Rib subluxations are common in hypermobility

Estimated reading time: 6 minutes I know it can be a common thing in hypermobility and it is very painful. It can make us anxious about exercising as we fear a subluxation. Some people have even been told by some medical professionals that a rib subluxation is physically impossible – but I think if you have hypermobility you may disagree with this.

It’s only happened to me once, thankfully, when attempting to demonstrate an advanced exercise in a Pilates mat class many years ago. I hadn’t prepared myself; I was rushing to demo and was generally anxious about doing it. It was a rollover exercise that requires a lot of thoracic mobility. My thoracic spine has always been my stiffest area – I literally felt it pop as I rolled over into the exercise. I had to continue as I had a room full of clients intently watching me.

This got me thinking about the whole topic of rib subluxations and what we can do to prevent them.

Anatomy of the thorax

There are 12 pairs of ribs. Each rib connects to the thoracic vertebrae at the back of the body. The ribs are then classified into three groups based on how they connect to the sternum (breastbone) with cartilage. The first seven ribs are the true ribs. Ribs 8 through 10 are known as false ribs because the cartilage they connect to doesn’t directly attach to the sternum but their costal cartilage connects to the seventh costal cartilage. Then there are the floating ribs – rib 11 and 12 that do not connect to the sternum at all.

There are layers of muscles and fascia around the ribcage because the spine moves in so many directions. Many muscles act on the ribs including the pectoralis muscles, the obliques, rectus abdominis, serratus anterior, intercostal muscles, the diaphragm, and more! There are many attachment points for the ribs, then the shoulder girdle sitting on top.

We can’t treat the ribcage in isolation – everything is connected. Moving my arms will impact the ribs, and moving my legs can impact the ribs.

Bucklin and Francomano state that posterior rib pain is most likely secondary muscle tension whether the rib head connects or articulates with the vertebra, whereas anterior pain in the 8th to 10th ribs may be more associated with “slipping rib”.  They also state that anterior rib pain should be checked by medical professionals to rule out other conditions (1).

The role of thoracic stiffness

I believe the common thoracic spine stiffness that many people with hypermobility have is partly the cause of rib subluxations. If I have a stiff, immobile ribcage and possibly a breathing pattern disorder as well (which I also see as a very common occurrence in hypermobility), when I ask my body to do a sudden or strenuous move (like the rollover I attempted) there is not enough elastic flexibility in the ribs to cope with this.

Maybe I turn suddenly to look over my shoulder or lift a heavy bag. Perhaps, I am also breathing in a shallow way or am holding my breath. I could also be bracing or guarding my abdomen, which tends to cause a pressure chamber scenario.

All these factors add up to a ribcage that acts like a ‘cage’. It is fixed, tense, and generally tight. It’s not responsive to extra stresses. Under the extra stress and strain, the ribs have little choice but to pop.

What contributes to thoracic stiffness?

There are so many things that can contribute to stiffness in the thorax. We can have one or any combination of these. The good news is, we can address many of these things to reduce stiffness and get the ribcage moving effectively.

• Fear of Pain: When we are in pain or scared of causing pain we tend to lock it down and prevent movement.
• Altered breathing patterns: Living with a chronic illness can be stressful, we often develop a subconscious pattern of protection. When this pattern becomes chronic it can definitely lead to tightening of the connective tissue.
• Lack of movement: Deconditioning or lack of movement can contribute to this stiffness. This can absolutely be addressed – there is always somewhere to start wherever you are!
• Bracing to find stability: “Hypermobiles frequently use a ‘bracing’ pattern with breath holding in an attempt to improve stability and produce more force . . . The ribs can become fixed and efficient respiration is affected (2).”
• Posture and muscle compensations could be impacting the thorax, leading to muscular imbalances and tension.
• Chronic pain: persistent pain can cause muscle guarding, where muscles tense up to protect the affected area.

The first step to reduce rib subluxations is the breath

So how can we prevent rib subluxations from being a regular occurrence? My first step is always breathing. I’ve found it is best to start any breathing techniques in a supine position. This way, the posterior muscles can relax and the body has a different relationship to gravity. Then progress to a seated position – with a back support to enable relaxed posterior muscles. Finally, move to a standing practice position. But this may take time and that’s OK.

The gold standard of breathing techniques is diaphragmatic breathing. It promotes relaxation and reduces muscular tension in the upper thoracic muscles. This type of breathing needs to be introduced and taught. It is actually very challenging for breath in this way if your thorax is not used to expanding. I always start with my 1,2,3 breathing which I explain in my book Hypermobility Without Tears. I also have a few videos using this technique as well as an audio meditation on The Zebra Club App.

A recent small study revealed measurable differences in proprioception of breath or the perception of lung volume (at moderate volumes) in people with hEDS compared to controls (sex, age, and weight-matched). They also found that the hEDS group had erratic breathing patterns when focusing on a cognitive task (3). The good news is we can improve our breathing!

Becoming aware of breath is the first step, noticing your patterns. Do you hold your breath? Do you breathe shallowly? Integrating breath into our movement practice will translate to make everyday life easier. With some simple breathing practices that focus on gentle expansion of the ribs and thorax, you can achieve a lot. Not only do you start to get natural movement in the thorax, but you also start to relax those overworking muscles around the ribcage.

 Managing hypermobility rib subluxations: Acute phase

Managing and treating acute rib subluxations requires a combination of immediate care, pain management, and rehabilitation strategies. Here are some ideas. Importantly try to relax above all else. If we are anxious, the tissues will tense more.

• Initial Rest and Immobilization: Rest may help you avoid further strain on the affected area. You may find using a supportive brace or wrap to provide support and reduce movement can be helpful.
• Pain Management: Apply ice packs to the affected area for 20-minute intervals several times a day during the first 48 hours to reduce inflammation and pain. Over-the-counter pain medications can help manage pain – please check with your physician.
• Breathing Exercises to relax the area: Gentle breathing exercises can help maintain rib mobility and relax. Try this video  or any of the breathing classes and meditations in The Zebra Club app 

If symptoms persist or worsen, always seek medical advice.

Jason Parry, a hypermobility physio states “What if it doesn’t go back? Don’t expect the joint to go straight back in. It is often not unusual for joints to remain out of place for hours or even days. But once it’s out, it’s out. It’s not going out even more, so try not to panic.” I think this a good reminder to keep in mind.

 How to prevent rib subluxations

• Starting low and slow: We can’t start with strength work – we need to find safety and connection. It is a common mistake to start hypermobile patients on stability and strength work, but this can cause more pain and even subluxations. The tensional habits must be addressed first before introducing stronger work.
• Focus on integrated movement patterns:
  • Whole body integration is going to take the load of any one particular area.
  • Fascial friendly work is particularly helpful as it helps distribute forces throughout the whole system.
  • With the Integral Movement Method (IMM) we teach the body to move in an integrated way, with even force distribution as opposed to taking the path of least resistance (something the brain will often try to do).
• Focus on the breath: This video has a great introduction to focusing on the breath to address rib subluxations
• Release tension: It is super key to release that habitual tension that acts as muscular armour for many people. We can do this through starting with gentle movement and meditation.
• Ease into stability work: Stability work is essential but there is no rush. It becomes so much easier too if you have allowed the body to settle without tension. Otherwise, we are just putting more tension on top of tension.
• Postural alignment can help as well as overall postural tone. Think about your environment too – is there a particular way I sit at my work desk that might be compressing the ribcage? How do I use my arms – check out this video on correct arm movement.
• External Support: Some people do find wearing supportive braces can help them feel safer during activities that strain the rib cage. This can be helpful if you are just starting out on your movement journey and rehabbing the thorax.

Here is my live class where I talk a bit about my approach to rib subluxations and walk you through a movement practice. If you are looking to go deeper The Zebra Club is here for you!

Works Cited

1. Bucklin & Francomano (2023) Chapter 41 Chapter 41 – Chest wall pain: Anterior rib subluxation. Symptomatic: The Symptom-Based Handbook for Ehlers-Danlos Syndromes and Hypermobility Spectrum Disorders. Eds. Francomano, Hakim, Henderson, Henderson Sr. Elsevier Press.
2. Keer & Butler (2010) Chapter 9: Physiotherapy and occupational therapy in the hypermobile adult. Hypermobility, Fibromyalgia and Chronic Pain. Churchill Livingstone, London; 2010. 143-61.
3. Hakimi et al (2024). Impairment of lung volume perception and breathing control in hypermobile Ehlers-Danlos syndrome. Scientific Reports.

“MedicalGraphics – Drawing Thoracic skeleton from anterolateral – no labels” by www.MedicalGraphics.de, license: CC BY-ND