How to Put the 1st Rib Back into its Rightful Place

June 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.

Brachial Plexus

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.

Figure 1-1

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. 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. 2.  Alternately press your fingers or thumbs downward with moderate pressure in a springlike fashion.
  3. 3.  Perform step 2 three to five times in order to make a correct assessment.
  4. 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).

Figure 1-2

Figure 1-3

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. 1.  With the client in supine position, stand on the opposite side of the targeted upper two ribs.
  2. 2.  Client’s head is rotated 30 degrees towards the side you’re standing on.
  3. 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. 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. 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. 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. 7.  Step 5 is held for 5-8 seconds and after such time tell the client to relax.
  8. 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. 9.  Repeat this technique a total of five to seven times.
  10. 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.

Figure 1-4

Figure 1-5

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 as I teach classes specifically on rib techniques. I teach all over the Northwest. Contact me for a schedule.

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14 Comments to “How to Put the 1st Rib Back into its Rightful Place”
  1. Liza says:

    Very informative and thank you, Brandon! This issue is so common it’s ridiculous :) Peace!

  2. Dee Jooyce says:

    Enjoyed reading this article!

    • admin says:

      Thank you Dee. I appreciate your comment. I’ve been away (booked with massages) from this website for a while. I’m going to be posting more and more articles on techniques very soon. So, come back when you can.

  3. Dee Joyce says:

    Misspelled my own name, lol, sorry!

  4. Tyler says:

    I’ve been having intense side-neck pain, collarbone pain, and jaw pain for three months. Sometimes it even tingles down into my elbow (ulnar nerve?). Other times it feels like the muscles are straining when I do something as simple as swallowing.

    I’m hoping that the method you described might be able to help someone like me! This is an inspirational article. Thank you!

    • admin says:

      Hi Tyler,

      You may also want to look into getting your scalenes worked on. They are a group of musles, in laymen terms, that originate on the side of the neck and insert on the upper two ribs. They can mimick carpal tunnel symptoms, thoracic outlet symptoms, nerve pain, frozen shoulder, so on and so forth – just like the pattern when the 1st rib is out of place. Find a massage therapist that knows how to work on your ribs, scalenes, infrahyoid muscles, and suprahyoid muscles (infra and supra should be worked on for your swallowing issues).

      Thanks Tyler,


      • Tyler says:

        Hi Brandon,

        Thank you for the tips. Just as I thought, you are a total genius! After just a few days of working on my neck muscles and one good massage session, I’m about 80% better – easily well enough to enjoy my life again. I hope that in a few more weeks, with dedicated stretching and massage, I’ll be back to normal.

        Thank you so much!

  5. Jessica says:

    Wonderful article, I can not wait to put this technique to use on my clients. Thank you so much for posting it.

  6. CHI says:


    My right rib hurt when I lay onmy back or stomach,It hurts when I breath in deep, when I reach out, drive,ect.ect.. I don’t remember hitting myself there, the only thing that comes to mind is, maybe i did it while lifting weights.. How do I know its outta place of fractured? I really don’t want to go to a doctor to get pain pill’s..

    • admin says:

      I would go to a skilled massage therapist who can assess the rib or to a Chiropractor/Osteopathic Doctor. A good indication that your rib is out of place is when you take a deep breath. If it hurts and feels like a knife is stabbing you in your back, i.e. a sharp pain, then it’s a good indication that your rib or ribs are out. I’d go to a skilled professional to get it put back into place.

      – Brandon

  7. CHI says:

    Hi Brandon,

    I actually went to a Chiropractor today, Yup its outta place.. So now my question is, How long does it take to heal from this? He said months, but i feel its just another way to drain my pocket with each visit.. So in reality, can he put it back in place with one visit or do i have to go numerous times?
    Thanks again..

    • admin says:

      Hi Chichi,

      Sorry I haven’t responded sooner. Everyone is different, so your healing time with the rib “just depends”. When a rib is out of place, it pushes on a nerve and sends pain throughout the area. In my experience, when my rib has been out and I’ve gone to a Chiropractor to get it put back in, it usually takes one to two times. If you continue to feel that pain though, then go in and see the chiropractor.

  8. Devon says:

    That totally worked!!! Thank you, got it back into place on the first try!!

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“Tension is who you think you should be. Relaxation is who you are.” - Chinese proverb