OMM 2, Lecture #11(PTR)
Atypical Ribs
Dickey, DO
Scribe: matthew jones
- 1 - of 4
Atypical Ribs(being reviewed-changes to be posted later)
I.
II.
III.
IV.
V.
VI.
VII.
Introduction to atypical ribs
A. Atypicals tend to have single facets (no demifacets): 1, 12, 11, and
sometimes 10.
B. Not called atypical due to lack of anterior attachment (not true for all
atypicals).
Introduction to first and second rib
A. Common sd in today’s world (particularly if elevated)
1. Associated with high stress
2. “Victim of the scalene muscles” as we will see.
3. Dickey referred to this sd (somatic dysfunction) as “wearing the
shoulders as ear rings.”
B. Also seen associated with overuse of accessory breathing muscles
(including scalenes)
1. Observed in extreme situations such as Polio.
2. In our generation, we should expect to intibate of we see
excessive use of scalenes
3. Especially indicative of respiratory failure in infants (rib cage
collapses with each breath)
C. First and second rib act primary as anchors for action of scalenes.
1. Very little involvement in respiration
2. Less spring than typicals
First rib is under the leading edge of the trapezius muscle in the midclavicular
line of the superior shoulder.
A. If patient has a large trapezius, the first rib should be accessed through the
muscle.
B. If not, then the leading edge of the muscle can be retracted to reach the rib.
Diagnosis
A. Test for symmetry with springing
B. Should feel equal rebound on each side
Dickey directed the class to the PP (provided at the end of scribe) for
illustrations of the following four techniques.
Dickey prefers this technique in the supine
A. Can adjust table to right height.
B. Patient is more relaxed
C. Patient not using postural muscles
Finding first rib with patient supine (Dickey used his thumb)
A. From spinous process move an inch to inch and half laterally to transverse
process
B. Head of rib articulates with transverse process at a costo-transverse
articulation.
C. Split difference between the neck and the head of the rib by moving
between spinous and transverse processes.
OMM 2, Lecture #11(PTR)
Atypical Ribs
Dickey, DO
Scribe: matthew jones
- 2 - of 4
VIII.
IX.
X.
XI.
Diagnosis
A. Spring on rib as in seated position
B. Negate muscle and pay attention only to movement of bone
Technique #1:ME for elevated first rib
A. Engage first rib as described above
B. Ask patient to take deep breaths
C. With each breath follow the rib down on expiration and hold it down on
inspiration
D. This can be augmented then by asking patient to shrug shoulders and
relax; follow rib down when they relax and hold it down when they shrug
1. With the shrug the patient is elevating the distal end of the rib
2. The physician’s thumb is acting as a false fulcrum (the true
fulcrum would be the costo-transverse articulation)
3. Normally this would mean the depression of the head and neck
relative to the shoulders
4. As distal end goes up the proximal end much go down.
5. This technique augments the natural fulcrum.
E. Make sure to take up the slack upon relaxation.
Technique #2:ME for depressed first rib
A. Usually only seen as a result of trauma
1. Remember that ant. and med. scalenes insert on the first rib and the
post. inserts on the second rib.
2. We have to lock out the second rib in order to isolate traction on the
first rib.
B. Engaging depressed first rib
1. Sidebend patient’s head away while holding down the second rib
2. Have patient shrug ipsilateral shoulder and find second rib high
in the axilla—highest rib accessible.
3. Curl fingers around the second rib to hold down, should produce
some apprehension in patient
C. Sidebend away, rotate away, and forward bend and backward bend as
needed while holding down the second rib
D. Have patient try to return head to normal against your force.
E. Then have them relax, wait, and take up slack
F. Repeat at least a couple of times
G. Must utilize the patients force to elevate the first rib
Technique #3:ME for depressed 11th or 12th rib
A. Muscle moves inferior due to excess tension of the quadratus lumborum
muscle
B. MSS reminder: quadratus lumborum muscle origin, iliac crest, iliolumbar
ligament, and transverse processes of lower lumbar vertebrae; insertion,
twelfth rib and transverse processes of upper lumbar vertebrae;action,
abducts trunk; nerve supply, ventral primary rami of upper lumbar spinal
nerves. Syn: musculus quadratus lumborum [TA].
OMM 2, Lecture #11(PTR)
Atypical Ribs
Dickey, DO
Scribe: matthew jones
- 3 - of 4
C. For those of you (like myself) who forgot the details of this muscle,
Dickey reminded us that we are not allowed to forget anything we learn in
medical school.
D. Shaft of thumb is placed post to the rib while physician reaches around
and grasps the patients ipsilateral ASIS.
E. The ASIS is lifted off the table while the rib is held down.
F. Patient is then asked to pull ASIS back to table, contracting the quadratus
lumborum.
G. When they relax the physician lifts the ASIS higher to take up the slack
XII. Technique #4:ME for elevated 11th or 12th ribs
A. Same as above with the following exceptions:
1. The rib is engaged with the thumb at the facet
2. This creates a false fulcrum
3. The result will be that the quadratus lumborum will pull the
distal rib inferiorly.
B. In both cases we lean into the thumb on the rib and adjust the table to the proper
height.
C. May find either a vestigial 12th rib or a 13th rib as a result of an overdevelopment
of the transverse process.
XIII. Make sure to look up what is expected on the next practical (on the web).
From the oldest osteopathic text:
Job 30:17* My bones are pierced in me in the night season: and my sinews take
no rest.
Job 30:30* My skin is black upon me, and my bones are burned with heat.
Job 33:19 He is chastened also with pain upon his bed, and the multitude of his
bones with strong pain:
Ps 6:2* Have mercy upon me, O LORD; for I am weak: O LORD, heal me; for my
bones are vexed.
Ps 22:14* I am poured out like water, and all my bones are out of joint: my heart
is like wax; it is melted in the midst of my bowels.
PS 7 ¶ Purge me with hyssop, and I shall be clean: wash me, and I shall be
whiter than snow.
8* Make me to hear joy and gladness; that the bones which thou hast broken
may rejoice.
9 Hide thy face from my sins, and blot out all mine iniquities.
10* Create in me a clean heart, O God; and renew a right spirit within me.
Atypical Ribs
Jerry Dickey, DO
OMM 2, Lecture #11(PTR)
Atypical Ribs
Dickey, DO
Scribe: matthew jones
- 4 - of 4
OMM Department
UNTHSC
January 28, 2003 @ 9am
Techniques

Seated – direct method – ME (isometric)
 4831.22A - pg. 136

Supine – direct method – patient coop. and resp. force
 4831.12D – pg. 135

Prone – direct method – traction, resp. force
 482.12 A – pg. 138

Prone – direct method – traction, resp. force
4832.22A – pg. 139