First Rib Assessment | 1st Rib Hypomobility Examination

Assessing the first rib can be useful when evaluating thoracic outlet symptoms or pain in the region of the cervicothoracic junction.
Fjellner et al. (1999) report low reliability for range of motion assessment of the first rib with a weighted kappa of .06 only.
There are several ways to assess the first rib:

Sitting position

The patient sits on the bench while you will stand behind them. The patient can rest against your thigh. Locate T1 for orientation and rotate the patient’s head towards the side you want to examine, which will bring the first rib backward and make it more accessible. Add lateral flexion to slacken the trapezius muscle and fixate this position by placing your elbow on the patient’s sternum. Then place your MCP 1 on the first rib and assess mobility by gently pushing into caudal, ventral, and medial direction. Or in other words: pushing towards the contralateral Anterior superior iliac spine. Assess end-feel, possible reproduction of symptoms, and compare with the other side.

Supine Position

The patient lies in supine position slightly diagonal on the treatment table. Rotate the head towards the side you want to evaluate as this will bring the first rib posteriorly and thus more accessible for palpation. Brace the cervical spine with one hand applying slight traction at the occiput.

Then place your MCP 1 flat on the rib and lock your hand against your pelvis. Then initiate a ventral, caudal and medial force with your body to assess movement of the first rib including end-feel and possible reproduction of symptoms.

Similarly, this same technique can be done with a cross grip.

Prone position

The patient lies in prone position slightly diagonal on the treatment table. Rotate the head towards the side you want to evaluate as this will bring the first rib posteriorly and thus more accessible for palpation. Brace the cervical spine with one hand applying slight traction at the occiput.

Then place your MCP 1 flat on the rib and lock your hand against your pelvis. Then initiate a ventral, caudal and medial force with your body to assess movement of the first rib including end-feel and possible reproduction of symptoms.

Similarly, this same technique can be done with a cross grip.

21 OF THE MOST USEFUL ORTHOPAEDIC TESTS IN CLINICAL PRACTICE

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Another way to assess for hypomobility of the first rib is the cervical rotation lateral flexion test.

If you are curious to learn more about joint play assessment &  treatment of the costotransversal joints, click here.

Fjellner, A., Bexander, C., Faleij, R., & Strender, L. E. (1999). Interexaminer reliability in physical examination of the cervical spine. Journal of manipulative and physiological therapeutics, 22(8), 511-516.