slightly behind the eighth, and impinge the intercostal nerves, which would explain the occasional sharp stabbing pains I had as a teenager.
Repeated kyphotic strain and slippage of that sort would also be the likely cause of inflammation and tenderness in that region and eventually stretch the intercostal attachments and leave the eighth rib permanently displaced.
During that process the eighth rib would also push the ninth to twelfth ribs downwards and they would tend to follow the forward curve of the abdominal wall, and that would explain the structural change.
I have also previously explained that my kyphosis occurred as the result of an illness at the age of six which involved nausea, vomiting, poor appetite and poor nutrition resulting in a temporary softening of bones, and the rib feature may have also occurred then, or developed later as the result of long term or repetitive kyphotic pressure on the rib cage.
I also explained that the occasionally sharp stabbing pains which I had in the left side of my chest as a teenager, had stopped when I was about 20.
That may have been due to the fact that teenage ribs are pliable and prone to slippage whereas they harden toward adulthood and therefore become more fixed in their position.
However, similar pains could also occur in adulthood where an injurious incident forced one rib over the other in a similar manner such as being hit in the chest by a solid object, or when the ribs are severely stretched at an awkward angle.
Those conclusions are consistent with Robb’s observation that the hooking manoeuvre which places the fingers down, under, and behind the lower ribs, and then pushes them forward, can reproduce the pain.
I applied it and felt various areas of tenderness, and when my fingers moved up and behind the lower ribs I felt a spot pain, which didn’t radiate, but it was in the same location where I had the radiating pains as a teenager.
i.e. Kyphotic and downward pressure on the seventh rib, and the hooking manoeuvre, both displace the lower ribs forward to produce a similar effect, which explains the cause that has previously been described as being unknown in most cases.
References:
1. 1980, June, Banfield M.A., The Matter of Framework, Australasian Nurses Journal, p.27-28.
2. 2014, March 30th, Banfield M.A. The Posture Theory as an explanation for many previously unexplainable symptoms, (Online rapid response) BMJ 2008:336:1124.
http://www.bmj.com/content/336/7653/1124/rr/692354
3. 2014, April 27th, Banfield M.A. Posture as a cause of previously unexplainable left sided chest pain, The British Medical Journal (Online Rapid Response), BMJ 2008; 336:1124.
http://www.bmj.com/content/336/7653/1124/rr/695879
4. August 3rd. 2013, Leon G. Robb et al, The Slipping Rib Syndrome: An Overlooked Cause of Abdominal Pain, Practical Pain Management.com
5. 2013, Rajender Kumar et al,, The painful rib syndrome, Indian Journal of Anaesthesia, Vol. 57, Issue 3, p.311-313.
6. Jean-Yves Meuwly et al 2002 (March 1st), Slipping Rib Syndrome, A Place for Sonongraphy in the Diagnosis of a Frequently Overlooked Cause of Abdominal or Low Thoracic Pain, Journal of Ultrasound in Medicine, Vol 23, no.3, p.339-343.
Competing interests: No competing interests
In previous discussions in BMJ I have described how kyphosis contributes to the symptoms of lower left sided chest pains, faintness, and abdominal pain.
I would now like to provide information which specifically refers to a type of breathlessness where I would occasionally feel as if I hadn’t gained enough air when I inhaled, so I had to force a deeper breath, sometimes two or three times in a row, where each time I felt as if I was breathing in against an obstruction.
I had noticed that various factors seemed to be related to it.
For example, it would sometimes, but not always occur when I leaned toward a desk or bench.
There were other isolated incidents when I was wearing a tight shirt which seemed to be restricting the outward expansion of my lungs and contributing to the symptom.
A few years later I came to the conclusion that I had a slightly abnormal forward curvature in my upper spine, kyphosis, which had not been previously evident to me because I had always looked at myself by facing frontwards into a mirror.
I therefore decided to stand sideways and look again, when I could see, for the first time, that my natural relaxed posture included a very significant forward curve in my upper spine, and a corresponding forward arch in my lower back.
The forward curvature of my upper spine placed the entire weight of my head and shoulders over and down onto my chest, which would restrict the upward expansion of my lungs and reduce the amount of air I was inhaling with each breath.
Conversely the forward arch in my lower spine projected my abdomen forward, which was impairing the natural free flowing downward expansion of my lungs during inhalation.
I then concluded that wearing a tight belt would restrict the downward movement of my abdominal contents which would in turn, also impair the downward movement of my lungs.
Furthermore the combination of factors was producing a sandwich effect on my lungs.
Many years later I observed other people sitting on a park bench, and one of them was middle aged, and had a stoop, and when they inhaled their lungs were driving their head and shoulders upwards, and when they exhaled their head and shoulders and chest dropped with a thump onto their abdomen.
I could then see, with some clarity, that their breathing was much more energetic and inefficient than that of the other people on the bench, who were sitting upright, and breathing in an unimpaired and effortless manner without any significant upward or downward movement of their head and shoulders.
I later found that most people have a forward angled sternum which provides a deep chest and ample lung space, whereas I had a vertical sternum which is roughly parallel to my spine and therefore reduces my lung space in the anterior and spinal direction.
In that context I also noticed that when I leaned forward, my sternum actually moved backwards, instead of forwards, and further compressed my lungs, which would partly explain why I occasionally felt breathless when I leaned toward benches.
I then noticed that bending at the waist increased the forward curve of my spine, and the pressure on my lungs, whereas bending at the hips kept my spine relatively straight, and didn’t affect my lungs to the same extent.
I also noticed that while leaning forward and inhaling my upper chest expanded instead of my lower chest.
While I was making those observations I was also reading about the anatomy and mechanism of respiration where breathing in and out involves the upward and downward movement of the diaphragm which is a broad band of muscle that is attached in front to the ensiform cartilage at the lowest end of the sternum, and on the sides to the inner cartilage and bony sections of sixth and seventh ribs, and behind to the lumbar vertebra of the spine, and it divides the chest from the abdomen.
When it relaxes it expands to a roughly dome shape and pushes air out of the lungs during exhalation, and then contracts and flattens, which increases the chest space to create a vacuum and produce the inhalation of air through the nose.
Consequently if I felt a sense of breathlessness and tried to breath deeper the diaphragm would reach it’s maximum amount of contraction and flatten between it’s attachments and couldn't descend any further, which would explain why I would sometimes feel as if I was breathing in against an obstruction.
I had also observed that the breathlessness was occasional at rest, but occurred more often when walking, and consistently increased in frequency during faster walking, jogging, or running, which I managed by taking occasional forced deep breaths, or stopping to rest for a few minutes if necessary.
There are also mechano and chemoreceptors which monitor and regulate respiration according to physiological requirements and may be implicated in the cause.
I was eventually able to treat that problem satisfactorily by improving my posture, and by wearing loose belts and shirts, and by avoiding activities which involve leaning or bending, and by refraining from activities or exercise which increase the frequency of the symptom.
References
1. M.A. Banfield, 1978 (May), To breathe or not to breathe - is that the question?, Australasian Nurses Journal, p.5-6.
2. Henry Gray, 1858, Gray’s anatomy, Republished by The Promotional Reprint Company Limited in 1991, Great Britain, p. 68-76 (the thorax), and p.238-241 (the diaphragm).
3. Maxwell M. Wintrobe et al., 1970, Harrison’s Principles of Internal Medicine, 6th edition, p.203.
4. 2014, April 27th, Max Allan Banfield, Posture as a cause of previously unexplainable left sided chest pain, The British Medical Journal (Online Rapid Response), BMJ 2008; 336:1124.
http://www.bmj.com/content/336/7653/1124/rr/695879
Competing interests: No competing interests
In response to my recent comments about the postural cause of lower left sided chest pains L.Sam Lewis provided a link to a research paper by Leon G. Robb et al about the slipping rib syndrome.
They stated that although the cause was obscure and unknown it was sometimes preceded by trauma to the chest which may have produced damage to the fibrous attachments of the ribs and made them loose and liable to slip and impinge on the intercostal nerves to cause the pain.
I can therefore give an example of a possible cause . . .
When I was about fourteen years old I attended a scout camp where we set up our tents and laid canvas ground sheets on hard ground inside.
Later that night I got into my sleeping bag and went to sleep.
I awoke in the middle of the night with my closed fist between my lower left ribs and the hard ground.
The left side of my chest and abdomen and my left arm and leg were numb.
I rolled onto my back and went to sleep again, and when I awoke in the morning everything had returned to normal.
A few months later, for no apparent reason, I felt a sharp stabbing pain in the same area, as if a sewing needle had pierced my chest to a depth of about five centimetres and came out again within a fraction of a second.
The same pain occurred in the same part of my chest at various times, many months apart, until I was about 20, and hasn’t happened since.
Discussion: The biomechanics of that pain . . .
When I began studying the cause of other health problems at the age of 25 I had already noticed that they were related to repetitively leaning toward a desk, and eventually that I had a forward curvature of my upper spine and a vertical sternum which disposed to pressure on my ribs and the intercostal nerves,
I also noticed that I had sideways curvature of the spine to the right which meant that the pressure would be compressing the ribs on the right, and slightly stretching those on the left, so that stretching of the ribs attachments would have had some influence, and the scoliosis would have been responsible for the unilateral nature of that pain.
Therefore when I recently read about the slipping rib syndrome I concluded that when I was asleep at the scout camp with my closed fist between the ground and my lower left ribs, that it was pushing one or more of them inwards and impinging the intercostal nerves for several minutes to produce the numbness which eventually made me wake up in the middle of the night.
Consequently when I rolled onto my back the pressure on the nerve was relieved, which is why the numbness was gone the next morning.
The pressure on the ribs may have also stretched or torn the fibrous attachments so that one of them was loose and prone to slipping.
The ribs would have returned to their normal position which is why I didn’t have any other symptoms for several months.
However, I did get the sharp stabbing pains occasionally after that, and although I was not aware of any specific reason at the time it was probably due to moving, bending, or twisting at an unusual angle which cause the loose rib to slip and impinge an intercostal nerve.
Furthermore the forward curvature of my upper spine would have placed my head and shoulders forward where their weight produced repetitive downward pressure on my lower ribs and may have prevented the damaged fibrous attachments from healing.
Nevertheless, I went through a rapid growth period in my late teens and that may have relieved or changed the dynamics of some of the pressure and allowed those attachments to heal, and that would explain why that particular symptom stopped.
Conclusion . . .
Trauma to the chest and, or kyphosis, scoliosis, and a long, narrow, or flat chest, which have a biomechanical effect on the lower ribs, can cause damage to their fibrous attachments and dispose to slippage, and consequent impingement of the intercostal nerves, and individually, or in combination account for the previously obscure and unexplainable symptoms.
References: related to these conclusions can be seen at the end of my recent comments here . . .
Banfield M.A., 2014 (May 6th), The postural and biomechanical causes of nerve pain in previously unexplainable chest pains, (Online rapid response) BMJ 2008;336:1124.
See also: A method of diagnosing the slipping rib syndrome with sonography . . .
Jean-Yves Meuwly et al, 2002 (March 1st), Slipping Rib Syndrome, A Place for Sonography in the Diagnosis of a Frequently Overlooked Cause of Abdominal or Low Thoracic Pain, Journal of Ultrasound in Medicine, vol.21 no.3, 339-343.
Competing interests: No competing interests
Banfield’s Chest Pain - Finding the elusive cause
As a teenager in the ealry 1960’s I experienced a brief sharp stabbing pain in the lower left side of my chest and when I asked my doctor about it he examined my chest with his stethoscope and said that there was no sign of heart or lung disease.
I then asked him if he knew the cause but he didn’t.
However the pain recurred on several occasions so he sent me for blood tests and x-rays but nothing was found, and like almost every other patient with that pain, I began to doubt if he had missed something.
One day, when I was in my early 20’s I noticed that I hadn’t had that pain for a while, but when I asked my doctor to explain why it stopped he couldn’t.
About a year or two later I was getting aches in my kidneys whenever I leaned forward, and a kidney stone was detected and treated.
I later started gettng abdominal pains, and then faintness, breathlessness, and dizziness, but despite various diagnostic procedures the cause was elusive so I decided to study the problems myself.
At high school I favored subjects of maths and physics, where facts, evidence, and proof were characteritic requirements, and on one occasion topped the class in a first term chemistry exam, and regularly participated in classroom discussions on various topics, and later, gained multiple scholarships to study leadership at the Institute of Technology where scientific principles and methods were part of the curriculum.
Consequently when I started studying health problems I made detailed observations, read the general medical literature, and then the research journals to get the best and most reliable information.
Within a few years I was able to identify that leaning forward was sometimes associated with various symptoms, and concluded that they probably all were including the chest pains I had as a teenager.
However I found general opinions that there was no evidence of physical illness, and that it was therefore impossible to have a physical cause and must be due to psychological factors such as worry, fear, or stress.
Nevertheless I also occasionally noted comments that the typical patient had a thin and stooped physique, and later found a book by Paul Wood which had a chapter discussing the problems as psychriatric states, but he noted that it was relieved by intramuscular injection of a painkiller, but not by subcutanious injection, and he concluded that it was related to fibrositis and low back pain, and may be due to postural factors, awkward movements, or anxiety which alters the action of the respiratory muscles and puts strain on the chest wall.
However I recognised that it indicated a physical cause of a physical symptom in a precise location.
His chapter also included a full page photo of a full sized portrait of the physique of the typical patient, and if his face was replaced by mine it would be the same.
Wood then presented his description of the personality of such patients describing them as insecure adults who had been timid children protected from the dangers of sport, gymnastics, and swimming, but I was an active teenager and participated in all of those activites, often as instructor or leader.
I found other comments that the cause of the pain was not evident on surgical inspection, and I wanted to attend an autopsy session to look at the region but was told that the only individuals permitted to do that medically qualified personel or students.
I also learned that J.M. Da Costa, in 1871, had reported that the symptoms seemed to be related to a clicking sound that he and others thought might be due to valvular disease of the heart, and he also noted that it seemed to be coming from outside the heart, but he couldn’t idenfity the source, so I became curious about the possibliities.
I also noted that although the research literature was reporting a general increase in knowledge, the actual cause could not be found.
I later began studying the problems again between 1994 and 2000 and looked for potentially useful information from a wide range of sources.
More than a decade later, in 2013 an internet contributor prompted me to send my ideas to the British Medical Journal, and after writing several essays on the chest pain L.Sam Lewis suggested I look into the topic of slipping rib syndrome, and after reading an essay by Leon G. Robb et. al. and others, I found an article by Jean-Yves Meuwely who used Valsalva’s Maneuver and sonograpy to examine a woman who overstreched her chest during a game of cricket.
The woman felt pain, he heard a click, and saw one rib bounce over another and rebound, which answered some of the questions.
I was then curious about an anatomical report by J.F. Holmes (1941) that the cartilage ends curl up under the ribs and he said that “there does not appear to be any clear conception of the development of this deformity”.
I then wondered why countless physical examinations, X-rays and CAT scans of my chest had never mentioned it, so I ran my fingers down my chest and found the 8th rib protruding, and all the pieces of the puzzle immediately fittted in place, so I described the cause and sent it to BMJ where it was published in April 2014.
I expected significant reports to be published about the solution to that major mystery but haven’t noticed any.
I have, however heard remarks like this . . . “You don’t need scientific methods to figure that out because it’s just common sense and anyone could have solved that problem if they tried”.
Needless to say the reason that my doctor didn’t know the cause in the 1960’s was because nobody in the world knew, and now, it won’t be long before everyone knows. It’s just postural pressure which makes a rib loose, and occasionally slip to pinch a nerve.
References:
1980, June, M.A. Banfield, The Matter of Framework, Australasian Nurses Journal, p.27-28.
2014, April 27th, M.A. Banfield, Posture as a cause of previously unexplainable left sided chest pain, The British Medical Journal (Online Rapid Response), BMJ 2008; 336:1124.
http://www.bmj.com/content/336/7653/1124/rr/695879
2014 (July 13th), M.A. Banfield, The Banfield explanation for anterior displacement of the eighth rib and the cause of previously unexplainable chest pain, The British Medical Journal (Online Rapid Responses), BMJ 2008;336:1124, Actual page of response http://www.bmj.com/content/336/7653/1124/rr/760594
1956, Paul Wood O.B.E., Diseases of the Heart and Circulation, Eyre & Spottiswoode, London, p.937-947.
2013, August 3rd., Leon G. Robb et al, The Slipping Rib Syndrome: An Overlooked Cause of Abdominal Pain, Practical Pain management.com
2002, March 1st, Jean-Yves Meuwly et al, Slipping Rib Syndrome, A Place for Sonongraphy in the Diagnosis of a Frequently Overlooked Cause of Abdominal or Low Thoracic Pain, Journal of Ultrasound in Medicine, Vol 23, no.3, p.339-343.
Competing interests: No competing interests