Diagnosing and treating a POSTERIORLY SUBLUXED RIB using MUSCLE ENERGY TECHNIQUE

When I started practicing as a physical therapist in 2002, and whenever I see a shoulder patient or a cervical patient, not once have I ever looked into the thoracic spine. And now, a very good clinician SHOULD examine the thoracic spine and go from there. Now, the thoracic spine is a looong topic  / area to discuss (don't even get me started on that) and my aim this week is diagnosing and correcting a Posterior rib.

A posterior rib can be found at the lateral part of the spine as you examine a patient through a thoracic screening. Depending on what author first started it, you can assess it through a clean sweep (brushing thru the lateral side of each thoracic spine and looking for "speed bumps") or prone by doing palpation on the rib cage (Thanks Jeff for the strain-counterstrain training on this!) A posterior rib can be very excruciating when found and can be a cause for a lot of trigger points around the area (typically rhomboids, levator scapulae and lower trapezius muscles). Causes of this can come from a high speed trauma (being rear ended while you're in a vehicle), prolonged use of one upper extremity (desk jobs a plus!), or someone slamming your back down like in MMA or Jiu Jitsu. (remember this Dewey!)

I also studied for the OCS and Tim Flynn's technique really is one of the most effective way of correcting this problem. Flynn recommends having the patient sit upright with the therapist standing behind the patient.
example: R POSTERIORLY SUBLUXED 6TH RIB

Patient's position and set up:
Sitting upright with the RUE across the chest (R hand holding on to the left anterior shoulder). Instruct the patient to push the tummy slightly forward to activate thoracic extension. Then have the patient actively bring the R scapula inferiorly (to add a slight R side bending to the thoracic spine. You should feel the rib translate anteriorly. 

Therapist: positioned behind the patient on the left side with the therapist's left hand on the patient's R elbow. Ask the patient to bring the elbow down and in (caudal and medial movements) and the therapist resists isometric contraction of this to activate the pectoral muscles to help translate the rib anteriorly. The therapist may add an antero-medially directed force using his R thumb on the posterior rib while doing the isometrics. Have the patient do 3 sets of 6 sec hold (even longer for some of my patients like 10 sec). The force of the Pectoralis major and minor muscles should be enough to translate the rib forward.

VARIATION: I have seen a technique done FORWARD AND MEDIALLY while the therapist provided an antero-medial force at the back. This one uses the Serratus Anterior to translate the rib.




I have done either of them on a patient and have achieved similar results. You should follow up with corrective thera-ex like rows, thoracic stretches (shoulder sweep or circles), Feldenkrais, etc... This correction provides you with a small window of opportunity to maintain them through corrective thera-ex. 

Use your clinical judgment in choosing the right technique for the right client. DO NOT PUT THE PATIENT ON THE FOAM ROLL IF YOU HAVE NOT CORRECTED THE POSTERIOR RIB YET. This will only make the trigger point facilitated by the offending rib worse!  

Mack