Many individuals commonly complain of pain and tightness in the upper trapezius region, which can be attributed to athletic participation. This pathology has been described as first rib subluxation, although the separation of joint articular structures is often not seen with diagnostic imaging.1 Consequently, the term rib dysfunction will be used hereafter in this article. Although several manual therapy techniques have been described to relieve rib dysfunction discomfort, a technique that is directed specifically to the mobilization of the first rib is often beneficial.
The first rib is relatively anatomically unstable and acts as the attachment site for the scalene muscles, which creates an upward pull on the rib. The first rib is most likely to move superiorly; however, muscular forces from the pectoralis minor can position the first rib relatively anteriorly as well. Signs and symptoms of a first-rib dysfunction include pain along the costosternal or costovertebral joints of the first rib; referred pain in the head, neck, shoulder, or arm; and restrictions or pain during exhalation or inhalation. Swelling, tenderness, or sensitivity of the first rib may also be present during palpation. The clinician should perform a thorough upper quarter examination to determine the presence of radicular symptoms and the source of pain prior to treatment.
The first-rib mobilization technique appears in the literature pertaining to osteopathic medicine and manual therapy. A systematic review in 19921 and textbook chapters first published in 19792 detail a technique similar to that described below, although an exhaustive literature search did not produce any relevant current research regarding this technique. Currently, no randomized clinical trials have been conducted to determine the effectiveness of mobilizations of the first fib in treating symptoms of first-rib dysfunction. Despite the lack of research, this technique can provide pain relief and help resolve the muscle spasms associated with first-rib dysfunction. The first-rib mobilization and muscle energy technique3 can be used in conjunction with other manual and active therapies to resolve pain in this area, and clinicians should use patient-reported outcomes to help clarify the benefit of this technique in practice.
First-Rib Mobilization and Muscle Energy Techniques
Figure 1 illustrates the position of the clinician and patient while using the superior first-rib dysfunction assessment technique. After an upper quarter examination, the clinician stands behind the seated patient, grasps the anterior aspect of the superior trapezius muscle, and pulls posteriorly (Figure 1). While the upper trapezius muscle is retracted, the clinician should palpate the posterior shaft of the first rib. The clinician should then palpate bilaterally and observe for asymmetries or tender areas, hypertonicity of the ipsilateral scalene muscles, and pain with exhalation. The clinician may find spasm of the scalene muscles on the affected side while palpating the anterior portion of the rib superior to the clavicle. Both pain and asymmetry would indicate first-rib dysfunction.
Figure 1. Assessment of superior first-rib dysfunction.
Figure 2 illustrates treatment of first-rib dysfunction with inferior mobilization. To treat first-rib dysfunction with the inferior mobilization technique, the clinician should:
- Stand behind the patient. The patient’s arm of the unaffected side is draped over the clinician’s thigh, with the clinician’s foot placed on the table. The clinician’s thigh helps to stabilize the patient’s body and permits the patient to relax and be moved by the clinician.
- Grasp the patient’s head and neck with one arm, and use the upper arm to stabilize the clavicle and scapular region with the forearm while applying slight pressure to the face. The clinician should pull the trapezius muscle posteriorly, locate the rib, and then palpate the first rib with the other hand.
- Laterally flex and rotate the patient’s head toward the side of dysfunction. This movement permits relaxation of the sternocleidomastoid and scalene muscles. The clinician then applies a posterior–inferior force on the first rib using the webspace of his or her thumb and index finger. Oscillations and grading of the mobilization should be determined by the discomfort of the mobilization and by the perception of the clinician.
- Following the mobilization of the first rib, have the patient laterally flex his or her neck away from the side of dysfunction against the resistance of the clinician. Activating the scalene muscles in this manner results in inhibition of the ipsilateral scalene group and thus restores symmetry of the dysfunctional first rib using the principle of reciprocal inhibition. This muscle energy technique is paired with mobilization to maintain alignment after the conclusion of the mobilization.
- Repeat this technique 2 to 3 times until symmetry is restored.
Figure 2. Treatment of first-rib dysfunction with inferior mobilization.
This method of first-rib mobilization can be incorporated into a comprehensive rehabilitation program or combined with additional manual therapy techniques. Patient feedback should guide the clinician, and therapeutic exercise should complement the mobilization to enhance overall function.
- Kamkar A, Cardi-Laurent C, Whitney SL. Conservative management of superior subluxation of the first rib. J Sport Rehabil. 1992;1(4):300–316.
- Mitchell FL Jr, Moran PS, Pruzzo NA. Evaluation and Treatment Manual of Osteopathic Muscle Energy Procedures. Valley Park, MO: Mitchell, Moran, & Pruzzo Assoc; 1979.
- DeStefano L. Greenman’s Principles of Manual Medicine. Philadelphia, PA: Lippincott Williams & Wilkins; 2011.