LRB - Yes! Physical Therapy, LLC

The Little Rib Book

Clinical Pearls

Any good treatment starts with a thorough evaluation, which always includes interview, observation and motion testing, at a minimum. In treating rib dysfunctions, a good deal of valuable information also comes from the palpatory examination.
For example:
a patient who states “my shoulder hurts when I reach into the back seat of the car” during the interview, should raise a flag of concern about an anteriorly-displaced second rib ipsilaterally.
Observing a sub-clavicular fullness can further the hypothesis.
Motion testing the second rib should disclose hypomobility to posterior glide and may provoke characteristic discomfort.
I usually start the physical exam of the ribs by motion testing first ribs, keeping in mind the influence of the lateral cervical muscles as well as the first thoracic vertebra.
Then checking the clavicles bilaterally for anterior/posterior displacement, inferior/superior displacement and lastly rotation. There are small depressions on the medial end of each clavicle that should line up. A superior/inferior difference between these depressions with no other clavicular asymmetry, suggests a rotational displacement.
The involved clavicle is revealed as hypomobile on motion testing.
Next we can examine the rest of the ribs, keeping in mind that rib lesions can:
♦ occur secondary to vertebral lesions, but the rib lesion can also be primary.
♦ cause intense pain because of their connection with the intercostal nerves.
♦ limit joint motion, at both vertebral and shoulder joints.
Primary rib lesions should be treated effectively as described below.
Rib lesions not easily treated should raise the likelihood of a rib lesion secondary to a primary vertebral lesion.
We can find respiratory restrictions due to inhaled (superiorly subluxed) or exhaled (inferiorly subluxed) ribs, but in my experience these are relatively rare, compared to anterior/posterior displacements, medial compressions and torsions.
Contralateral comparisons can be valuable as an initial screen but are fraught with additional confounding variables compared to same-side palpation.
Evaluating ribs in order on the same side makes deviations from what should be a smooth sequential progression more immediately obvious, in my experience.
Any deviation should be identified from the front and from the back to ascertain its nature.
This can be done in almost any position, but a supine patient position makes this task easier for all concerned.

Examination of the Ribs and Clavicles

The clavicles may be displaced anteriorly, posteriorly, superiorly or inferiorly, as well as medially or laterally.
In addition, they can exhibit internal or external rotation, best gauged by palpating the small flat spots on the superior surface near the medial ends.

Treatment by muscle energy aims to first position the affected clavicle just away from its motion barrier, indicated by an increase in mobility and decrease in pain, and then to ask for low level contraction of the antagonist muscle(s)

Elevated 1st Rib Treatment

The affected rib will be prominent superiorly, with limited inferior glide, which may elicit symptoms. Cervical sidebending toward may be limited.

If the first rib is a primary effect, muscle energy technique (MET) should be helpful.
An elevated first rib forces T1 to sidebend away, so from an MET standpoint,the major barrier will be sidebending toward and the MET will start in a position of sidebending away.
Because of the possibility of eliciting a cramp in the presumably tight ipsilateral scalenes as the muscles shorten, contraction of the opposite sidebenders (reciprocal inhibition) is usually employed.
After each contraction, repositioning is done by sidebending the cervical spine towards the elevated rib, maintaining the neutral zone.
Use rotation and flexion/extension to fine-tune positioning.
After 3-4 contractions, normal 1st rib pain-free mobility should be restored.

Anterior (4th) Rib Treatment

The affected rib will be prominent anteriorly, and deeper posteriorly, compared to its neighbors.
Posterior glide will be limited and may elicit symptoms.

Treatment by muscle energy technique can be accomplished easily. Horizontally adduct the ipsilateral arm (bring forward) until pressing from A to P no longer elicits rib tenderness, or only minimal tenderness. The rib should also regain mobility to A-P glide. Ask the patient to horizontally abduct (posterior). Reposition the elbow toward the barrier (horiz. abd). Repeat contraction, reposition, for a total of 3 repetitions.

Posterior (4th) Rib Treatment

The affected rib will be deeper anteriorly, and prominent posteriorly, compared to its neighbors.
Anterior glide will be limited and may elicit symptoms.

Treatment by muscle energy technique can be accomplished easily.
Place the patient’s ipsilateral arm into abduction to emphasize the appropriate rib, then horizontal abduction until pressing from P to A no longer elicits tenderness, or only minimal tenderness, with increased rib mobility to P-A glide. Ask the patient to raise the ipsilateral elbow up into horizontal adduction and hold 6 seconds. Reposition the elbow toward the barrier (horiz. add). Repeat contraction, reposition, for a total of 3 repetitions.

Medially-Compressed (2nd) Rib Treatment

This condition I named “camper’s rib” from the idea that a camper sleeping on hard or rocky ground, could compress a rib. Although no patient has ever admitted to this mechanism, I persist in my delusion. You will find a hypomobile rib which is prominent both anteriorly AND posteriorly, with reduced mobility in both A-P and P-A glide (making standard single plane technique less effective as a treatment).

Treatment for this fairly common condition can be done functionally, by applying a medially-directed compression force to the rib. Compress gently, using 3 plane shoulder motion, to find the appropriate plane to deliver the force so that the affected rib becomes more mobile and painless to A-P and P-A compression. Hold for 90 seconds and release slowly. A forced expiratory effort (cough) can be used to supplement release, but usually isn’t needed.

Internally-Torsioned (2nd) Rib Treatment

Rib torsions are twists in the long axis of the rib, named according to displacement of the superior edge. If the superior edge twists inward, it is called an internal torsion. You will find a rib in which the inferior edge is prominent, the superior edge hard to palpate, with reduced mobility.

Treatment for this fairly common condition is easily done using muscle energy. Abduct the ipsilateral arm at the shoulder to focus on the appropriate rib.
Rotate the ipsilateral shoulder externally until the rib becomes more mobile. Ask for an isometric contraction of the shoulder internal rotators. Repeat twice more, each time slightly increasing shoulder internal rotation positioning prior to contraction.

Externally-Torsioned (3rd) Rib Treatment

Rib torsions are twists in the long axis of the rib, named according to displacement of the superior edge. If the superior edge twists outward, it is called an external torsion. You will find a rib in which the superior edge is prominent, the inferior edge hard to palpate, with reduced mobility.

Treatment for this fairly common condition is easily done using muscle energy. Abduct the ipsilateral arm at the shoulder to focus on the appropriate rib.
Rotate the ipsilateral shoulder internally until the rib becomes more mobile. Ask for an isometric contraction of the shoulder external rotators. Repeat twice more, each time slightly increasing shoulder external rotation positioning prior to contraction.

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