First Rib Mobility Test

The First Rib Mobility Test is a hands-on orthopedic assessment designed to evaluate the mobility of the first rib, which is crucial for proper neck, shoulder, and upper thoracic mechanics. A hypomobile (stiff or elevated) first rib can contribute to neck pain, restricted cervical motion, thoracic outlet syndrome (neurovascular compression), headaches, and upper back or shoulder dysfunction.

How the Test is Performed

  • Client position: Most commonly performed with the client seated.

  • The client is instructed to fully rotate their head away from the side being tested, and then flex their head forward (chin to chest).

  • The therapist may also palpate or spring the first rib directly in a sitting or supine position, using their fingers or MCP joint to assess for end-feel, excursion, and symmetry compared to the other side.

  • Sometimes, gentle overpressure or mobilization is applied in an inferior/medial direction toward the opposite hip to feel rib movement or compare left vs. right mobility.

  • A positive test: Reduced neck flexion on the tested side or a stiff/hard end-feel when springing the rib, indicating hypomobility or possible elevation.

Clinical Significance

  • Decreased first rib mobility is associated with:

    • Scalene muscle hypertonicity or overuse. Scalenes elevate the first rib and may hold it in a restricted position.

    • Thoracic outlet syndrome, leading to nerve or vascular symptoms in the upper limb (numbness, tingling, weakness, or vascular changes).

    • Cervical and shoulder movement restrictions and postural complaints.

  • Normal first rib movement is essential for smooth neck sidebending, rotation, and efficient breathing.

Assessment

  • Use this test for clients with:

    • Neck pain

    • Shoulder dysfunction

    • Upper limb numbness, tingling, or weakness (suspected thoracic outlet syndrome)

    • Chronic headaches or breathing/postural complaints.

  • Carefully record side-to-side differences, quality of end-feel, and changes in symptoms or motion after treatment.

Treatment

  • If positive for hypomobility:

    • Integrate targeted soft tissue therapy for first rib mobilization, focusing on surrounding muscles (scalenes, upper trapezius, levator scapulae, subclavius).

    • Use gentle rib mobilization techniques (grades 1–2 for pain, grades 3–4 for increased mobility as tolerated).

    • Educate about posture, breathing retraining, workspace/ergonomic set-up, and home self-release exercises.

    • Strengthen scapular stabilizers and correct global postural patterns for lasting change.

  • Reassess after manual therapy to ensure improvement in mobility and refer if neurovascular symptoms persist or worsen.

Safety and Referral

  • Do not force rib mobilization if acute trauma, fracture, severe osteoporosis, or vascular compromise is suspected.

  • Refer for multidisciplinary evaluation if manual therapy does not resolve functional limitations or if symptoms of progressive thoracic outlet syndrome are present.