The print version of this article is in the JACA (Journal of the American Chiropractic Association), summer 2005 Issue. Note: The host location for this article is being phased out. For up to date info about Dr. Lew including new articles about Painful Shoulder, Scoliosis, Low Back Core Strengthening Exercises, Ice Therapy (cryotherapy), and more, please go to
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Dr. Makani Lew, BSc, DC
Professor at Palmer College of Chiropractic, West Campus, San Jose, CA
Web page revised 5/11/2014
The Elusive (and Painful) First Rib
By Dr. Makani Lew, DC
The first rib can be one of the most aggravating subluxations for a patient and occasionally the chiropractor. The purpose of this article is to ameliorate the annoyance for both.
A first rib patient will present in your office with some rather interesting findings. She will be experiencing persistent, nagging pain. She will point to the area just in front of the trapezii and complain while shrugging her shoulder area, as if to “writhe out" the discomfort. Her complaints will often include a variety of issues such as:
"Something's not right in my shoulder."
"Something catches when I move my arm."
“My shoulder feels achy.”
"I feel tingling down the arm + in my shoulder"
"My fingers go numb."
"It hurts in the angle at the base of my neck."
"It hurts when I sleep on that side"
"I can’t seem to take a deep breath."
Figure 1: The pain is anterior to the middle trapezius and posterior to the clavicle, deep in the shoulder “pocket”.
We need to make sure to rule out (or in) the first rib subluxation when the patient complains of a myriad of other complaints, since it is frequently confounded with them: neck pain, headaches, carpal tunnel syndrome, chest pain, rhomboid pain, upper and middle thoracic pain, elbow, wrist, and hand pain, and clavicular pain.
Figure 2: Many other problems may actually be relieved by addressing the first rib subluxation.
The plethora of events that could lead to the first rib subluxation includes, but is not limited to: writing a lot (student syndrome); gardening; cooking that involves a lot of whisking; working at a desk, using a mouse or keyboard for too long of a time (especially if the seat is too low and the shoulder has to shrug to use the mouse); playing computer, video and handheld games; sleeping on the side with too small of a pillow; and driving in terribly bothersome traffic.
Evaluating the Rib
Evaluating the first rib often involves finding a position where the doctor is able to sneak past the irritated trapezii and scalenes. This is done by adding a little laxity to the muscles by bending the head toward the involved side and palpating through the little pocket that this creates. Pushing superior to inferior will reveal a very hard bony feel that the patient reports as very tender. On some patients, palpation may suggest that both of the first ribs are subluxated superiorly, but one is reported as more tender. Start by adjusting the more tender of the two but don't hesitate to adjust the other side if it still feels tender after the first adjustment. Lastly, a very superior first rib may turn out not to be a matter of subluxation at all, but rather a cervical rib.
If you move the patient's head about, you can check for superior movement of the rib during ipsilateral rotation. You can check for inferior movement of the rib by applying contralateral rotation, but it's hard to feel through the taut muscles and might cause further irritation of the surrounding musculature.
The First Rib Adjustment
Now that you have found this offending rib, it's time to adjust it. I've used several adjustments and here are my preferred approaches.
One move is supine and the other is prone. Both moves are set up very similarly, involving laterally flexing the head to same side and slightly rotating away from the superior first rib. I have noticed that the patient is more relaxed and easier to stabilize while performing the prone move, which is therefore preferred. The stabilization hand presses lateral to medial on the opposite side, bracing the side of head and some of the postero-lateral aspect of the neck. Both moves use a doctor's contact point of the proximal interphalangeal joint of the index finger on the superior first rib along with the web of the hand contacting the surrounding area. The thrust is superior to inferior and lateral to medial. I would suggest thrusting toward the patient's inferior angle of the scapula on the opposite side. The thrust is quick and gentle, using the cushion of the softened and lax trapezius and the web of the doctor's hand to soften the impact.
Figure 3 illustrates the prone move on a superior left rib. The picture in the forefront shows the adjusting hand and the rear picture in the mirror shows the stabilization hand.
Other Important Tidbits
I find that this adjustment is so effective, that treatment success may be achieved in as few as one or two visits. However, because of the tenderness factor, the doctor generally gets only one chance to perform this maneuver satisfactorily, so a succinct thrust is essential. If the patient truly has a superior first rib, is relaxed, and the doctor's line of drive is well directed, the rib will sink back into the wonderful feeling of normal position and function. If it doesn't go as well as that, there may be other adjustments and soft tissue work that need to be done in related anatomical areas. The other associated subluxations include the superior clavicle, the anterior-superior humerus, and C7 or T1 subluxations. Lastly, it's important to note that the first rib subluxation may also be associated with the first signs of a common cold. Because of the lymphatic drainage that can create tenderness just inferior to the medial aspect of the clavicles, there is sometimes an overall malaise in the area that might mask or be complicated by a superior first rib.
Good luck and go forth to save the world, one rib at a time.
Dr. Makani Lew, DC is a faculty member at Palmer of Chiropractic West and teaches in the technique department. Contact by email: Makani.Lew@palmer.edu
Rollis, C. Costovertebral Adjusting Is a Reality.
Dynamic Chiropractic - May 20, 1994, Volume 12, Issue 11
Peterson D, Bergmann T. Chiropractic Technique: Principles and Procedures, 2nd Ed., St Louis, 2002, Mosby.
Private Practice: Santa Cruz, California