Expert: Dr. J. Shawn Leatherman - 10/21/2006

Question
before i did ask you the question below. thanks very much. after 2 chiro treatments it did go away. but now 2 months later it has come back the pain in the area. Now you did say  to do postural exercises and stretching of the associated musculature. Well as this could be chronic just what can i do in way of exact stretches and strenghten excersizes for the area. Ive tried almost every conceivable rotator cuff excersize with large bands and shoulder retrations and scap pushups. nothing seems to help as the rib is in the wrong place. i guess they may be good once the rib is put back into the correct place. even trying all kinds of stretches i just cant get it back to where it belongs. now i can keep going back to the chiro but where i live he is very far and expensive. what the chrio did to help the situation was my guess a sort of form of ART active release technique where his thumb or finger was pressed on the 1st rib joint and his assistants swung my one arm freely from fully contratced to fully extented. then afterwards went on to the adjustment bed and he lined up upper back with the raised part of the bed that moves up and down and physically pushed my uppper back up and down. now i have tried to replicate this ART that he did but i just cant get it to help. what i can get which the chiro did get was the clicking of the 1st rib when the arms is going from fully contracted to fully exteneded.  when he did the ART he put the 1st rib back into the right place and stoped the clicking. that is the part that i am unable replicate. Well please could you give me some suggestions. thanking you in advance.

Question
i have researched extensively on the back and and  shoulder problems that can occur. i was having sometimes pain near the medial scapula and long head of the bicep. i have done many many different planes of excersizes with the bands to try and stenghten or increase the endurance of the rotator cuff muscles. i was almost sure that i did have the labrum torn somewhat from the symptoms. As also no matter what i did try to increase the rotator cuff the problem remained. even when i got rid of all overhead presses. But to my surpise when i went to the chiro he told me that he does not think it is the labrum but the first rib that is out position. I have never came across this. Have you and do you believe that could be the cause? and Just what kind of movements would of caused this? thanking you in advance.

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Answer
Dear JII,

The first rib can absolutely be a souce of pain and dysfunction when it becomes fixated, or the joint becomes irritated.  The anatomical connections are diverse because it joins with the 1st thoracic vertebra in the upper back, and joins with the manubrium of the sternum on the upper chest.  Not to mention that it also has numerous myofascial connections such as the scalene muscles which integrate it with neck movements  

The rib is classified as an atypical rib becuase of its differences in shape and articulation.  It is the broadest, shortest and most sharply curved off all the ribs.  It also has a very close relationship with the subclavian artery and the brachial plexus which supplies all the nerve function to the arms, the shoulder, and some to the upper back.  

I find that many athletes and active/fit patients that I treat have first rib fixations.  Symptoms can be diverse such as dizziness, tingling in the arms, cold hands/fingers, pain in the arms, upperback, shoulder and upper chest.  Most of the time, 1st rib fixation problems get immediate relief in symptoms after the first adjustment, which is a confirmation of the problem.  Sometimes the area is chronic and multiple treatments are needed to resolve the issue.

Although there is no definite cause to pinpoint for the problem, there are factors that contribute, such as:  forward head posture, throwing sports, rounded shoulders, hunched forward posture, tight pectoralis musculature, and tight anterior scalene musculature.  The best fix to the problem is the adjustment and postural exercises and stretching of the associated musculature.  In addition, any deformity or prior injury of the collar bone (clavicle) can have a contributing negative effect on the first rib due to their anatomical proximity.  {The clavicle rests directly above the first rib at the manubrium of the sternum.}

Concerning your possible labral tear, the only way to definitively diagnose the problem is with an MRI of the interior shoulder joint.  There are orthopedic tests that can be performed to aid in the evaluation, but the MRI is the gold standard for imaging and diagnosis.  Also if you do have a labral tear, rotator cuff exercises will help to stabilize the joint, but they will not fix the problem.  You may need to have the shoulder scoped by an orthopedist in surgery to remove any debris and/or repair damage.  

If the tear is small, then nutritional considerations such as glucosamine HCL/sulfate, chondroitin sulfate and methylsulfonylmethane(msm), will help the body repair the labrum, and you should rest the area...no heavy activity or workouts for a period of at least 6 weeks.

Please feel free to follow-up with any further comments or questions.

Respectfully,
Dr. J. Shawn Leatherman  

Answer
Dear Jii,

Unfortunately you are not going to be able to replicate the ART.  You would need an additional set of hands to be able to accomplish that.  In addition, you may be able to get the rib to make a poping sound, but that is not an adjustment.  The articulation of the rib head and two adjacent vertebra has complex biomechanics, and when the chiropractor adjusts the area he does so in a manner that works with the normal lines of movement in the joint space. I would recommend that you go back to the chiropractor and have the joint addressed appropriately.

As far as the exercises are concerned, you are on the right track with the scap push-ups, shoulder retractions and rotator cuff exercies...although I am pretty sure your rotator cuff is not the problem.  Include some stretching for the pec minor and pec major muscles.  This is easily accomplished in a doorframe with the arms straight out, and then elevated at approximately a 45 degree angle to focus on the pec minor.  This will help alleviatre stress on the rib head due to any muscle imbalance.  

In addition, you probably have tight anterior and middle scalene muscles which are contributory to the problem.  Those muscles are located on the front of the neck, so lying flat on your back with your head over the end of a table or bed will help to stretch them.  As you do this rotate your head slightly to each side..about 45 degrees.  If you can work up to 20 minutes in this position daily.  I would aslo ask your chiropractor about any specific imbalances he found upon examination that may need to be addressed.

I know you were hoping for some more do-it yourself types of things, but when it comes to rib problems, they can be hard to get a handle on, and it may take a week of care every month or so for a few months to get the problem under control.

Respectfully,
Dr. J. Shawn Leatherman