Is the pain and dysfunction of shoulder impingement lesion really second rib syndrome in disguise? Two case reports

Abstract

This paper presents two case studies supportive of a previously unreported clinical presentation. The author proposes that sprain of the second rib spinal articulations in isolation, either acutely or chronically induced, is a cause of shoulder pain that is commonly misdiagnosed as shoulder impingement syndrome and/or rotator cuff muscle partial tear. The following two cases present an alternate diagnosis for patterns of pain and dysfunction consistent with these diagnoses. These cases may be representative of a relatively common clinical presentation. An extensive search of orthopaedic and manual therapy texts revealed that Grieve (1988) appears to be the first to describe second rib syndrome as a single entity. Symptoms included reports of a useless or heavy limb and the inability to grip efficiently. Upper cervical joint problems with referral of pain to the head may be associated and shoulder pain may be reported (Grieve 1988). No further description is given in relation to specifics of the shoulder dysfunction. A Medline search of English and non-English literature from 1991 to July 1998, and an extensive follow-up of referenced articles from the papers revealed by this search, failed to identify any report of the current observations proposed. Kobayashi et al. (1991) described a case study of a 25-year-old female with fibromyalgia who presented with multiple pain sites including bilateral shoulder pain. They indicated that the second rib was one specific point of marked tenderness but made no direct association with the shoulder pain. Upper limb symptoms including shoulder pain have been frequently reported for thoracic outlet syndrome and its association with the first rib (Tucker 1994; Nichols 1996; Davidovic et al. 1998). Additionally Lindgren & Leino (1988) reported four case studies that described an association between sub-