The 1st rib is not just the distant obnoxious uncle you see at reunions, but actually may be the disgruntling next-door neighbor you have to deal with everyday.  In conventional terms, it is usually involved in cervical, thoracic, and upper extremity pain more often than you think.

This is not just my opinion, but has been substantiated in the literature over the years via a few sources:

Shoulder pain here and here

Neck/Upper trapezius pain here

Thoracic Outlet Syndrome here, here, and here

Referral pain here and here

From a surgical standpoint, I wouldn’t delve into resection of the first rib to fix all problems but from our standpoint, its really a no-brainer.  We can assess and treat the mobility of the first rib with quite amount of ease.

A detailed anatomy lesson and comprehensive background of this region is outside the scope of this post but can be found elsewhere here and here.  In all reality, we assess this region with all of these patients with above complaints but may not think we are assessing the first rib.  We should. This post satisfies the latter.

The mobility of the first rib is not that difficult but must be careful that you are actually assessing the mobility of the first rib and not just the awkward trigger points that face the upper trapezius.  Be sure you have “peeled” back the fibers from trapezius ridge and feel the mobility, or most likely the lack of.  Involvement of the first rib can be assessed through the following:

1. Cervical Rotation Lateral Flexion Test (for elevated first rib in particular)

2.  1st Rib Spring Test Supine (I use it for mobility rather than capability of neurovascular bundles)

I find assessing the joint play in supine to be more effective.  The patient seems more relaxed and can actually detect mobility differences side-to-side.  Some sources will show it sitting or prone. Also, you can delve right into a treatment approach this way too.  Choose what works best for you.

For the sake of shortened discussion here, I did not appraise other problems that are usually present.  Simple conclusion is that if one segment is affected, restriction of an adjacent is very expected.  Myogenic issues include the scalenes, levator scapulae, pectoralis minor, serratus anterior, etc.; and arthrogenic issues include mobility of the AC joint, SC joint, end-range GH  joint, cervical and thoracic spine.   As you can imagine, the posts could get as long as a famous Leo Tolstoy novel.  Just keep in mind the first rib with dealing with these issues, as I am sure you will not be disappointed in the results.

As always, I’ll entertain your comments and suggestions.


  1. Harrison, good read here.

    I have a query. Why are you testing the first rib (supine) using a caudal glide? WIth contralateral rotation and side-flexion, the rib is supposed to move superiorly or cranially. It follows the cervical spine, where by ipsilateral side-flexion and ipsilateral rotation tends to move the facet joint inferiorly (medially and posteriorly)

    Let me know please.

    1. Hey Carl,
      Great comment! I am simply assessing the mobility of the rib in the inferior/caudal direction with the spring test. If it doesn’t have the accessory/joint play, it will glide superiorly/cephalically with the motions you mentioned, particularly lateral flexion in contralateral direction.
      This is why the “upper trap” stretch is not my favorite with neck patients as if the rib is not mobile (hypomobile), then the stretch will actually lift it up further (through the pull of the scalenes).

      This test is similar to assessing mobility at the cervical spine using lateral glide test; it is simply examining the joint dysfunction.

      Does this answer your question?

  2. Harrison,
    I think this is a good discussion starter on first rib. I also agree that springing the rib for hypomobility is a good way of scanning first rib function. Of course, your post just covers a part of a good upper assessment. Good videos too.


    1. Thanks for the comments Braedan. Definitely just a general assessment here.
      If you have any further detail that you find clinically relevant, please share. I would love to learn more.


  3. Harrison,
    Good article. I am a student and just saw an eval w/ first rib involvement in thoracic outlet syndrome. Is it possible that the cranial glide could be limited while the caudal glide is normal? Also, should you always check the thoracic spine involvement, specifically T1/2 facet joints to see if that has to do with an elevated first rib?

    1. Tim,
      My thoughts on the caudal vs cephalic glide is how do we treat it. Without making arthrokinematic specialists upset, I bet (but don’t know of any evidence off top of my head) that if you provide a caudal glide to fix a cephalic block, then you will get results. Its just easier as the practitioner and patient due to the hand placement needed between the two to get results (using heel of hand with larger surface area on superior aspect vs a more lumbrical grip on inferior aspect).

      I would absolutely check T1-2. Highly likely multiple joints are involved. Good point.


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