How to Put the 1st Rib Back into its Rightful PlaceJune 6, 2011 14 Comments
In this blog post you’ll learn how to put a superior 1st rib back into place with PNF (Proprioceptive Neuromuscular Facilitation), a technique that involves passive stretching and isometric contractions on a muscle or group of muscles. This is a rib technique that I’ve used in my practice many, many times. It’s helped my client’s quickly get over a nagging, stabbing, numbing, debilitating, and/or paralyzing pain in their arm, shoulder, upper back, chest and/or neck. A simple 1st rib out of place can put a person out of work and on the couch or in bed for weeks and months on end. Even breathing becomes difficult.
Part 1 : Anatomy
To know the anatomy is crucial when understanding why the 1st rib can cause so much discomfort in a person when it’s not in place or, in other words, when it’s being pulled superior (usually from the anterior and middle scalene muscles).
When the 1st rib is pulled closer to the clavicle (superior), it pinches a network of nerve fibers called the brachial plexus, creating an entire pattern of pains and limitations in the shoulder, arm, upper back, chest and/or neck. The pattern is very similar to the patterns that scalene trigger points present, which can also be created because of an issue with the 1st rib. Easing the 1st rib back into place creates more space between the clavicle and rib, deactivating chronic trigger points in the anterior, middle, and even the posterior scalene muscles, and taking the pressure off of the brachial plexus. This alleviates the pains and limitations that the client is experiencing in the areas described above.
The brachial Plexus (figure 1-1) is a set of nerves coming out of the lower cervicals and upper thoracics (C4 – T1 or T2), passing between the upper ribs and clavicle, and connecting to muscles in the arm, forearm, and hand. Some of the nerves that are in the brachial plexus are the ulnar nerve, radial nerve, median nerve, axillary nerve, pectoral nerve, subscapular nerve, and nerves that attach to the scalenes. All of these nerves, when pinched or irritated, limit arm movement, rib inhalation and exhalation, and range of motion in the neck via pain, tightness, numbness or weakness.
Part 2: Assessment
When a client walks into your office with a complaint identical or similar to the pattern of pain described above, have them take a seat or sit on the massage table and check their 1st rib. It’s a simple four step assessment test described below:
- 1. Stand behind the seated client and press your fingers or thumbs on the portion of the trapezius that’s slightly medial and posterior to the base angle of the neck (figure 1-2). You’re now on the superior angle of the first rib (figure 1-3).
- 2. Alternately press your fingers or thumbs downward with moderate pressure in a springlike fashion.
- 3. Perform step 2 three to five times in order to make a correct assessment.
- 4. Whichever side has less spring, exhibits pain, or feels elevated is the side that’s labeled as elevated or superior (which is most likely the side of the complaint).
Part 3: Active Technique – PNF (Proprioceptive Neuromuscular Facilitation)
Ribs 1 and 2
When the 1st rib is superior, the 2nd rib usually follows. The technique described below helps to bring ribs 1 and 2 less superior and back into place, taking pressure off of the brachial plexus and clavicle by easing up scalene tension:
- 1. With the client in supine position, stand on the opposite side of the targeted upper two ribs.
- 2. Client’s head is rotated 30 degrees towards the side you’re standing on.
- 3. The client’s posterior wrist, that of the opposite side of the you, is placed on the client’s forehead (figure 1-4).
- 4. Appropriately place your hand under the client, making sure to touch the client’s upper scapula on the opposite side of you, and press your fingers on the angle where the trapezius and base of the neck meet. This puts you on the superior angle of the first rib.
- 5. Gently pull the superior angle of the first rib, with moderate pressure, downward toward the client’s feet and in a lateral direction.
- 6. With the client’s head still rotated 30 degrees, place your hand on the client’s posterior wrist. Have the client flex the head and neck against your unyielding counterforce at 20 percent of the client’s strength (figure 1-5).
- 7. Step 5 is held for 5-8 seconds and after such time tell the client to relax.
- 8. After the client has relaxed for 1-2 seconds, gently pull the superior angle of the first rib downward toward the client’s feet and in a lateral direction again. Remember, every pull should be gentle and at the client’s comfort level. Very little movement to no movement should occur at each pull. The moment movement occurs, it can indicate that the 1st rib is almost in place or is in place.
- 9. Repeat this technique a total of five to seven times.
- 10. Reassess the targeted scalenes and ribs. If tension has eased in the scalenes or if client feels significant change and ease of tension, then the therapist should move onto the next step of the massage. If not, the therapist can repeat steps 1-8. In this case, step 9 then changes from five to seven times to one to three times.
I hope this helps you in your massage practice.
Also, to learn more, I’ve added my upcoming workshops to the website. They’re fun, informative, and full of advanced techniques to help your massage career bloom that much more. Check them out – Upcoming Workshops. It shows the dates, times, and how many continuing education credits you’ll receive when you attend one.
I know you’ll enjoy them.
Brandon Ellis, LMT
PS – The other ribs – 3 through 12 – can go out as well. If you are interested in learning those techniques, contact me at firstname.lastname@example.org as I teach classes specifically on rib techniques. I teach all over the Northwest. Contact me for a schedule.
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