Journal of Orthopaedic Medicine

ISSN: 1355-297X (Print) (Online) Journal homepage: http://www.tandfonline.com/loi/yimm19

A Series of 43 Patients Complaining of Shoulder

Pain Who Responded to Treatment of the First Rib

George Eddie

To cite this article: George Eddie (1995) A Series of 43 Patients Complaining of Shoulder Pain
Who Responded to Treatment of the First Rib, Journal of Orthopaedic Medicine, 17:2, 62-65, DOI:
10.1080/1355297X.1995.11719788

To link to this article: http://dx.doi.org/10.1080/1355297X.1995.11719788

Published online: 10 May 2016.

Submit your article to this journal

View related articles

Full Terms & Conditions of access and use can be found at

http://www.tandfonline.com/action/journalInformation?journalCode=yimm19

Download by: [University of Calgary] Date: 07 August 2017, At: 20:01

 62 The Journal of Orthopaedic Medicine 17[2] 1995

A SERIES OF 43 PATIENTS COMPLAINING OF

SHOULDER PAIN WHO RESPONDED TO
TREATMENT OF THE FIRST RIB
GEORGE EDDIE, MD
Guernsey, Channel Islands

INTRODUCTION
A group of 43 patients, suffering from shoulder pai n which did
not fit into any diagnostic criteria in a standard orthopaedic
medicaltextbook 1, were seen over a period of two years. In the
system of shoulder pain diagnosis given by Cyriax 1 these cases
would probably have fal len into the 'incomprehensible bursitis'
group. All except one bad fai led to respond to conventional
Downloaded by [University of Calgary] at 20:01 07 August 2017
Of the 43 patients, onl y two had suffered pain for Jess than one
month - ironicall y the youngest and oldest patients. All the
patients complained of pai n in the C4 dermatome; ie from the
base of the neck to the shoulder tip. Fifteen patients, when
directly questioned, adm itted having "pins and needles
sometimes". They were asked to make an assessment of their

treatment by general practitioners, or ph ysiotherapists and a few
also by orthopaedic specialists. They presented to the author by
self-referral "as a last hope" . The exception was the youngest
patient seen; she bad been delivered by the author and from then
on her mother presumed the author could solve all the famil y
problems!
PATIENTS
Only patients who failed to fulfil the criteria of any specific
lesion as defined by Cyriax 1 were included among the group of
43. All except one had suffered vague, often severe, pain in the
shoulder region for a considerable time. Age varied from 16
years to 64 years, females being affected almost twice as often
as males. In 4 1 cases the pain had been present for longer than
12 weeks, and in 20 of these, the pain had been present for longer
than 24 weeks. (Figure l)
-en
.::t:.
Q)
48
45
pai n (0-10 scale); whether or not sleep was disturbed by the pain ;
were normal acti vities disrupted;did they need to take analgesics.
(Table l)
Of those patients who admitted 'pins and needles' on specific
questioning, most also admitted some pain in an ulnar distribution
(Table 2). AlliS admitted the 'pins and needles' were intermittent
and were not contributory to the sleeplessness, and were felt
mainly in the whole hand. When asked if there was any time
when the symptoms were worse than any other, they all stated
that these symptoms were most noticeable in the evening.
Precipitating factors and duration of symptoms
Due to the length oftim e be tween the onset of the pai n and being
seen by the author, it was often diffi cult to decide with any
accuracy the actual precipi tating factor.
Patients suspected certa in acti vities
... (Table 3)

Q) 42 The mechanism of the injury may be

u
-~
(/)
~
39
36 ... 0...
stretching arms and lifting, or being
pulled. Tension round theshoulder girdle
... u and cervico-thoracic junction may play
~
a..
33 _i
...
their part.

~ 30 0 ... 0 p 0 Presenting Symptoms

~ 27
0
0 .& b ... All the patients presented complaining
u.. 24 0 ofshoulderpain. The pain was described
0 0
... Q Q
...... c as being "nagging" or a severe ache. No
z 21 one complained of the pai n being excru-
0 18 u ... ciating. Many complained of being
~ 15 ~ ... E 0 c unable to sleep. Sometimes there was
0
a: 12 0 difficulty in getting to sleep; others were
:::>
0 :> 0 ... also awakened by the pai n at some time
during the night. Pain was mainl y fe lt in
10 15 20 25 30 35 40 45 50 55 60 65 the C4 dermatome area. It was aggravated
AGE

Figure 1
 The Journal of Orthopaedic Medicine 17[2] 1995 63
- 1 -
Patients
Total M F M F M F M F M F
Sleep Affects Need Average
Disturbance Activities Analgesic Pain Score

Teens 5 - 5 - 2 - 5 - 2 - 6
20s 7 2 5 1 2 2 5 - 1 6 6
30s 7 3 4 2 2 3 4 2 3 6.6 7
40s 11 4 7 2 3 4 7 1 2 7.3 7
50s 7 1 6 - 4 1 6 1 2 8 6
60s 6 6 0 3 - 6 - 2 - 6.3 -
43 16 27 8 13 16 27 6 10
Table 1
Patients' symptoms

·•:. .,
Total M F '
; Teens 201 30s 40s SOl 601
Lifting children 2 1
-
Downloaded by [University of Calgary] at 20:01 07 August 2017

Teens 2
Gymnasium work 1
20s - 2
Horseriding 2
30s - 2
$kiing -
40s 1 3
Windsurfing
.sos - 2
Sailing
60s 3 - Professional cellist -
,i

4 11
Handling luggage 2 3 2 3
Table2 Moving house- 2
Those who on direct questioning Strain at work -
admitted some "pins and needles"
Table 3
Cause of 'injury' to which pain attributed

by lying on the affected side and after using the arm for a long
time. All work was affected as were leisure activities, particularly
in the sporting types, where in a few their sport was completely
curtailed.
Presenting Signs
The affected shoulder is seen to be slightly lower than normal in
the majority of cases, as may be the following:
Head slightly flexed to affected side
Head slightly rotated away from affected side
No capsular pattern of restriction was found in the gleno
humeral joint
No muscular weakness was found in the shoulder or arm
In 24 patients there was some discomfort on active, passive and
resisted medial rotation of the gleno humeral joint; also some
complained of pain in the last few degrees of passive abduction.
Pulling away trapezius an acutdy tender elevated frrst rib on the
affected side showed greater sensitivity at or near the costo
transverse joint. The examination of the neck was essentially
normal
TREATMENT
A Soft Tissue Massage Technique
The patient lies supine on the couch with bead supported by a
pillow. Soft tissue massage is initiated by standing at the head,
gently stretching the posterior and lateral muscles of the neck
inducing trape ziu s, levator scap ulae, spleniu s,
sternocleidomastoid and the scalenes. The author works from
the base of the neck with cephalic movement, tending after a
short time also to move anteriorly.
Still with the patient supine, the upper edge of trapezius is gently
kneaded and squeezed. It is often easier on the operator to kneel
during this stage. The next stage is to perform some gentle
manual traction by grasping the occipllt with both hands as if
cupping it. Then lean backwards slowly until at full stretch.
Hold this position for about 30 seconds then slowly release
traction by leaning forward into starting position. This is
followed by gentle side bending alternately to each side. The
author uses his abdomen as a soft lever to push the head over.
The patient is then asked to be in the prone position. Face now
in face hole. This makes it more comfortable for the patient and
keeps the cervical spine as near straight as possible. The patient
puts the arms in the most comfortable position. The muscles of
the upper trunk are massaged gently but frrmly, working from
the spine outwards, but at varying angles. The back of the neck
is again treated, this time with gently pinching between thumbs
and fingers. The patient is then laid on the affected side, the
pillow having been reinstated. The shoulder girdle is massaged
using the McClurg technique - as taught at the London College
of Osteopathic Medicine. This is a mixture of crossfibre and
muscle stretching.
 64 The Joumal of Orthopaedic Medicine 17 [2] 1995

First: the patient's uppermost arm is laid over the contra lateral
arm of the operator. Using both hands, the operator massages
round the shoulder girdle while rhythmically rocking on to the
heels to provide a stretching movement antero caudally.
Second: the patient puts his hand on the operator's shoulder
furthest from the patient's shoulder. The operator's palms
massage trapezius, deltoid, biceps, triceps, etc; again the rocking
movement stretches the muscles.
Third: the patient's ann is laid over the ipsilateral arm of the
operator. The flrst process is repeated again except this is in a
different direction, ie more antero cephalically.
The patient is then turned so that the painful side is uppermost.
The above three processes are then repeated on the affected side.
The author spends slightly longer on the affected side.
After this, the author repeats a little gentle traction and massage
Downloaded by [University of Calgary] at 20:01 07 August 2017
slowly and deeply to establish if normal movement is taking
place and the rib is back to normal position. Although most of
the patients are successfully treated by this m eth~ there were
5 who initially still had an elevated immobile flrst rib. They
were still tender on palpation and had their presenting pain.
These were evenly spread through the age groups, the 20s being
the only exception.
In these cases, the author resorted to using the cervico-thoracic
technique well-documented and illustrated by Stoddard2, and
also beautifully explained by Bourdillon 5•
Re-examined
As the rib appeared to be in a normal position, the author then
used acupuncture for approximately 20 minutes. Patients who
refused acupuncture did so for a variety of reasons - from
religious to needle phobia. Patients were seen again one week
later, re-assessed and received further treatment. Those with no
rib elevation were treated by soft tissue massage only; in the rest,

with the patient again supine. the initial treatment was repeated.

Manipulation RESULTS
The author always uses a particular non-specific manipulation The results are shown in Table 4. All the patients were treated
initially. He adopted the technique from those taught at the with soft tissue massage and manipulation; and 36 patients
London College of Osteopathic Medicine. received acupuncture after manual therapy.

The patient sits on the couch with back to the operator, bottom Poor Results and Recurrences
as near the edge of the couch as possible near to the operator. Two women in their 40s did not continue treatment as they felt
The operator then places a sof~ flrm pad between this sternum they were not improving and wished a further opinion. One
and T3 of the patient. Then slips his own arms underneath the male in his 60s felt better after treatment, but deteriorated after
patient's axillae and places the heel of his bands below the about one week, possibly indicating that the diagnosis was
patient's occiput, hypothernar erninences just below the mastoid incorrect or incomplete, or that there was a need for different
processes. The patient's hands are linked together directly on treatment. The sports people are all back to their respecti ve
top of the operator's. Firm pressure is placed on the pad by (a) sports.
the operator pushing forward and (b) the patient leaning back.
This creates a fulcrum at T3. The manoeuvre is completed by Recurrences
the patient breathing in and out deeply. Then at almost the end Length No
of the patient's expiration, the operator gives a short, sharp lift of time Sex Comment
with the hands and a small push forward with the sternum on to Teens 16/12 1F Nanny
the pad. As previously stated, it is not specific for the fl rst rib, 20s 0
but includes upper thoracic and cervical spine. It is, however, 30s 0
one of the safest methods as it avoids any flexion, rotation or side 40s 1 year 2F 1 pulled by large dog
bending of the cervical spine. & 14/12 1 fell from horse
50s 16/12 1F Lifted shopping from trolley
The ribs are examined as before from behind. Acute tenderness 60s 8/12 & 2M 1 lifted and carried golf bag
is usually markedly diminished. The patient is asked to breath & 13/12 1 carried coal hod

Teens 20s 30s 40s 50s 60s

Total 5 7 7 11 7 6
Total no of treatments 14 19 21 30 25 25
Average no of treatments 2.8 2.7 3.0 2.7 3.5 4.0
Had acupuncture 3 5 6 10 7 5
Average pain score 1 week after treatment:
Male 0 1 1.25 2.2 3
Female 1.6 2 2 2.6 3 0
One vis~ 1 0 0
Pain not improved 0 0 0 3 0
Table4
Dropped out 0 0 0 2 0 0 Results of treatment
 The Journal of Orthopaedic Medicine 17[2] 1995 65

DISCUSSION
The43 patients were consecutive cases seen in specialist practice.
The author's method is based on the anatomy of the area. The
anterior and middle scale muscles must be contracted when the
ftrst rib is elevated. Probably the posterior scalene is also
affected. Stoddard 2 postulates that initability of the scalenes
can cause much pain the shoulderand ann, because oftheirclose
association with the brachial plexus. Dovey 3 states that initation
in the C4 seg ment of the neck will give spasm of the scalenes.
He also states that the cervico-dorsal regions are characterised
by inter-scapular or scapular pain. Brachial neuralgia is also
present from fixation of the first and second ribs.
costo-transverse joint involving the nerve roots and the stell ate
gangl ion can explain subjective sensory loss in the ulnar nerve
distribution and also partly explain those patients with additional
symptoms of reflex sympathetic dystrophy.
CONCLUSIONS
First rib dysfunction can be a cause of shoulder pain. Older age
groups who have arthritic changes in the costotransverse joint
need more treatment and may have more recurrences. Soft
tissue massage and a non-specific manipulation technique are
effective in the majority of patients, but in 5 of 36 patients, the
ftrst rib had to be specificall y manipulated.

The ftrst rib being rai sed pulls on the subclavius which in turn
pulls the clavicle downwards and forwards, hence depressing
the shoulder. The clavicle with its connection through the
coraco-clavicular ligament pulls forward the scapula which
results in a compression of the sub-acromial joint. Hutson6
states that the "subacromial joint is responsible for the majority
Downloaded by [University of Calgary] at 20:01 07 August 2017
REFERENCES
Cyriax JH Textbook of Orthopaedic Medicine 7th Edn 1978
BailliereTindall, London
2 Stoddard A Textbook of Osteopathic Practice 1969 Hutchinson,
London
3 Dovey H The cervical spine and brachial neuralgia J Orth Med

of painful shoulders". 1989 11 :61-4

4 Stoddard A Manual of Osteopathic Technique 1962 Hutchinson,
Cyriax 1 speaksof"eccentric bursitis" where no specific diagnosis London
could be made: "difficult cases may be a double lesion or a 5 Bourdillon JF Treatment of structural rib dysfunctions J Orth Med
pattern bard to interpret". In his Group 4 of 'eccentric bursitis' 1991 13:20-2
be does say there may be some limitation of passive abduction 6 Hutson MA Sports Injuries: Recognition and Management 1990
alone or passive medial rotation. I did lind a few who had OUP, London
discomfort at the limit of passive abduction - due I think to 7 Maitland GO Vertebral Manipulation 1977 Butterworth, London
inflamed subscapularis and scapulothoracic joint. Maitland 7 8 Fraser OM T3 syndrome J Orth Med 1986 8:9-11
admits that even in ancillary tests there is a small percentage of 9 Fraser OM T3 revisited J Orth Med 1993 15:3-4
patients with shoulder pain in whom a definitive diagnosis 10 Lindgren Thoracic Outlet Syndrome and the First Rib
cannot be made. Frase~ emphasis that the thoracic segments Rehabilitation Clinic, Kuopio University Hospital 1992
connect liberally with the sympathetic chain. In further di scussion
of the 'T3 syndrome' 9, be mentions there is no capsular pattern
at the shoulder and there is rotation of the clavicle, paresthesia Address for correspondence:
and pain. Though many of his finding s and symptoms do not DrG Eddie
The Clinic
concur with mine, others are similar. Ebanista
Braye Road
Lindgren 10 found a restrictive movement pattern of the first rib Vale
frequently in patients with symptoms indicative of 'thoracic Guernsey GY3 5QN
outlet syndrome'. He used cineradiography. Irritation of the Channel Islands

BIMM Alpine
Conference/Workshops
are proposed for
24 February-2 March 1996

The programme is being planned to include:

0 Manipulation techniques 0 Injection techniques
0 Hazards of injections 0 Psychological methods for chronic pain
and post-traumatic stress disorder

at Livigno (Italian I Swiss Engadine border)

Please contact now to register interest and your contribution to programme
Dr Richard Ellis Tel:Ol 722 336262 Ext:4219/Fax:Ol 722 325904