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Elevated 1st Rib

 
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Elevated 1st Rib - August 1, 2005 10:35:00 PM   
eam

 

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I was wondering if I could get some help on a patient I am treating. I think I need some new ideas as mine are not currently working at this point!
30+ female-Wall St Broker. 2 cc: bilateral upper back pain (t1-t3), intermittent, and seemingly unrelated posterior axilla and upper arm pain. Arm pain reproduced with "down dog" position in yoga and sometimes just sitting in her natural position.
Cervical ROM -WNL's except for some limitation with rotation right but pain free. Upper back pain reproduced with Cervical Extension/Rotation. Upper arm pain (R) not reproduced with cervical motion. A wicked elevated 1st rib, which I mobilized and the yoga position gets better. However, patient not able to carryover gains in treatment. She also has some limitations at C5-6 (R). Taking a deep breath also reproduces arm pain.
I have not checked ULTT yet-but I will next visit. and the patient still needs to make ergonomic changes to her office set up.
I have tried manual tx, stm to scalenes etc and mobs for c5-6, MET for the rib and does not seem to be helping. I don't believe it is disc or even facet joint related. I believe that the 1st rib is the problem (am open to new ideas!!) and was wondering if anybody had any other ideas for the rib etc. I tried to keep this brief, left alot out but will answer any question re: the eval etc.
Thanks!
Erica
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Re: Elevated 1st Rib - August 2, 2005 1:12:00 AM   
Synergy

 

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Erica,

Just a quick question. What method are you employing to mobilize the first rib? Can you tell me the technique your performing? I'm not saying anything to the effect of 'your technique is wrong'. I'm just curious. :)

When I come across a patient who appears to have an elevated forst rib, I usually treat it with several [read: 3 to 5] repetitions of METs...mainly autogenic inhibition (have tried reciprocal is A.I. didn't work). After these repetitions, I have found, and this is not the case all the time, that the first rib will either 'let go' on its own or if it doesn't, I immediately provide a quick downward thrust.

I actually did this to my wife about a year ago and felt/heard a cavitation. She had immediate relief and with some simple stretching exercises she has done well and no return of that nasty rib.

I'm curious to hear what everyone else has to offer as I am willing to try different methods.

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Re: Elevated 1st Rib - August 2, 2005 8:34:00 AM   
JLS_PT_OCS

 

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I agree with chris, I'd try the MET first and as a prelude to the manip.
I use the CRLF test to give me an idea if it's needed.
Erica- I like where you're going with the neurodynamic stuff, I was thinking that, too. I would try the ULTT with the radial, median, and ulnar biases to see if you can reproduce symptoms. I've had some good luck with neuromobs lately in some chronic patients. But then again, since I'm reading Shacklock's Clinical Neurodynamics, now I think EVERYONE has a neurodynamic problem! :)
Sounds like you're on the right track otherwise...

J

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Re: Elevated 1st Rib - August 2, 2005 8:40:00 AM   
eam

 

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Chris,
The technique I am using is a MET -patient seated -their arm resting on my knee-I am behind to the left of her-right cervical sb and rot right-then resist left sb. Like an inhibition for the right scalenes. I also perform a caudal glide in supine which I incorporate with breathing.
The more I think about the axilla pain-I wonder if she has any other rib issues. (I am fishing here! :) ) I also have only treated her twice plus a little on the evaluation. Although she has had this problem for some time now, I would think she would have some relief, even a little.
Thanks for your reply.
Erica

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Re: Elevated 1st Rib - August 2, 2005 8:52:00 AM   
eam

 

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Hi Jason-
I think you and I were typing at the same time here :) )! Interesting you mention the CRLF test. There is an artilce in Vol 13 Number 2 of The Journal of Manual and Manipulative Therapy- "Differential Diagnosis and Treatment of Chronic Neck and Upper Trapezius Pain and Upper Extremity Paresthesia : A Case Study Involving the Management of an Elevated 1st Rib and Uncovertebral Joint Dysfunction". Great article, by the way. They incorporated ULTT with rib mobs etc. I had never come across this CRLF test before, and this particular test was used as the definitive confirmatory test for this patient. So I tried it on my patient yesterday and she did have some limitation but not as much as I would have thought. I will try again Thursday.
I also have had great success with the ULTT in chronic patients. It seems that, at least for me , those techniques are the icing on the cake so to speak-the minute the neural mobility clears up-everything falls into place. :)
Erica

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Re: Elevated 1st Rib - August 2, 2005 9:23:00 AM   
Alex Brenner PT MPT OCS

 

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I guess I am fairly aggressive. I would manipulate this. There are two good methods that I know of.

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Re: Elevated 1st Rib - August 2, 2005 10:51:00 AM   
JLS_PT_OCS

 

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Alex-
Which techniques do you use?

I agree that if the pain is not acute and pnt can tolerate it, manip is I think a good bet. I have found personally that the MET helps about 30% of people anecdotally without need for the thrust, so in my acute people or those I don't want to stir up, I might use it only. Plus, I don't think I'm very good at the manip, so maybe that explains my preference. :)
J

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jasonsilvernail@gmail.com

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Re: Elevated 1st Rib - August 2, 2005 12:32:00 PM   
ehanso

 

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Strain Counter Strain for AR1-2 and AT 1-2-3. Not unsual in clients who sit and use keyboards.

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Re: Elevated 1st Rib - August 2, 2005 12:46:00 PM   
JLS_PT_OCS

 

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OK, I'll play along, what are AR1-2 and AT 1-2-3?

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Certified Strength and Conditioning Specialist
www.silvernailstudios.com
jasonsilvernail@gmail.com

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Re: Elevated 1st Rib - August 2, 2005 3:01:00 PM   
ehanso

 

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Jason, Sorry for the abrv. Terms developed by Larry Jones,DO for Strain CounterStrain. Anterior Rib 1&2, and Anterior Thoracics 1,2,3. Very simple treatment technique. In this case, I would follow up with some Rocabado exercises for upper cervical and thoracic rebalancing. Ed

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Re: Elevated 1st Rib - August 2, 2005 10:49:00 PM   
eam

 

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Thanks everyone for the replies.
Alex-what techniques would you use for this? I think she probably needs this-but frankly have never manipulated a 1st rib. At this point-the MET is just not working.
Also, not familiar with the SCS stuff either. Have the book-will check it out. (you can tell that I have not read it :) ). I cleared her thoracic spine out-don't think it is a contrib. factor. Ed-What do you do for upper cervical and thoracic rebalancing? I have my own set of tools am curious as to what others would do in this case.
Thanks!
Erica

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Re: Elevated 1st Rib - August 2, 2005 11:50:00 PM   
Synergy

 

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Erica,

I'm not sure of the technique Alex employs, but what I described above has been sufficient for me. I've found it difficult to take up all the planes of motion at the first rib to get a manipulation. I usually perform the MET to at least relax the involved muscles. If that doesn't reduce the rib, then immediately following the MET, I'll sidebend the patient's head towards the involved side, place the lateral border of my MCP on the proximal portion of the rib, and attempt a quick thrust.

I have to admit that I've only done this to a handful of people and it has worked the majority of the time. I'm very interested to see how your technique is performed Alex.

Hope this helps Erica! :)

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Re: Elevated 1st Rib - August 3, 2005 8:32:00 AM   
eam

 

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Chris-
I will try the MET again with the addition.
Ed-Also, I took a look at the SCS stuff and the 1st rib tech is somewhat similiar to the tech I am now employing with a slightly different bias.
Other ideas welcome! :)
Erica

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Re: Elevated 1st Rib - August 3, 2005 9:31:00 AM   
Shill

 

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All,
What are the current theories as to why or how the first rib becomes elevated, and how this is set apart from structural, non-clinically significant asymmetry? Ive always wondered, what if it has always been "elevated". I never palpated them before they had this "problem". I think we base too much on this area being tender.
What makes it go "out of alignment", and how to we propose to keep it "in whack"?
Ive now used my daily quota of quotes.
Not questioning anyones' techniques, just want to hear your thoughts.
Thanks,
Steve

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Steve Hill PT

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Re: Elevated 1st Rib - August 3, 2005 9:59:00 AM   
ehanso

 

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eam, I use Rocabado's routine and try to keep it real simple. Also deep neck flexors sometimes need attention. There was a thread about this earlier. I have even had patients stand and walk balancing a book on their head. Basic but requires good posture.

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Re: Elevated 1st Rib - August 3, 2005 5:23:00 PM   
srcase

 

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What is the CRLF test?

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Re: Elevated 1st Rib - August 3, 2005 6:12:00 PM   
Timothy

 

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Hi.
I may be completely off the mark here, but have you tested for/or considered Thoracic Outlet Syndrome?
Ciao,
Tim

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Re: Elevated 1st Rib - August 3, 2005 7:03:00 PM   
Dr.Wagner


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There are some really good osteopathic techniques for elevated first ribs (most of which have already been discussed)
I find the HVLA technique, if properly learned, is quite easy and extremely effective. It is my favorite to use.
Best of luck!

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Re: Elevated 1st Rib - August 3, 2005 9:18:00 PM   
eam

 

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Hi everyone,
Sarah-the CRLF test is contralateral rotation, lateral flexion test. I admit that I had not been exposed to that test prior to the article I mentioned above. Ed-I agree with the DNF and postural work. I like the book on the head deal. :)
Steve-I tried to make a differential diagnosis and felt that the rib was a significant contributory factor :) -I see alot of elevated ribs-do not always treat them as I feel sometimes it is not contributing to the patients problem. But in this case, it is too prominent to ignore. If I don't treat I would be doing the patient a disservice. I don't think that it is the be all and the end all of her problems. I personally think that the way she maintains her cerv spine while she is on the phone (she is a broker) and turning to the side to talk to her colleague is what needs to be changed and alot of her problems will be mitigated. Repeated movements like that on a daily basis over years, must be tiring on that poor neck of hers! :)
Tim-In addition to the ULTT that I will test on her tomorrow I will test for thoracic outlet. Her s/s did not prompt me to do that on the first couple of visits.
I will repost when I see her again.
Erica

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Re: Elevated 1st Rib - August 4, 2005 3:15:00 AM   
Alex Brenner PT MPT OCS

 

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Hi. There are two manipulation techniques that I have used with this condition. They are both on Tim-Flynn's CD-ROM Thoracic and cervical techniques. They are difficult to describe in a forum like this.

Jason and Erica,
The manipulation technique that I use most frequently is the one that Tim Flynn demonstrated at the spine course that Jason and I went to together. Jason, do you remember when Flynn and Wainner compared techniques with two separate students in the class who had elevated 1st ribs. Flynn referred jokingly to the technique as "Off with their head" due to the slight rotation that is administered. It is demonstrated well on the CD-ROM and I have best luck with this technique.

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Alex Brenner, PT, MPT, OCS

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