• Review of anatomy
– True rib pair has 10 joints.
• Discuss common structural dysfunction which can cause pain with breathing.
• Discuss cardiopulmonary dysfunction which can cause mechanical dysfunction within the rib cage.

• Rib dysfunctions are grouped into two categories:
– Respiratory rib dysfunctions
• Happens during breathing
– Structural rib dysfunctions
• Happens with rib itself or with movement.
• Treat thoracic spine for rotational dysfunctions in extension or flexion before treating the rib dysfunctions
– Thoracic spine fixes rib issues commonly

• After you assess the thoracic contour and evaluate symmetry/asymmetry:
– Symmetry, humps with flexion, breathing, rib mobility, springing on ribs, measuring volume.
– Rule of three: T1-T3 rib at level of transver, T3: ½ below
T10: whole level, T11: ½ level, T12:
-Evaluate the rib angle, should gradually move laterally
• With the patient supine, push on the lateral aspect of the ribs.
• Resistance to this pushing force indicates rib restriction.

PRINCIPLES OF DIAGNOSIS
• You can evaluate rib motion without the patient actively breathing.
• Simply passively move the ribs into exhalation and inhalation.
• Remember: “Down in front, up in back”
(flexion) for exhalation and “Up in front, down in back” for inhalation (extension).
• Palpate posteriorly for tenderness/tissue change at the rib angle.
• Palpate anteriorly; look for anterior counterstrain points.

On inhalation, the thoracic A-P curve flattens, on exhalation it increases.
1. An extended thoracic area should be associated with inhalation dysfunction in ribs.
2. A flexed thoracic area should be associated with exhalation dysfunction in ribs.
3. Sometimes, an atypical pattern rib dysfunction exists with reversal of the pattern.

• Manual muscle test of the diaphragm
– Push belly up, and we then give resistance to push it back in.
• When breathing is compromised, then the diaphram forgets its posture role, and focuses just on breathing.

• AP glides of the sternochondral joints
– Ribs 1-7
– Tzsitie Syndrome: swelling
– Costochondritisi: no swelling
• Mobility testing of the
Costotransverse and
Costovertebral joints
– Ribs 1-10
– Sitting, PA pressure at rib angle tests costotransverse joint
– Maintain pressure, pull laterally to test mobility of the costovertebral joint

• Rib Angles
• Changes in AP symmetry
• Inferior border for sharpness
• Changes in intercostal spaces
• Hypertonicity and tenderness
• Changes with flexion or extension of the spine
• Sharp angle/edge, means that it is a rotational injury

• Cervical Rotation/Lateral
Flexion Test (CRLF) for
Diagnosis of Superiorly subluxed first rib
• Patient supine or sitting
• PT maximally rotates head to one side, then laterally flexes head
• Rotate head to left and laterally flex, are testing the right first rib mobility
• Rotate head to the right, then left scalenes and
SCM are tight then flexing asses the left 1 st rib

Pump handle breathing
• Can be assessed in sitting or supine
• Place hands on anterior chest
• Ask patient to breathe in and out
• Assess rib movement
Bucket handle breathing
• Can be assessed in sitting or supine
• Place hands on lateral chest wall
• Ask patient to breathe in and out
• Assess rib movement

Caliper motion breathing
• Can be assessed in prone
• Place hands on lower trunk
• Ask patient to breathe in and out
• Assess rib movement
Individual rib movement
• Can best be assessed in supine
• Place hands on anterior chest
• Thumbs over both ribs
• Ask patient to breathe in and out
• Assess which rib stops moving first
• Assess if movement occurs on inspiration or expiration
• Key Rib: need to t(x) this rib, the 1 st superior rib that does not move compared to the other side in inhalation. In exhalation it is the 1 st inferior rib that does not move.

• Restriction in rib mobility secondary to one of the below:
– Non-neutral vertebral dysfunction: ERS (not able to exhale) or FRS (not able to inhale) at that level (90%)
– A structural rib dysfunction
– A respiratory rib dysfunction
Rib vs. Facet
– Rib dysfunction: pain will wrap around the body
– Facet dysfunction: pain will shoot straight through the body

STRUCTURAL RIB CLASSIFICATION
(Greenman)
• Anterior Rib Subluxation Diagnosis :
– Rib angle tender
– Rib angle less prominent posteriorly
– Prominence of anterior portion of rib
– Marked motion restriction for both inhalation and exhalation
• Posterior Rib Subluxation Diagnosis :
– Rib angle tender
– Rib angle more prominent posteriorly
– Anterior portion of rib less prominent
– Marked motion restriction for both inhalation and exhalation

• Superior 1st Rib Subluxation
Diagnosis:
– Palpation of superior aspect of 1st rib shows dysfunctional side to be 5-6mm cephalic compared to other side
– Marked tenderness of superior aspect of first rib
– Restriction primarily during Exhalation
– Positive Cervical Rotation Lateral Flexion Test

• T1 is dysfunction – check for non-neutral dysfunctions – ERS or
FRS
• T2 is laterally flexed and won’t allow T1 to return to normal position

• Key Rib:
– Rib which stops moving first upon inhalation

Treatment of Inhalation Restrictions
Ribs 1-2
Key Muscle: Scalenes

nd
• Evaluate:
– Acute tenderness to palpation of pect minor
– Positive neural tension signs
– Failed first rib treatment
• Treatment:
– Patient supine with arm outstretched in median nerve neural tension position
– Patient’s head in flexion sidebending away and rotation away from side of dysfunction
– Elbow is flexed and extended
– PT will put pressure on second rib

Key Muscle: Pectoralis Minor

Key Muscle: Serratus Anterior

• Key Rib:
– Rib which stops moving first upon exhalation

Exhalation Restriction
Trunk is placed in Flexion, Sidebending
On restricted side.
-Can place a wedge or lift of table to help

• Muscular attachments contributing to respiratory dysfunctions:
– Scalenes to ribs 1-2
– External & Internal intercostals
– Pectoralis minor ribs 3-5
– Serratus anterior ribs 3-9
– Diaphragm to inner surface ribs 6-12
– Quadratus lumborum to rib 12
• Ligamentous strain
– Costo-transverse & costo-vertebral articulations
• Chondral dysfunction
• Thoracic vertebral dysfunction

Insert slides

M uscles of the Spine and Thorax
Text
Manual Therapy in the Treatment of Patients with Cardiovascular and Rib Dysfunctions

D iaphragm

Teitze’s Syndrome and Costochondritis

Acute Care Examples of Patients with
Rib Dysfunctions
• Post Surgical
– Sternotomy
– Thoracic incisions from CABG, valve replacement and chest tube placements
– Spinal surgeries
– Abdominal incisions from any organ surgery and
PEG tube placements/ostomy
– Mastectomy
– Tracheostomy

• Full Median Sternotomy: central incision through the length of the sternum
– Standard approach for a CABG
• Partial Median Sternotomy: central incision from sternal notch to ribs 4,5
– Common in surgeries of the heart valves

• Exacerbations of Disease
– COPD
– MS
– Pneumonia

• Neuromusculoskeletal Dysfunctions
– CVA
• Depressed on one side
– Trauma to the spine, ribs, pelvis with or without surgical procedures
• Mechanical Rib Dysfunctions
– Amputation with co-morbidities of cardiopulmonary disorders

• What effects would scoliosis have on rib cage movement?
– Convexity of Left: rib smaller, humps up and laterally being squished.
• What would happen to breathing if a rib separation occurred at an intercostal joint?
– Can’t pull rib below it, with it when you breath in.
Pain with breathing, pt will hold rib and breath away from separation.