Indiana Osteopathic Association
RIB CAGE
JOHN G HOHNER, DO, FAAO
Department of Osteopathic Manipulative Medicine
Chicago College of Osteopathic Medicine
Midwestern University
MAY 4, 2012
OBJECTIVES
1. Describe the relationship between
the thoracic spine, ribs and
associated soft tissues.
2. Describe the physiologic motion of
the ribs.
3. Diagnose somatic dysfunction in the
region.
4. Apply osteopathic principles to
specific cases
Bony Landm arks
M usclesofthe Spine and Thorax
Text
ErectorSpinae G roup
Spinalis
Longissim us
Iliocostalis
Text
ErectorSpinae G roup
Text
M usclesofthe Shoulderand A rm
Text
Latissim usD orsi
SerratusA nterior
A bdom inals
RectusA bdom inis
ExternalO blique
InternalO blique
Transverse A bdom inis
RectusA bdom inis
Text
ExternalO blique (leftside)
Text
M usclesofthe Spine and Thorax
Text
D iaphragm
D iaphragm
ANATOMY OF THE THORACIC
REGION
Costovertebral Joints
The head of the first rib does not
contact C7.
2nd and below ribs contact the superior
hemi-facet plus the
inferior hemi-facet of the vertebra
above.
Rib 11 and 12 articulate with the side of
the vertebral body.
ANATOMY
Costotransverse
Joints
Rib articulates
with transverse
process.
Ribs 11 and 12
have no
costotransverse
articulation.
ANATOMY
Costochondral
Joints
Costosternal junction
There is a
section of
cartilage
between a rib
and the
sternum.
Costochondral
junction
CLASSIFICATION
Cartilage
Ribs 1-7 "true ribs"
attach to sternum
Ribs 8-10 "false
ribs" attach via
cartilage
Ribs 11, 12
"floating"
1.
2.
3.
4.
5.
The second rib attaches to:
The body of T1 and no
transverse process
The body of T1 and T2 and
no transverse processes
The bodies of T1 and T2, and
the T1 transverse process
The bodies of T1 and T2, and
the T2 transverse process
The body of T2 and no
transverse process
NEUROVASCULAR STRUCTURES
Brachial plexus
passes between
anterior and middle
scalene muscles.
Autonomics:
sympathetic
ganglia and
chain lie just
anterior to ribs
Intercostal:
artery, vein,
nerve pass
along inferior
surface of rib.
THORACIC OUTLET SYNDROMES
"Thoracic outlet": 3 sites of
neurovascular compression.
+ Between anterior and
middle scalene (anterior
scalene syndrome)
+ Between clavicle and
1st rib (costoclavicular
syndrome)
+ Between pectoralis
minor muscle and chest
wall.
Adson’s test is POSITIVE
with compression
syndromes
DEFINED BOUNDARIES
THORACIC INLET
first thoracic vertebra
the first ribs
manubrium upper
border
THORACIC OUTLET
12th thoracic vertebra
subcostal margin
xiphoid process
RESPIRATION
The diaphragm is the primary muscle of
respiration. Innervated by phrenic nerve
(C3-5 origin).
Scalenes are secondary muscles of
respiration.
Inhalation/exhalation = ventilation:
exchange of gasses
Fluid movement: venous return,
lymphatic return
MOTION OF THORACIC CAGE
There are two basic components to thoracic
cage motion:
1.
Movement of the thoracic cage
during movement of the trunk
(flexion/extension, rotation,
sidebending).
2.
Movement of the ribs and thoracic
cage during breathing (ventilation).
3.
The thoracic A-P curve changes
during breathing.
MOTION OF THE RIBS DURING
INHALATION AND EXHALATION
PUMP HANDLE MOTION
“Pump handle motion”
increases the A-P
diameter of the chest on
inhalation. The sternum
moves anteriorly and
superiorly on inhalation.
It is primarily related to
the upper ribs (1 or 25). (Rib one is
sometimes excluded).
BUCKET HANDLE MOTION
“Bucket handle
motion” increases the
lateral or transverse
diameter of the chest on
inhalation.
Bucket Handle: Affects
transverse diameter,
lower ribs (6-10).
In “bucket handle”
motion, the A-P axis
that we define as
passing from the back
to the front of the rib
does not exist. The ribs
do expand laterally, but
not about an A-P axis.
AXIS OF RIB MOTION
The axis of rib rotation of all
ribs goes from the head of
the rib and exits at the angle
of the rib.
Consider the top ribs. This
axis is nearly horizontal.
This axis declines more and
more inferiorly from the top
to the bottom of the rib cage.
At the bottom of the rib cage,
this axis is at about 45o from
horizontal.
AXIS OF RIB MOTION
The other change is the relationship of the
axis to the coronal or frontal plane. At the
first rib, this axis is almost in the coronal
plane.
Progressing downward the axis becomes
progressively more posterior from the head
of the rib.
The upper ribs as they rotate about this axis
move the sternum anteriorly and superiorly
on inhalation.
The lower ribs expand laterally, increasing
the lateral diameter of the thoracic cage.
WHAT ABOUT RIB 1 ?
The terminology of Rib 1 motion becomes
somewhat confused in the literature.
First rib dysfunctions tend to be associated
with “elevation” of the rib. Motion testing
reveals a reluctance for the rib to be
“depressed” with downward pressure.
From another perspective, rib 1 follows
sidebending and rotational mechanics of T1.
When T1 is sidebent left, the rib is elevated
on the right side.
WHAT ABOUT RIBS 11-12 ?
Ribs 11 and 12 are “floating ribs” in that
they have no anterior cartilaginous
attachment to the sternum. Also, they have
no costotransverse articulation.
The motion of ribs 11 and 12 is described
as “pincer” or “caliper” motion. They move
posteriorly and laterally on inhalation and
anteriorly and medially on exhalation.
(reference Foundations p. 578).
RIB SOMATIC DYSFUNCTION
Rib dysfunctions are grouped into two
categories:
Respiratory rib dysfunctions
Structural rib dysfunctions
RESPIRATORY RIB DYSFUNCTION
Respiratory ribs exhibit motion
restriction in the movement of
inhalation/exhalation.
An “exhaled rib” is positioned in
exhalation, it completes a full exhalation
cycle, but “stops early” in inhalation.
The physical finding of “stops early” is
the usual basis of interpreting motion
testing of ribs.
RESPIRATORY RIB DYSFUNCTION
Respiratory Rib Terminology (named for
direction of freer motion)
1. Exhalation (exhaled) rib =
restriction of inhalation
2. Inhalation (inhaled) rib =
restriction of exhalation
3. Elevated rib/depressed rib
STRUCTURAL RIB DYSFUNCTION
Structural Ribs tend to exhibit restrictions
of motion associated with thoracic cage
restriction/dysfunction.
Inhalation/exhalation is not
the basic motion restriction.
STRUCTURAL RIB CLASSIFICATION
(Greenman)
Anterior Subluxation – rib angle less prominent in
posterior rib cage.
Posterior Subluxation – rib angle prominent in
posterior rib cage.
External rib torsion – associated with extended
thoracic dysfunction.
Superior 1st rib Subluxation.
Anteroposterior rib compression.
Lateral rib compression
Lateral Flexed rib (usually 2nd rib)
GROUP RIB DYSFUNCTION
For an exhalation group, the top rib is the “key rib”
restricting inhalation. When it gets “stuck” in
exhalation, all the ribs below it act “stuck” and painful
during each attempted inhalation
GROUP RIB DYSFUNCTION
For an inhalation group, the bottom rib
is the “key rib” restricting exhalation.
Note: Greenman states that the key rib is often a structural rib.
Treating the structural rib removes the respiratory restriction of
the group.
REFLEX RIB DYSFUNCTION
Reflex dysfunction - tenderpoints,
viscerosomatic patterns ("V S patterns")
MECHANICAL CONSIDERATIONS
On inhalation, the thoracic A-P curve flattens, on
exhalation it increases.
1. 1. An extended thoracic area should be
associated in inhalational ribs.
2. A flexed thoracic area should be
associated with exhalation ribs.
3. Sometimes, an atypical pattern rib
dysfunctions exists with reversal of the
pattern.
PRINCIPLES OF DIAGNOSIS
After you assess the thoracic contour
and evaluate symmetry/asymmetry:
With the patient supine, push on the
lateral aspect of the ribs.
Resistance to this pushing force
indicates rib restriction.
PRINCIPLES OF DIAGNOSIS
For pump handle motion, place finger on
anterior portion of upper ribs.
Have patient breathe. Look for a rib that
“stops early”
For bucket handle motion, place finger on
lateral aspect of lower ribs.
Have patient breathe. Look for a rib that
stops early.
Example: An exhaled rib stops early on
inhalation.
PRINCIPLES OF DIAGNOSIS
You can evaluate rib motion without the
patient breathing.
Simply passively move the ribs into inhalation
and inhalation.
Remember: “Down in front, up in back” for
exhalation and “Up in front, down in back” for
inhalation.
Palpate posteriorly for tenderness/tissue
change at the rib angle.
Palpate anteriorly; look for anterior
counterstrain points.
TREATMENT
Treat thoracic spine component first (unless you
are using counterstrain or indirect). Treat
structural ribs before respiratory rib dysfunction
1st and 2nd rib require special techniques
11th and 12th ribs have special anatomy, exhibit
“caliper motion”, and require special techniques.
“Shotgun techniques” such as the Kirksville
Crunch, cross pisiform thrust, chin pivot are used
for ribs.
TREATMENT
Avoid excessive pressure on the
cartilaginous portion of the ribs anteriorly.
Ribs tend to be in trouble with extended
dysfunctions and crossover points of lateral
curves.
Interpret tissue texture abnormality. Is the
rib problem a viscerosomatic reflex?
Counterstrain, indirect, and myofascial
release are clinically useful.
Case 1
24 yo male
Resolving URI
Still coughing
Pain in right side, worse with inhalation
No local rash, lungs clear
Case 2
Upper back and right shoulder pain, radiating to
right arm
Neuro intact, lungs clear, distal CMS intact
Positive Adson’s
Case 3
23 yo female
Progressive cough, DOE, generalized chest wall
pain
Thorough normal cardiac and pulmonary
workup, except for drop in pulse ox with exertion
Chronic back pain
Poor chest wall excursion
SUGGESTED READING
Foundations of Osteopathic Medicine,
3rd Edition, Chapter 39, Thoracic Region &
Rib Cage.
An Osteopathic Approach to Diagnosis and
Treatment, DiGiovanna and Schiowitz, pp.
239-244, 248-255.
Greenman, Principles of Manual Medicine,
2nd Ed., Chapter 15, Rib Cage.