Rib Out Of Place?

The purpose of this blog is to discuss a rib out of place, review the anatomy of the region, go through symptoms and differential diagnosis, dispel myths, and review exercise options for the pain.

Do you have new, lingering, or recurring neck or thoracic symptoms that’s stopping you from doing the things you enjoy or keeping you from feeling like yourself? Check out our Neck & Thoracic Resilience Program!

Anatomy

The rib cage is made up of 24 ribs, 12 on each side. Your ribs attach posteriorly to the thoracic spine where each rib makes two joints with the spine, a costovertebral joint and a costotransverse joint. These joints are supported by a dense network of ligaments, helping to provide a great deal of stability to the region. The upper seven ribs on each side are connected to the sternum directly through costal cartilage, whereas the 8th, 9th, and 10th ribs are called false ribs as they do not directly attach to the sternum. The 11th and 12th ribs are classified as floating ribs due to not having any costal cartilage connection to the sternum. The rib cage has 3 main layers of muscle connecting each rib, as well as multiple muscles attaching onto the ribs to support in motion of the ribs, spine, and scapula.

Movement

The primary motion of the ribs occurs during breathing. The upper ribs have a pump handle motion, moving up and forward with inhalation, and down and back with exhalation. The middle ribs have a bucket handle motion, moving out and up with inhalation, and in and down with exhalation. The lower ribs have a caliper motion, moving laterally with inhalation and centrally with exhalation.

Along with their motion during breathing, the ribs also move when the thoracic spine moves, rotating along to allow trunk motion. The thoracic spine goes through primary motions of flexion, extension, lateral flexion, and rotation.

Beliefs & Evidence

You may experience pain around the ribs, often localized near the various joints the ribs are a part of. This pain is usually coupled with discomfort during breathing and moving the trunk. Due to these sensations, the pain is often described to a rib being out of place. This concern is usually then coupled with a clinician of some kind providing a manipulation to the rib “putting it back into place.”

While you may feel the sensation of the rib being out of place, a rib out of place is considered a very serious injury which has only been shown to truly happen from injuries such as motor vehicle accidents, often requiring surgery. As well, no research has demonstrated that a manipulation is able to move a rib’s resting position.

Differential Diagnosis

So if the rib isn’t out, why do you have pain? Well there are a few different diagnoses that could be considered that closely match symptoms. The most likely thing that you are experiencing is some kind of local ligament sprain and or muscle strain around the costovertebral and costotransverse joints. This would make sense as the muscles may be spasming in the region, leading to the various sensations you feel. As well, when you or a clinician touches the region, if the muscle is spasming it could feel like a small bump that may be perceived as a rib being out of place.

Other possibilities would be cervical radiculopathy, costochondritis, rib fractures, or some kind of referral pain from the cardiopulmonary, renal, or GI systems. Cervical radiculopathy has been found to present as pain in the rhomboid region, which can overlap with this. Costochondritis is a condition where the cartilage that connects the ribs and sternum becomes irritated. This can radiate along to the backside of the ribs and present with similar issues with breathing and rotation. The treatment I will discuss in a moment would fit well for both of these as well.

Referral pains from the cardiopulmonary, renal, or GI systems typically present with pain that cannot be relieved and are often accompanied by other signs or symptoms such as nausea or vomiting. These are best investigated by a medical professional.

Exercise Options

Unless you’ve been in a serious traumatic incident, such as a motor vehicle accident, your rib is likely not out of place. I’m going to discuss 4 categories of exercises that you can use to help in reducing your symptoms.

The first two categories are aimed at improving range of motion at your spine and ribs, and the second two are optional for increasing strength and capacity. Within each category, I’ll demonstrate two options that you can select between.

Cervical & Thoracic Rotation

Getting some localized motion for the thoracic spine and ribs is beneficial, and if there happens to be any neck involvement, it can be helpful to get it moving as well.

Option 1 – Seated Thoracic Rotation. Sit down with your arms stretched out in front of you. Keep one arm in place while rotating your trunk and reaching back behind you with the other arm. Return back and do the other side.

Option 2 – Half kneeling Thoracic Rotation. Get into half kneeling with your arms stretched out in front of you and then execute the movement the same way, keeping one arm in place and reaching back with the other arm. If you want to make it more challenging, you can perform it against a wall.

Try to perform these movements 2 to 4 times a day for 5 to 10 repetitions per side.

Cervical & Thoracic Flexion-Extension

Similar to the last category, the intent is on getting your thoracic region comfortable moving, while also getting some neck movement.

Option 1 – Seated thoracic extension. Sit down with your fingers laced behind your head and elbows pointing forward. Tuck your chin and curl your chest down, reverse up and point your elbows to the roof. You can alternatively do this with your arms straight, reaching towards the floor and then reaching to the roof.

Option 2 – Roller extensions. Lay down with a foam roller across your upper back and perform the same movement, rounding and arching your upper back over the foam roller.

Try to perform these movements 2 to 4 times a day for 5 to 10 repetitions per side.

Rowing

To continue progressing the demands, you can begin to perform upper body movements which challenge the spine and ribs to move, along with getting a more challenging stimulus on the muscles which attach in the region. Rowing movements focus on the upper back muscles.

Option 1 – Two arm row. In a bent over position with your back flat and arms extended, pull your elbows back and squeeze your shoulders blades down and together. Return your arms back down and let your shoulder blades stretch forward. You can perform this with DBs, a barbell, or bands.

Option 2 – One arm row. Set up the same way, however now you’ll perform this with just one arm at a time. This will increase the demand on resisting rotation. You can perform this with a DB, a landmine, or a band.

Try to perform these movements for 2 to 4 sets every other day for 5 to 15 repetitions.

Pressing

In addition to rowing, working the anterior muscles on the rib cage is beneficial, which is predominantly done through pressing movements.

Option 1 – Push Ups. Set up on your hands and feet with a shoulder width grip. Lower your body towards the ground and then press back up while keeping a straight line from your head to heels. If it’s too challenging, elevate your hands. If it’s too easy, elevate your feet.

Option 2 – Bench Press. Laying on a bench with your arms extended, lower your hands until they are beside your ribs, then press back up. You can do this with a barbell, DBs, or a band.

Try to perform these movements for 2 to 4 sets every other day for 5 to 15 repetitions.

Summary

While you may experience pain around the ribs that is labeled as a rib out of place, it’s unlikely that the rib is truly out of place. Instead, it’s more likely that a local ligament or muscle is strained, or that it could be a radiating symptom from elsewhere. Considering this, focusing on load management and activity modification to continue doing as many of your regular routines as possible. You can consider adding in some exercises that will help in getting motion to the region, grade exposure back to loading it, and building your capacity.

Do you have new, lingering, or recurring neck or thoracic symptoms that’s stopping you from doing the things you enjoy or keeping you from feeling like yourself? Check out our Neck & Thoracic Resilience Program!

Rhomboid Pain Exercises, Neck and Shoulder Pain Exercises, Scoliosis

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