Ankylosing spondylitis, an inflammatory form of arthritis, primarily impacts the spine, but it can also affect other areas of the body, such as the ribs. According to the Spondylitis Association of America (SAA), about 70 percent of people who have ankylosing spondylitis experience inflammation in the joints between the ribs and spine as well as the area where the ribs connect with the breastbone in the front of the chest.
How Ankylosing Spondylitis Affects Your Ribs: The Bucket Handle
Inflammation in this area can cause discomfort or pain when you breathe, and over time, can lead to scarring of tissue at these connection points, causing stiffness. This can decrease your chest’s ability to expand fully, making it more difficult to breathe. “Chest expansion is reduced in people with ankylosing spondylitis, and this can cause significant respiratory restrictions,” says David Minna, MD, a rheumatologist and professor of internal medicine at the University of Texas Southwestern Medical Center in Dallas.
Picture each rib as a bucket handle, says Dr. Minna. One end of the handle is connected at the back of your spine and the handle goes around to the front to your breastbone. “As you breathe in and out, it’s like lifting a bucket handle up and down,” says Minna. In people who have ankylosing spondylitis, he explains, “the bucket handle can’t move as much and that restricts the amount of air you can bring in, and you have to start relying more on your diaphragm pulling down to bring air in.” But the diaphragm — a dome-shaped muscle at the base of the lungs — can only move down to a limited point, says Minna.
If the rib joints at your back have more tension, as they do in ankylosing spondylitis — although stress can also occur due to bad posture or insufficient core strength — the front part of your body is going to have to do a lot more work to move when you’re breathing, says Deeba Minhas, MD, a rheumatologist at Michigan Medicine at the University of Michigan in Ann Arbor. The area where the ribs attach to the breastbone is delicate, explains Dr. Minhas, “so when they work aggressively with every breath you take, that strain and irritation and inflammation can cause costochondritis [chest wall pain].” In other words, stiffness in your back can contribute to pain and restriction of chest movement. “In ankylosing spondylitis, your back becomes less mobile, which makes the costochondritis worse,” explains Minhas.
The SAA notes that anyone who experiences chest pain should seek medical attention to make sure it’s not a symptom of a more serious condition. “You want to rule out something dangerous like a heart attack,” says Minhas.
Another thing you’ll want your doctor to check out: According to the SAA, some patients with restricted rib movement may develop scarring at the top of the lungs, which can impair proper lung function and lead to problems such as prolonged colds and upper respiratory infections.
Who Gets Ankylosing Spondylitis in the Ribs?
There’s no way to tell who may develop rib problems, says Minna. “You can have people who have very severe joint disease but have minimal spine involvement,” says Minna. “On the other hand, you can have people that have maximum spine involvement and no peripheral disease [meaning outside of the spine area, such as in the ribs].” It’s not a linear thing where as you get more inflammation and more disease, there’s a certain progression toward rib involvement, he explains. “It can be very random,” says Minna.
Spotting Rib Involvement Early
When it comes to managing ankylosing spondylitis in the ribs, early detection and action can make a difference in how much the problem affects your daily function. “One of the things we do at the clinic is take measurements of how much [a patient’s] chest expands when they breathe in or out to see if it’s moving well or not,” says Minhas.
The measuring of chest expansion during breathing is a simple but potentially important tool in spotting rib involvement early. “Chest expansion is one of the basic measurements that we probably don’t do as frequently as we should,” says Minna. This technique is straightforward, he says, requiring nothing more than a doctor using a tape measure around a patient’s chest to measure chest movements during breathing. This number, along with a pulmonary function test, can provide the rheumatologist with clues about whether or not the ribs may be affected, says Minna.
Pulmonary functions tests measure your breathing and how well your lungs are working. An Iranian study of 60 ankylosing spondylitis patients published in April 2018 in the journal Rheumatology Research found that as many as 25 percent had abnormal pulmonary function test results, and that lung problems were largely due to restriction from reduced range of motion. The researchers noted that performing pulmonary function tests and taking chest X-rays may be beneficial for all patients with ankylosing spondylitis, even if they do not have symptoms of respiratory problems.
While there’s no cure that can stop ankylosing spondylitis from affecting the ribs, interventions can help maintain function, says Minna. The goal is to decrease the impact that chest pain and chronic inflammation in the rib area will have on your chest expansion and breathing. “Try to maintain as upright a posture as possible and maintain flexibility through exercises,” says Minna.
Tips for Managing the Effects of Ankylosing Spondylitis on the Ribs
How well someone does when the ribs are affected by ankylosing spondylitis depends on factors like how successfully the disease is managed with treatment and how much the individual follows exercise and physical therapy recommendations. “I have patients who have severe ankylosing spondylitis and are really diligent about practicing their range of motion exercises from one visit to another,” says Minhas. “They were able to improve their scores on measurements I was taking of their back mobility and [other metrics] within two or three months,” says Minhas.
Try these strategies to help manage symptoms like rib pain and difficulty breathing:
Work with your doctor to make sure your medication is working. With ankylosing spondylitis, the first line of treatment is typically a nonsteroidal anti-inflammatory drug (NSAID) to reduce inflammation and pain, says Minhas. Then, if that’s not effective or you experience side effects, doctors may try TNF inhibitors or IL-17 inhibitors, which target the underlying cause of inflammation and may alter the course of the disease. Making sure your medication is working to manage your ankylosing spondylitis is an important part of preventing disease progression, says Minhas. If necessary, talk to your doctor about adjusting your treatment plan.
Use cold or heat. For some people, applying ice packs on the chest, back, or other affected areas may be helpful in easing pain and inflammation. For others, a hot shower or a warm bath can do the trick.
Try a topical NSAID. Applying a topical NSAID to the affected area can also be effective in reducing inflammation and pain, says Minhas.
Practice breathing exercises daily. One way to help prevent worsening of chest stiffness is to practice taking deep breaths every day, before you even get to the point where you have decreased range of motion. Try doing your breathing exercises after taking a warm shower or bath. Measures like performing breathing exercises and working with a physical therapist to improve strength in your back may make it less necessary for you to see a respiratory therapist at a later, more serious phase of the disease, says Minhas.
Diaphragmatic breathing is one technique your doctor might recommend to help you maximize air intake by using your stomach muscles rather than your chest. You may want to schedule a few sessions with a physical therapist or respiratory therapist to learn this technique, which involves lying on your back with one hand on your upper chest and the other on your stomach. As you breathe in through your nose, expand your stomach so that it pushes against your hand. Your chest should not move out. Exhale through pursed lips and contract your stomach muscles, while keeping the hand on your chest as still as possible.
This exercise can help strengthen your diaphragm and decrease the effort required to breathe, according to the Cleveland Clinic. But keep in mind its limitations: “You can teach people how to try to use a means to breathe by using their diaphragm instead of their chest, but you can’t actually make your diaphragm go down further than it can,” notes Minna.
Tape your ribs. Minha suggests using athletic tape, which is used by individuals, athletic trainers, physical therapists, and other medical professionals to support injured muscles and joints, improve circulation, and decrease pain. “Any kind of joint trauma will make arthritis worse,” notes Minha. “Joint-protection techniques like this can help by giving you support and reducing inflammation, but it’s not a brace so it doesn’t restrict your motion.”
The research on whether or not athletic tape is effective at doing these things is conflicting, with some studies showing no benefit to using these types of tapes and others showing there might be some improvement for injured areas. One review of seven studies, published in June 2018 in the Orthopedic Journal at Harvard Medical School, found that taping combined with physical therapy may be better at effectively reducing pain for a short period of time (in this study, for up to two weeks) in people with recently diagnosed shoulder impingement compared to physical therapy alone. Talk to your doctor about whether this method may be right for you.
Stretch and exercise daily to help keep your back as mobile as possible. “This is something that people don’t realize is connected,” says Minhas. “If your back is stiff, then your ribs have to do more to breathe in or out.” To get ideas for exercises that stretch your back, work with a physical therapist.
Physical therapy and exercise are an essential part of ankylosing spondylitis management, and have been shown to maintain and improve function and decrease pain and disability, says Minhas. “Physical therapists have techniques to further immobilize the spine and ribs to prevent them from becoming too stiff,” says Minhas.
Every day, do some gentle stretching and range of motion exercises such as raising your arms over your head to open up your chest and breathing deeply to work on your diaphragm muscle.
Make posture muscles stronger with exercises like the mountain pose, which prompts you on how to stand properly, with your chest open, ribs out, glutes tightened, and core tucked in, says Minhas. “I tell my patients to start with that and then add to that by keeping that pose in mind while walking around or sitting down during the day.”
You may also be able to find stretching and exercise ideas on YouTube. Minhas suggests following Bob and Brad, two physical therapists who have created scores of workout videos, including ones particularly designed for people with ankylosing spondylitis.
The bottom line: Don’t stop moving. “If you have a flare, you can make it worse by not being mobile,” says Minhas.