First Rib Fixation by Dr. Perry Nickelston

Case scenario #1: Patient X presents with chronic left sided trapezius muscle spasm and mid-back pain. Previous chiropractic, physical therapy and massage treatment has provided minimal results. Case scenario #2: Patient Y presents with chronic shoulder pain. Surgery, physical therapy and chiropractic temporarily alleviated symptoms, but it has returned worse than ever. Case scenario #3: Patient Z presents with chronic cervical pain and radiculopathy into the left upper extremity. MRI results are normal and manipulation of the cervical and thoracic spine has been unremarkable.

How can you help these patients? What are you going to do differently than all the other healthcare providers who treated these people? I’ll tell you. Look outside the proverbial box for a First Rib Fixation Syndrome. A majority of doctors will overlook this syndrome as part of their initial examination and diagnosis. This is unfortunate because an elevated first rib can cause a myriad of symptoms and complications, leaving a patient to suffer unnecessarily for years.

Possible Symptoms:

· Trapezius Spasm

· Neck Pain

· Headaches

· Shoulder Pain

· Radiculopathy

· Jaw Pain

· Mid-back Pain

· Paraesthesia

· Chest & Sternal Pain

Anatomy and Mechanics

The primary components of the supraclavicular notch and muscular attachments to the first rib include: the anterior and medial scalenes, subclavius and serratus anterior. At risk of compression with an elevated first rib are the Sublavian artery and the three trunks of the Brachial Plexus.

Secondary kinetic movement muscles of the syndrome include: the pectoralis major/minor, sternocleidomastoid, trapezius, infraspinatus, subscapularis, supraspinatus, rhomboid major/minor, serratus posterior superior and the levator scapulae.

A superior rib develops in a person affected by a muscular imbalance condition known as ‘The Upper Crossed Syndrome.” In this syndrome, the subscapularis and infraspinatus are loaded with trigger points, resulting in weakness and the inability to keep the humeral head externally rotated and inferior. The humeral head translates superior and anterior affecting the acromioclavicular joint and sternoclavicular joint pivot mechanics. The cervical spine becomes kyphotic and the patient develops rounded shoulders and a hyperkyphotic thoracic spine. The scalenes, serratus anterior and sternocleidomastoid over compensate and develop active trigger points. Referred pain from these trigger points manifests as new and erratic symptoms. Due to the attachment of these spastic muscles on the first rib, superior elevation occurs. The trapezius has an instant reflex guarding mechanism and goes into tightness and spasm. Compression of the brachial plexus and subclavian artery may now cause Thoracic Outlet Syndrome.

Evaluation and Treatment

90% of your diagnosis should come from the patient history. Your examination is designed to confirm your diagnosis. During the patient history ask about sleeping habits. Elevated first ribs typically occur in patients that are stomach sleepers. They may sleep with one arm tucked under their head, or sleep with minimal or multiple pillows. Extensive work in front of computers and the use of a mouse may result in micro-traumatic contracture of the trapezius muscle. Patient will complain of constant dull achy pain and tightness in the trapezius muscle.

Hyperflexion/hyperextension injuries usually have a rib involvement. First Rib Syndrome is mandatory for evaluation in all athletes, particularly tennis players and weight lifters. Almost every athlete is affected by one component of the syndrome. This should be a mainstay of your clinical evaluation in athletes.

During examination palpate the supraclavicular notch for tenderness, spasm, and edema. A patient will inherently pull away when you touch an elevated first rib. Look for the ‘Jump Sign.” You will find active/latent trigger points in almost all of the muscles listed above, particularly the scalenes, SCM, and infraspinatus. X-ray the patient’s cervical spine with AP, lateral, and oblique views to rule out a possible cervical rib involvement.

Following are a list of therapies that are effective for treatment. A combination of all gives you greater success in clinical outcomes.

(Note: Therapy techniques are recommended prior to any manipulation)

· Laser therapy of the supraclavicular notch and all primary trigger points. Recommended dosage of 500 Joules in the notch and 250-500 Joules per trigger point. The cervical spine may need laser for relaxing the multifidus stabilizer muscles allowing for a more effective and longer lasting adjustment by reducing ‘muscle memory splinting’ reaction.

· Soft tissue mobilization per your technique (MFR, PNF, ART, TPT, etc) on all the muscles listed above. Pay close attention to the anterior, medial, posterior scalenes and the pectoralis major/minor.

· Manipulation (adjustment) of the first rib. Speed is of utmost important. Take a scissor stance on the opposite side of the rib involved. Laterally flex head to the involved side and find the tension point. Line of drive is superior to inferior and lateral to medial, towards the inferior angle of the opposite scapulae. Use a slight body drop and elbow torque with the contact hand to increase speed.

· Adjustments of the cervical and thoracic spine per your technique.

· EMS and heat of rhomboids and serratus posterior superior.

· Scapular retraction exercises. 3 Sets of 15-20 reps daily with resistance bands.

· Self Myofascial Release with Biofoam Rollers on the shoulder posterior capsule and thoracic spine 3x per week.

· Stretching of the pectoralis muscles.

· Revision of sleeping habits. Prescribe a cervical pillow and exercise bands.

By taking a little extra time to investigate areas outside the focal point of pain you can have a profound impact on a patient’s quality of life. Remember, if you chase pain you will forever be lost. Now you can be the one physician who gets to the root cause of a problem. Your patient’s will thank you for it. I know I would!