Case scenario #1: Patient X presents with chronic left sided trapezius muscle spasm and mid-back pain. Previous chiropractic, physical therapy and massage treatment has given minimal results.
Case scenario #2: Patient Y presents with chronic shoulder pain. Surgery, physical therapy and chiropractic temporarily alleviated symptoms, but it has returned worse than ever.
Case scenario #3: Patient Z presents with chronic cervical pain and radiculopathy into the left upper extremity. MRI results are normal and chiropractic manipulation of the cervical and thoracic spine has not helped.
How can you help these patients? What are you going to do differently than all the other healthcare providers who treated these people? I’ll tell you. 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.
Possible Symptoms:·
Trapezius Spasm·
Neck Pain·
Headaches·
Shoulder Pain·
Radiculopathy·
Jaw Pain·
Mid-back Pain·
Paraesthesia·
Chest & Sternal Pain
Anatomy and Mechanics
The primary components of the supraclavicular fossa and muscular attachments to the first rib include: the anterior and medial scalenes, subclavius and serratus anterior. At risk of compression with an elevated first rib are the Sublavian Artery and the three trunks of the Brachial plexus.
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 problem 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 acromioclavisular joint and sternoclavicular joint mechanics. The cervical spine becomes kyphotic and the patient has forward head carriage resulting in rounded shoulders and a hyperkyphotic thoracic spine. The scalenes, serratus anterior and sternocleidomastoids over compensate and develop trigger points. Referred pain from these trigger points manifest new symptoms. Due to the attachment of these 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 may occur leading to Thoracic Outlet Syndrome.
Evaluation and Treatment 90% of your diagnosis should come from the patient history. Your examination is designed to confirm your diagnosis. During your patient history ask about sleeping habits. Typically, elevated first ribs occur in patients that are stomach sleepers, they may sleep with one arm tucked under their head, or sleep with multiple pillows. Extensive work in front of computers and the use of a mouse may result in micro-trauma to the trapezius muscle. Hyperflexion/hyperextension injuries usually have a rib involvement. First Rib Syndrome is mandatory for evaluation in all athletes, especially tennis players and weight lifters. Almost every athlete is affected by one component of the syndrome. This should be a mainstay of your clinical evaluations. During examination palpate the supraclavicular fossa 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.Following are a list of therapies that are effective for treatment. A combination of all gives you greater success in clinical outcomes.
· Laser therapy of the supraclavicular notch and all primary trigger points. Recommended dosage of 500 Joules in the notch and 250-500 Joules per trigger point. The cervical spine may need laser for relaxing the mulitifidi stabilizer muscles allowing for a more effective and longer lasting adjustment by reducing the ‘muscle memory splinting’ reaction.
· Soft tissue mobilization per your technique (MFR, PNF, ART, TPT, etc) on all the muscles listed above. Pay close attention to the anterior, medial, posterior scalenes and the pectoralis major/minor.
· Manipulation (adjustment) of the first rib. Speed is of utmost important. (See photo)
· Adjustments of the cervical and thoracic spine per your preferred technique.
· EMS and heat of rhomboids and serratus posterior superior.
· Scapular retraction exercises. 3 Sets of 15-20 reps daily with resistance bands.
· Self Myofascial Release with Biofoam Rollers on the shoulder posterior capsule and thoracic spine 3x per week.
· Stretching of the pectoralis muscles.
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 cause of a problem. Your patient’s will thank you for it.
Dr. Perry Nickelston is VP of Practice Development for K-Laser,USA and Clinic Director of The Pain Laser Center, LLC in Ramsey, NJ. He may be contacted at www.k-laserusa.com, pnickelston@k-laserusa.com, or 1-866-595-7749 Ext. 102.
Tags: Integrative Treatment Strategies, Class 4 Laser Therapy, General by Dr. Perry
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