Rib Hypomobility and Shoulder Pain

Something I have been assessing more lately is rib mobility for my upper quarter patients. In the past, unless there were signs indicative of rib dysfunction, I typically only checked the 1st rib's mobility. Lately, I have been assessing ribs 2-4 (and further down if significant restriction noted) for many of my upper quarter patients and seen some interesting effects.

​Usually when we think of rib involvement, we think of pain with breathing and thoracic motions. While other tissues often have pain recreated with breathing as well, some recommend differentiating non-musculoskeletal pain from musculoskeletal by incorporating thoracic motions with holding one's breath. If the patient fully exhales ( deflating the lungs and providing less pressure on lung tissue), rotates and sidebends the thorax and pain is recreated, the pain is assumed to be coming from the ribs or thoracic spine or potentially muscles in the involved area. If pain is not present while moving the thorax with deflated lungs, the pain is assumed to be based in lung tissue. These rules may not be perfect, but can still be useful in differential diagnosis. 

Several patients I've seen recently with scapular and/or posterior shoulder pain have presented with restricted rib 2-4 mobility (or some variation). They didn't have any pain with breathing, however, had significant reduction in pain and improved mobility following simply grade IV mobilizations to the restricted ribs. Even greater improvement was noted in the following day. Now the mechanism is not fully understood as manual therapy can have quite a few different effects. It's possible the patient would have had just as effective or more effective response to other treatments. Nonetheless, with the excellent response by my patient, I plan on regularly incorporating upper rib assessment to determine if there are some patterns for application.

​-Dr. Chris Fox, PT, DPT, OCS

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