OMM Ribs Lecture
SAM DETWILER, DO
Objectives

To understand the autonomic nervous system
balance and the role of rib dysfunction with organ
function and systemic disease

To review basic rib anatomy and function

To understand the approach to Osteopathic Rib
Dysfunctions

To review basic OMT techniques for rib dysfunctions
BUTLER HEALTH SYSTEM FASTERCARE
DRSAMUELDETWILER@GMAIL.COM
Differential Diagnosis of Chest Pain

Potentially life-threatening causes of chest pain

Acute coronary syndromes

• Acute myocardial infarction

• ST segment elevation AMI

• Non-ST segment elevation AMI

• Unstable angina

Pulmonary embolism

Aortic dissection

Myocarditis (most common cause of sudden death in the

young)

Tension pneumothorax

Acute chest syndrome (in sickle cell disease)

Pericarditis

Boerhaave’s syndrome (perforated esophagus)
Case Presentation
A 64 year old male patient presents to
the ER with a week-long history of cough
and fevers. Recently, he started
producing sputum that was colored in
nature. He feels “short of breath” with
minimal exertion and feels “run down”
and fatigued. His cough occurs
throughout the day and is forceful to the
point of vomiting. He complains of pain
when trying to take a big breath in. He is
a non-smoker.
Differential Diagnosis of Chest Pain

Common non-life-threatening causes of chest pain

Gastrointestinal

• Biliary colic

• Gastroesophageal reflux

• Peptic ulcer disease

Pulmonary

• Pneumonia

• Pleurisy

Chest wall syndromes

• Musculoskeletal pain

• Costochondritis

• Thoracic radiculopathy

• Texidor’s twinge (precordial catch syndrome)

Psychiatric

• Anxiety

Shingles
Case Presentation

Physical Exam:

Vitals: T=101.4 P=126 R= 24 BP=115/70

Gen: Pale in appearance; no acute distress but
uncomfortable; alert and oriented

CV: No murmurs; tachycardic

Pulm: Rhonchi in right base, poor air movement
throughout; shallow breaths noted
1
Case Presentation

MSk/OMM:

Levator scapulae muscles and scalenes boggy and tender to
palpation bilaterally
Case Presentation

Labs:

WBC: 14,500 with a left shift

Na: 133

T3 FRSL

O2 Sat: 90%

T6 bilaterally flexed

CXR: Right lower lobe pneumonia with minimal effusion

T7-10 Neutral SRRL

Rib dysfunction: right ribs 7-10 prefer exhalation, left ribs 6-8 prefer
exhalation

Abdominal hemi-diaphragms: limited motion on right
Ribs Affect Sympathetic Tone

Autonomic Nervous System

Visceral-Somatic Reflexes

Somato-Visceral Reflexes
Segmental sympathetic nerve
supply for the viscera
2
Anatomy

Ribs and their
connections to
the transverse
processes

Note rib angles
(for treatment
purposes)
Muscles of
Inspiration
3
Muscles of
Expiration
OMM Concepts

Upper ribs

Lower ribs

Ribs 11 & 12



Osteopathic Principles of Movement

Upper ribs

Caliper ribs


In order to diagnose
these well, patient
must be able to
achieve maximum
inhalation
Bucket handle ribs
Caliper ribs
Osteopathic Principles of Movement

Osteopathic Principles of
Movement
Pump handle ribs
Lower ribs
Terminology – For Board
Review

Think “somatic dysfunction does” and name the
dysfunction for what it likes to do:

Exhalation dysfunction: the ribs do not rise with
inhalation but move easily with exhalation

Inhalation dysfunction: the ribs rise easily with
inhalation but do not lower with exhalation
Please insert OPP pics of caliper
rib diagrams
4
More Terminology – For Board
Review
 Exhalation dysfunction:

Pump handle: ribs are stuck down in the front and up in the back

Bucket handle: ribs are stuck down and in

Caliper: ribs are stuck pincing in
 Inhalation dysfunction:

Pump handle: ribs are stuck up in the front and down in the back

Bucket handle: ribs are stuck up and out

Caliper: ribs are stuck pincing out
Osteopathic Goals of
Treatment






Which is the ‘key rib’?


When Treating Groups of Ribs:

Exhalation dysfunction: treat the upper rib in the group (frees up all
ribs below it)

Inhalation dysfunction: treat the lower rib of the group (this rib is
holding all ribs above it in an inhaled position)
Using Functional Methods Diagnosis:

This approach will lead to the key rib because you are comparing
each rib with the one above and the one below. You are finding the
one that doesn’t move.
Increased Sympathetic Tone:
Increase rib motion
Enable greater air intake
Decrease pain
Decrease parasympathetic tone while
promoting sympathetic tone
Improve lymphatic drainage for the thorax
and lungs
Improve antibiotic access to affected lung.
Parasympathic Tone Effects
Treatments

Techniques:

Muscle Energy
Rib raising
Respiratory diaphragm facilitation/release
 Soft tissue techniques
 HVLA (consider patient’s age and history)



With all techniques used, one must
determine the patient’s
condition/medical stability and to which
techniques their body will best respond
5
Treatment order

Some find treating the thoracic spine before the ribs
beneficial

Some find treating ribs works without having to treat
the thoracic spine

Find what works for your patient!

One may find the rib dysfunction resolved
Muscle
Energy for
Exhalation
Dysfunction
Ribs
Muscle
Energy for
Exhalation
Dysfunction
Ribs
Muscle Energy

Easy to do for your hospitalized patient on bed
rest/limited activity

Know which muscle groups you want to activate
depending on the dysfunctional ribs involved

Pectoralis minor muscle for upper ribs (3-5)

Serratus anterior muscle for middle ribs (4-9)

Latissimus dorsi muscle for lower ribs (7-12)
Muscle
Energy for
Exhalation
Dysfunctio
n Ribs
Rib Raising
Goals of rib raising are to facilitate rib
head movement (and, thus, facilitate full
rib movement), increase lymphatic
outflow, and “encourage” sympathetic
nervous system (SNS) activation
 Be careful not to overdo your SNS
activation!


Initially, may locally stimulate the SNS to
associated organs; eventually leads to a
prolonged reduction in SNS outflow from the
treated area
6
Rib
Raising
Rib Raising

Placement of fingertips at rib angles

Giving slow, methodical pulses anteriorly and laterally with the
addition of caudal (or cranial) pressure will:

Increase motion,

Activate SNS chain ganglia

Improve lymphatic flow
Ribs 3-10 HVLA Supine
Inhalation or Exhalation Restriction
Soft Tissue

For use in treating levator scapulae and scalene
muscles, used as accessory muscles of respiration

Your facilitator may demonstrate soft tissue
techniques which you may find you prefer to those
you learned in school

Hand set up

Thumb and thenar eminence are fulcrum

Thumb on inferior or superior aspect of rib

Inhalation restriction- contact on superior aspect of rib shaft

Exhalation restriction- thumb below rib



HVLA: Considerations in Hand Placement
From
P. Greenman, DO
Principles of
Manual Medicine
2nd Ed., p.275
Superior force
Pt. grasps opposite shoulder
Ribs 3-10 HVLA Supine
Inhalation or Exhalation Restriction
Inhalation restriction
Exhalation restriction
Carry rib caudad

Pt. supine - doc stands opposite dysfunctional rib

Pt. grasps opposite shoulder

Roll pt. toward you and place caudad hand on rib
for appropriate dysfunction

Return trunk to midline- body localizes to fulcrum
over pt. lever arm

Impulse-body dropped through lever arm to
fulcrum with thumb and thenar eminence exerting
a cephalad force for exhalation restriction and a
caudad force for inhalation restriction
 Thrust on exhalation
Greenman pp. 303-304
7
HVLA

Hand set up is similar to thoracic HVLA
but hand placement is on the rib angle
and not on the transverse process

Tips for HVLA:

When treating exhalation dysfunction, place
your thenar eminence on top of the rib angle
and thrust downward

When treating inhalation dysfunction, place
your thenar eminence below the rib angle
and thrust upward
SUMMARY
8