Lindgren Test: Cervical Rotation Lateral Flexion for First Rib Subluxation
In short
The Lindgren Cervical Rotation Lateral Flexion test is the most accurate physical test for detecting an elevated first rib. Learn how clinicians perform and interpret this maneuver.
In this guide (4 sections)
The Lindgren test, formally known as the Cervical Rotation Lateral Flexion (CRLF) test, represents the most clinically valid and biomechanically sound physical examination procedure for identifying structural elevation or hypomobility of the first rib. Described by Swedish orthopedic surgeon Carl-Axel Lindgren, this test isolates the costovertebral articulation of the first rib from the surrounding cervical facet joints. While conventional thoracic outlet provocative maneuvers rely heavily on subjective symptom reproduction or unreliable radial pulse dampening, the Lindgren test delivers an objective, palpable mechanical end-feel. A positive finding indicates that an elevated first rib is physically blocking normal cervical lateral flexion, establishing an anatomical diagnosis of costoclavicular outlet compromise.
Unilateral Weight Carrying, Neck Cricking, and Indian Commutes
In routine Indian daily life, unilateral carrying habits place asymmetrical forces across the upper rib cage. Commuters carrying heavy laptop bags or gym sacks on one shoulder unconsciously elevate that shoulder girdle to keep the strap from slipping. Mothers carrying toddlers on one hip lean their upper trunk to the opposite side while their ipsilateral neck muscles contract forcefully. Furthermore, many individuals wake up with acute neck stiffness after sleeping on thick, unsupportive cotton pillows on train journeys or rigid mattresses. These common domestic scenarios trigger sustained scalene spasm that pulls the first rib superiorly, locking it into an elevated subluxation that the Lindgren test reveals.
Facet Locking Biomechanics, Bony Impingement, and the Hard End-Feel
To execute the Lindgren test correctly, the patient sits upright while the examiner passively rotates the cervical spine maximally away from the symptomatic side. This rotation fully engages and closes the ipsilateral cervical facet joints from C1 down to C7. From this fully rotated position, the examiner gently side-flexes the neck forward toward the patient chest. In a normal joint, the neck flexes smoothly through approximately forty to forty-five degrees. However, if the first rib is elevated, the transverse process of the seventh cervical vertebra (C7) makes direct, premature bony contact with the superior margin of the elevated first rib, producing an abrupt, rigid bony end-feel and severe limitation of motion.
Post-Test Mobilization Protocols, Patient Education, and Retesting
When the Lindgren test confirms first rib elevation, the physiotherapist immediately initiates targeted joint mobilization rather than generalized cervical traction. Mobilization involves grade III or IV downward, medial, and slightly anterior oscillatory pressure directed through the clinician first metacarpophalangeal joint placed against the posterior-superior aspect of the rib. Immediately following three to four cycles of manual mobilization, the Lindgren test is repeated. Successful treatment results in an immediate, observable increase in lateral flexion range of motion, providing real-time verification of joint decompression.
Self-Assessed Lateral Flexion Mobility and Rib Softening Drill
Objective: Promote gentle lower cervical lateral flexion and mobilize the costovertebral joint into depression
- 1Sit upright on a firm chair with your head in a neutral resting position.
- 2Rotate your head fully to the left as far as comfortable without straining.
- 3From this left-turned position, gently tilt your ear forward toward the center of your chest.
- 4Notice if your movement feels smooth and springy or if you encounter a sharp, rigid bony block on the right side of your neck.
- 5Repeat the sequence on the opposite side to compare symmetry; perform 5 gentle, rhythmic oscillations into the soft end-range on the stiffer side.
| Test Parameter | Normal (Negative) Finding | Elevated First Rib (Positive Finding) |
|---|---|---|
| Lateral Flexion Range | Symmetrical excursion of 40 to 45 degrees of lateral flexion toward the chest. | Marked restriction; lateral flexion halted at less than 15 to 20 degrees. |
| Mechanical End-Feel | Soft, elastic muscular end-feel with comfortable tissue compliance. | Abrupt, unyielding, hard bony block; mechanical abutment between C7 and rib. |
| Symptom Reproduction | Absence of radiating paresthesia; mild stretch sensation in upper neck. | Localized deep ache at base of neck; reproduction of ulnar-sided arm tingling. |
| Post-Mobilization Change | No significant change in already physiological range of motion. | Immediate 15 to 25 degree restoration of motion following rib depression. |
Ensure that passive cervical rotation does not produce sharp, shooting electric pains down the arm before initiating lateral flexion. If rotation alone reproduces radiating dermatomal pain, cervical disc herniation or severe facet arthrosis with nerve root impingement (Spurling phenomenon) must be investigated with cervical imaging.
Frequently Asked Questions
Is the Lindgren test painful to perform?
When performed by a skilled physiotherapist, the Lindgren test is not painful. You may feel a firm stretching sensation or a localized stiffness at the base of your neck if your first rib is elevated, but the examiner never forces your neck past its natural mechanical stop.
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