First Rib Rotation vs. Rotator Cuff Injury

by Dena Denali | Jul 31, 2025 | Ask The Expert, Case Study

Many people assume persistent shoulder pain means a rotator cuff injury, but sometimes the true culprit hides in plain sight: a rotated first rib.

Recently, a patient traveled all the way from Australia to see me in Okotoks, Alberta, after years of unresolved shoulder dysfunction. His story is a perfect example of why assessment-driven, myofascial-based care can reveal what traditional shoulder rehab often misses.

Case Study: 7 Years of Shoulder Pain and Limited Mobility

Patient Profile:

• 35-year-old male — journeyman electrician, strength & conditioning coach for elite athletes, and sensei-level martial artist

• 2010 subscapularis full-thickness tear and shoulder dislocation, surgically repaired with full rehabilitation

• 2018: Martial arts training injury → acute upper trapezius pain, radiating nerve pain into arm and elbow, and sudden inability to raise the arm overhead

• 2022: Pain decreased enough to sleep through the night and regain partial range of motion, but persistent limitations and weakness remained

• Recent ultrasound radiology report stated thickened subscapularis, supraspinatus and infraspinatus tendons but no evidence of bursitis, but the 2010 surgical repair of subscapularis tendon was noted

Functional Shoulder Assessments of Note:

• Abduction: 110°

• Flexion: 150°

• Internal rotation (with abduction): 50°

• External rotation (with abduction): 30°

• Painful and weak in resisted flexion, abduction, and neutral external rotation

Posture & Palpation:

• Forward head posture and moderate functional thoracic hyperkyphosis

• Tight anterior musculature (SCM, scalenes, pecs, subscapularis, serratus anterior)

• Long, inhibited posterior chain (rhomboids, traps, deep neck extensors)

• Painful first rib costal cartilage at the manubrium joint, A/C joint, and scalene attachment sites

• Palpable rotated 1st rib in supine

Clinical Insight: Thinking Beyond the Rotator Cuff

At first glance, his history and imaging naturally led previous practitioners to focus on the rotator cuff and surrounding shoulder structures. After all, his surgical history and imaging findings suggested a straightforward shoulder problem. However, despite years of therapy, his pain and functional limitations persisted.

Over time, a pattern began to emerge. Manual therapy and traditional interventions provided brief, temporary relief, but the improvements never lasted. This inconsistency prompted a deeper investigation into the underlying cause of his symptoms.

Through careful orthopaedic assessment and postural analysis, it became clear to me that the true issue extended beyond the rotator cuff itself. A rotated first rib had likely become the primary driver of his ongoing pain, muscular compensation, and restricted mobility—a root problem that traditional shoulder-focused therapy had overlooked.

Treatment Plan

My treatment plan for this case was both integrative and myofascial-focused, combining microcurrent scar release, targeted soft tissue therapy, and ongoing functional reassessment to ensure each session built upon the last.

PHASE 1: Scar and myofascial release

I started by performing microcurrent scar release at the site of his 2010 shoulder surgery, which immediately improved both his range of motion and overall comfort. From there, I used myofascial release and cupping to address tight, overactive anterior muscles including the sternocleidomastoid (SCM), scalenes, pectoralis major and minor, subscapularis, serratus anterior, and latissimus dorsi. To restore muscular balance, I also focused on re-activating the inhibited posterior chain—specifically the rhomboids, mid- and lower trapezius, splenius capitis and cervicis, and semispinalis capitis. This early phase laid the groundwork for improved shoulder and cervical mechanics.

PHASE 2: Functional alignment and joint-specific work

Once the initial restrictions were released, I treated the first rib musculature, including the subclavius, anterior and middle scalenes, and serratus anterior, to restore proper rib and clavicle movement. I also addressed S/C and A/C joint mechanics, as well as key scapular movers such as the levator scapulae, pectoralis minor, latissimus dorsi, and serratus anterior, to improve shoulder stability and overhead motion.

PHASE 3: Neurological and postural reinforcement

To ensure the first rib remained stable and functional gains would hold, I introduced NET (No Extra Time) home care exercises designed to strengthen deep neck flexors, promote scapular retraction, and retrain diaphragmatic breathing patterns. During this stage, we avoided extreme shoulder adduction and clavicular depression to protect the rib’s alignment and allow the surrounding tissues to adapt.

Through this progressive, assessment-driven plan, the treatment addressed not only the symptoms but the root cause of his chronic shoulder dysfunction—creating the conditions for lasting resolution.

Treatment Outcome: Measurable Progress and Key Insights

Over the course of three 90-minute sessions in nine days, we saw both immediate improvements and valuable clinical lessons that shaped the patient’s long-term plan.

During the first session, the rotated first rib was corrected entirely through soft tissue release rather than direct joint mobilization. This approach immediately improved his range of motion and reduced his pain, confirming that the rib alignment was a significant driver of his symptoms. However, in the days following, he experienced a relapse after performing an extreme shoulder adduction movement with cervical rotation, which reproduced his previous discomfort and reduced his shoulder mobility again.

In the second session, we successfully realigned the first rib using the same myofascial release and postural correction approach. This time, the rib remained stable until his third appointment, reinforcing that the treatment approach was effective when he avoided provocative movements.

By the third session, we uncovered a critical piece of the puzzle. While performing soft tissue work on the SCM and scalenes with gentle head rotation, the first rib rotated out of position again. This clearly demonstrated that scalene overactivity combined with cervical rotation was the primary trigger for his rib instability. Once the scalenes were released, the rib returned to a neutral, stable position, confirming both the source of the problem and the path forward for long-term stability.

Through this sequence of sessions, we not only achieved significant pain reduction and improved mobility, but also identified the mechanical triggers behind his chronic first rib rotation. This insight became the foundation for his home care strategy and postural retraining plan, setting him up for continued progress after returning home.

Understanding 1st Rib Rotation

A rotated first rib is a subtle but significant dysfunction that can mimic rotator cuff injuries or even resemble thoracic outlet syndrome, leading to chronic neck and shoulder pain, restricted movement, and nerve-related symptoms. To fully understand why this occurs, it is important to examine rib anatomy, muscle forces, common triggers, and key symptoms.

Anatomy of the First Rib and Its Joints

From an anatomical perspective, the first rib connects to the spine at the costovertebral and costotransverse joints, which are synovial gliding joints. These joints are inherently stable, but their stability relies heavily on strong ligaments and balanced muscular support rather than deep bony interlocking like the hip or shoulder. Because of this, even small muscle imbalances or postural changes can alter the rib’s position and lead to dysfunction.

How Muscle Forces Influence First Rib Rotation

Muscle forces play a critical role in both stabilizing and rotating the first rib. The anterior and middle scalenes attach directly to the rib, elevating it during inspiration and contributing to anterior or posterior rotation when tension is uneven or chronic. The subclavius muscle, which stabilizes the clavicle, can pull the rib forward when overactive or guarding after injury. Meanwhile, the serratus anterior and upper trapezius indirectly influence rib mechanics through scapular elevation and depression, showing how shoulder function and rib alignment are closely linked.

Common Triggers for First Rib Rotation

Several common triggers can set the stage for first rib dysfunction. Repetitive overhead activity, often seen in electricians, athletes, or martial artists, creates constant loading on the rib and surrounding musculature. Forward head posture and patterns like Upper Cross Syndrome shorten the scalenes and overwork the anterior chain, predisposing the rib to rotation. Additionally, chronic accessory breathing patterns, where scalenes and upper traps dominate over the diaphragm, can perpetuate tension. Trauma, whiplash injuries, or even unresolved postural compensation after surgery can further destabilize the area, and when chronic, the condition can increase the risk of thoracic outlet syndrome.

Symptoms

Symptoms of a rotated first rib often include persistent neck and shoulder tightness, a sense of heaviness or tingling in the arm due to brachial plexus compression, and restricted cervical rotation or side bending. Because these symptoms overlap with more common shoulder injuries, first rib rotation is often overlooked, leading to years of ineffective treatment until the true source is addressed.

Next Steps for This Patient

To ensure long-term success and prevent the first rib from rotating again, the patient left with a structured care planfocusing on myofascial therapy, postural correction, breathing retraining, and progressive strengthening.

Ongoing Myofascial Release for Rib and Shoulder Mechanics

Continued myofascial release will be a key component of his recovery. By replicating the soft tissue techniques that were effective in my clinic, the patient can maintain mobility, prevent scar tissue restrictions, and continue improving shoulder and rib mechanics once back in Australia.

Breathing Retraining to Reduce Scalene Overload

Diaphragmatic breathing is equally essential in the recovery plan. By reducing reliance on the scalenes and upper trapezius as accessory breathing muscles, the patient can offload chronic tension, improve rib stability, and decrease the risk of first rib rotation returning.

Postural and Ergonomic Correction to Address Upper Cross Syndrome

The next priority is correcting postural imbalances. Years of Upper Cross Syndrome, marked by forward head posture and tight anterior musculature, contributed significantly to the rib dysfunction. Gradually introducing low-load, high-repetition exercises for scapular stabilization and deep neck activation will help the patient restore alignment and prevent recurrence during daily activities.

Strength and Stability Progressions for Lasting Results

Progressive strengthening will follow a phased approach to protect the rib while building long-term stability. Initial isometric exercises encourage rib and scapular stabilization without risking early rotation. Once the rib remains neutral and stable for an extended period, the patient can transition to dynamic exercises that reinforce shoulder and cervical mechanics:

• Serratus anterior activation: wall slides and push-up plus

• Lower trapezius and rhomboid engagement: rows and prone Y/T/W exercises

• Deep neck flexor strengthening: chin tucks and supine nods

By following this integrated plan, the patient can reinforce first rib stability, improve posture, restore functional shoulder movement, and reduce the risk of chronic pain or future relapse.

If Symptoms Persist: Advanced Options for First Rib Instability

Even with a structured treatment plan that includes myofascial release, postural correction, breathing retraining, and progressive strengthening, some patients may still experience recurrent first rib rotation or lingering symptoms. When this occurs, the next step is to reassess the underlying cause of instability and consider advanced interventions.

Diagnostic Imaging to Identify Ligament Laxity

Ultrasound or MRI imaging can reveal whether ligament laxity or microinstability exists at the costovertebral or costotransverse joints. These synovial gliding joints rely heavily on ligamentous and muscular support, so any compromise in these structures can make the first rib more prone to rotation.

Regenerative Injection Therapy for Rib Stability

If imaging confirms ligament involvement and conservative care has been fully maximized, two regenerative therapy options may help reinforce rib stability:

1. PROLOTHERAPY FOR LIGAMENT REINFORCEMENT: Prolotherapy involves injecting a mild irritant solution, often dextrose, into ligament or tendon attachment sites (entheses). The goal is to stimulate collagen production, which tightens and strengthens lax ligaments that contribute to first rib instability.
2. PLATELET-RICH PLASMA (PRP) FOR TISSUE HEALING: Platelet-Rich Plasma (PRP) therapy uses a concentrate of the patient’s own platelets injected into targeted soft tissue structures to stimulate healing and tissue repair. While PRP is more commonly used for tendon or enthesis injuries, it can support ligament stability in complex rib cases when combined with functional retraining.

Why Regenerative Injections Are Not a Standalone Solution

It is important to understand that PRP and prolotherapy are not shortcuts. Even if imaging identifies ligamentous laxity, these injections are most successful when combined with postural correction, myofascial therapy, and scapular stabilization exercises. Without addressing muscular compensation and breathing dysfunction, the first rib may continue to rotate despite injections.

Key Takeaway

Ultimately, the path to lasting resolution for chronic first rib rotation is a combination of structural reinforcement and functional retraining. Injections can provide stability at the ligament level, but movement re-education, myofascial therapy, and postural corrections are what make those results sustainable.