Case 1: Patient X presents with chronic left-sided trapezius spasm and mid-back pain. Previous chiropractic, physical therapy and massage treatment provided minimal results.
Case 2: Patient Y presents with chronic shoulder pain. Surgery, physical therapy and chiropractic temporarily alleviated symptoms, but the pain has returned worse than ever.
Case 3: Patient Z presents with chronic cervical pain and radiculopathy into the left upper extremity. MRI results are normal and manipulation of the cervical and thoracic spine was unremarkable.
How can you help these patients? What are you going to do differently than all the other health care providers who treated these people? Look outside the proverbial box for a first-rib fixation syndrome. A majority of doctors will overlook this syndrome as part of their initial examination and diagnosis. This is unfortunate because an elevated first rib can cause a myriad of symptoms and complications, leaving a patient to suffer unnecessarily for years.
Symptoms of First-Rib Fixation Syndrome
Anatomy and Mechanics
The primary components of the supraclavicular notch and muscular attachments to the first rib include: the anterior and medial scalenes, subclavius and serratus anterior. Secondary, kinetic movement muscles of the syndrome include: the pectoralis major/minor, sternocleidomastoid, trapezius, infraspinatus, subscapularis, supraspinatus, rhomboid major/minor, serratus posterior superior and the levator scapulae.
A superior rib develops in a person affected by a muscular-imbalance condition known as the upper crossed syndrome. In this syndrome, the subscapularis and infraspinatus are loaded with trigger points, resulting in weakness and the inability to keep the humeral head externally rotated and inferior. The humeral head translates superior and anterior, affecting the acromioclavicular joint and sternoclavicular joint pivot mechanics. The cervical spine becomes kyphotic and the patient develops rounded shoulders and a hyperkyphotic thoracic spine. The scalenes, serratus anterior and sternocleidomastoid overcompensate and develop active trigger points. Referred pain from these trigger points manifests as new and erratic symptoms. Due to the attachment of these spastic muscles on the first rib, superior elevation occurs. The trapezius has an instant reflex-guarding mechanism and goes into tightness and spasm. Compression of the brachial plexus and subclavian artery might now cause thoracic outlet syndrome.
Evaluation and Treatment
Ninety percent of your diagnosis should come from patient history. Your examination is designed to confirm your diagnosis. During the patient history, ask about sleeping habits. Elevated first ribs typically occur in patients who are stomach sleepers. They might sleep with one arm tucked under their head or sleep with minimal or multiple pillows. Extensive work in front of computers and the use of a mouse may result in micro-traumatic contracture of the trapezius. Patients will complain of constant dull, aching pain and tightness in the trapezius.
Hyperflexion/hyperextension injuries usually have a rib involvement. First-rib syndrome is mandatory for evaluation in all athletes, particularly tennis players and weight lifters. Almost every athlete is affected by one component of the syndrome. This should be a mainstay of your clinical evaluation in athletes.
During examination, palpate the supraclavicular notch for tenderness, spasm and edema. A patient will inherently pull away when you touch an elevated first rib. Look for the "jump sign." You will find active/latent trigger points in almost all of the muscles listed above, particularly the scalenes, SCM, and infraspinatus. X-ray the patient's cervical spine with AP, lateral and oblique views to rule out a possible cervical rib involvement.
The following is a list of effective treatment therapies. A combination gives you greater success in clinical outcomes. (Note: Therapy techniques are recommended prior to any manipulation.)
By taking a little extra time to investigate areas outside the focal point of pain, you can have a profound impact on a patient's quality of life. Remember, if you chase pain, you will forever be lost. Now you can be the one physician who gets to the root of a problem. Your patients will thank you for it.
When sports chiropractors first appeared at the Olympic Games in the 1980s, it was alongside individual athletes who had experienced the benefits of chiropractic care in their training and recovery processes at home. Fast forward to Paris 2024, where chiropractic care was available in the polyclinic for all athletes, and the attitude has now evolved to recognize that “every athlete deserves access to sports chiropractic."
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Some doctors thrive in a personality-based clinic and have a loyal following no matter what services or equipment they offer, but for most chiropractic offices who are trying to grow and expand, new equipment purchases help us stay relevant and continue to service our client base in the best, most up-to-date manner possible. So, regarding equipment purchasing: should you lease, get a bank loan, or pay cash?
