Rib OMM Scott Klosterman DO

Objectives Demonstrate screening exam for rib dysfunction. Identify to your faculty “pump handle” and “bucket handle” rib motion. Recognize exhalation and inhalation somatic dysfunction. Name the various muscles and muscle groups involved with diagnosing and treatment rib somatic dysfunction. Diagnose, properly set up, and treat typical rib somatic dysfunctions using both direct (ME, resp. cooperation) and indirect methods. Know your bony landmarks for the rib and thoracic levels Be familiar with the muscles of inhalation and exhalation and how to utilize these muscular attachments for treating rib somatic dysfunction

Thoracic Examination Observation Palpation Posture Breathing Palpation Global Screen GROM Directed soft tissue screen Paraspinal red reflex Paraspinal hypertonic changes Segmental screen Springing If changes found diagnose specific area. If segmental dysfunction make a segmental diagnosis. If changes soft tissue make a soft tissue diagnosis

Rib Screening Pump handle ribs 2-5 Bucket handle ribs 5-10 Caliper ribs 11+12

General tx principles Treat thoracic spine first and soft tissues Inhalation somatic dysfunction (stuck up need to be brought to knees/down a notch/humbled) – tx the lowest rib Exhalation somatic dysfunction (stuck down pull up by your bootstraps) tx the highest rib with dysfunction Recheck and if not improved tx the other side with opposite technique or try and identify the key rib (Inhalation on R maybe Exhalation on L)

Exhalation Somatic Dysfunction Inhalation Somatic Dysfunction When treating an inhalation somatic dysfunction (“stuck up in inhalation”) Treat the lowest rib of the group of ribs that is restricted When treating an exhalation somatic dysfunction (“stuck down in exhalation”) Treat the highest rib of the group of ribs that is restricted

Rib Groups: Typical vs. Atypical “Typical” Ribs: Ribs 3-9 display both transverse axis (pump handle) and AP axis (bucket handle) motion Upper 1/3 ribs- predominant pump handle type mechanics around a transverse axis Middle 1/3 ribs- mix of pump and bucket handle mechanics Lower 1/3 ribs- predominant bucket handle mechanics around an AP axis “Atypical” Ribs Ribs 1, 2, 10-12

Rib Inhalation Pump Anterior end moves cephalad on inspiration but is restricted on expiration Anterior narrowing of interspace above dysfunctional rib Breathing and/or certain body movements esp coughing may precipitate pain Tissue texture changes or tenderness over costochondral or chondrosternal junctions or posteriorly over the rib angles Anterior end elevated (cephalad) Superior edge of posterior angle is prominent

Supine, Direct: Respiratory Cooperation (4821 Supine, Direct: Respiratory Cooperation (4821.12B) - “Pump Handle” InHalation SD Physician stands at head of table, Pt. supine. Contact the superior aspect of dysfunctional rib (or lowest rib of dysfunctional group) with the lateral margin of his/her thumb at the mid- clavicular line. Other hand slides under the patient with fingers hooked under the inferior margin of the posterior angle of rib.

Supine, Direct: Respiratory Cooperation (4821 Supine, Direct: Respiratory Cooperation (4821.12B) - “Pump Handle” Inhalation SD Flex the upper thorax up to the level of the dysfunctional rib. Apply cephalad tension on posterior angle of rib carrying it to restrictive barrier. Pt. Instructed to “Take a deep breath and let it out forcibly” Anterior hand carries anterior portion of dysfunctional rib caudad and holds rib at new restrictive barrier.

SUPine, Indirect: Respiratory Cooperation (4821 SUPine, Indirect: Respiratory Cooperation (4821.12C) “Pump Handle” Inhalation SD (Ribs 2-10) Pt is seated, with physician on side of dysfunction. Contact dysfunctional rib: Posterior: superior margin of the angle of dysfunctional rib. Anterior: interspace below dysfunctional rib. Lateral: Both thumbs contact rib shaft along the mid-axillary line.

SUpine, Indirect: Respiratory Cooperation (4821 SUpine, Indirect: Respiratory Cooperation (4821.12C) “Pump Handle” Inhalation SD (Ribs 2-10) Postion the hands on the lowest rib with pt rotating head and body away to free the rib head from the demifacets Use both hands simultaneously to move both the posterior angle and anterior end of the rib in the direction of inhalation to the point of balanced ligamentous tension Instruct patient to “inhale deeply and hold your breath as long as you can” Repeat x 2 and recheck

Practice One up/One down

Rib Inhalation Bucket Tissue texture changes and tenderness in the intercostal muscles at the mid-axillary line or posteriorly over the rib angles. Shaft approximates the rib above Intercostal space is wide below, greatest at the mid-axillary line. Lower edge of shaft prominent. Shaft may move slightly upward on inspiration. Shaft does not move on expiration. Usually a deep ache or pain with respiration.

Supine, Direct: Muscle Energy (4822 Supine, Direct: Muscle Energy (4822.12A) - “Bucket Handle” Inhalation SD (Ribs 4-10) Physician stands at head of table w/ pt supine. Physician slides one hand under patient from above to mid- scapular region while letting the patient’s head rest on his/her forearm. Physician contacts the shaft of the dysfunctional rib at its mid- axillary line with the web between the thumb and index finger. We want to move the “stuck up” group down….so contact the inferior S/D rib CONTACT SHAFT WITH OUTSTRETCHED INDEX FINGER/THUMB IN MID-AXILLARY LINE Localize to maximize the Muscle Energy tx. DOC USES OTHER HAND TO LIFT, FB & SB TOWARDS THE LESION We ask the patient to attempt to return to a neutral position against doctors counterforce Muscles used will depend upon the rib(s) being treated.

Supine, Direct: Muscle Energy (4822 Supine, Direct: Muscle Energy (4822.12A) - “Bucket Handle” Inhalation SD (Ribs 4-10) Pt. is lifted into forward bending and side bending toward side of dysfunctional rib until restrictive barrier is reached. Pt. is instructed to “bend body back to neutral position” against the physician’s resistance for 3-5 sec. After pt. relaxes, physician takes up slack with hand at mid-axillary line to the new restrictive barrier. Repeat x 2 and recheck.

SEated, Direct: Muscle Energy (4822 SEated, Direct: Muscle Energy (4822.12B) - “Bucket Handle” Inhalation SD (Ribs 2-3) Pt is seated with physician standing behind patient. Physician contacts shaft of dysfunctional rib in the mid- axillary line with the fingers of his/her caudad hand. Physician uses other hand to side bend and rotate away from side of dysfunctional rib. With patient seated, the axilla provides access to these ribs. Inspiratory (stuck up), so we want to contact the bottom rib in the group to help bring it down. GRASP SUPERIOR ASPECT ON SHAFT OF LOWEST S/D RIB in MID AXILLA DOC USES OTHER HAND TO POSITION PT HEAD. DOC PROVIDES ISOMETRIC COUNTER FORCE HERE. The force vector is provided by the patient -instructed to pull their head to the side against Doc hand.

Seated, Direct: Muscle Energy (4822 Seated, Direct: Muscle Energy (4822.12B) - “Bucket Handle” Inhalation SD (Ribs 2-3) Pt. is instructed to sidebend head towards side of dysfunction while physician offers isometric counterforce for 3-5 seconds After patient relaxes for 2-3 seconds, physician takes up slack with the hand at the mid-axillary line to the new restrictive barrier Repeat x 2 and recheck

Practice One up/One down

Rib Exhalation Pump Anterior end moves (caudad) on expiration but restricted on inspiration Anterior narrowing of interspace below dysfunctional rib (bottom of the group) Pain may be precipitatied by breathing and/or movements esp coughing Tissue texture changes and tenderness to palpation over the costochondral or chondrosternal junctions or posteriorly over the rib angles Anterior end displaced inferiorly (caudad) Inferior edge of posterior angle prominent

Supine, Direct: Muscle Energy (4821 Supine, Direct: Muscle Energy (4821.22B) “Pump Handle” Exhalation SD (Ribs 2-10) Pt supine, with doctor on side of dysfunction. Hooks fingers of caudad hand over superior margin of the angle of the dysfunction rib Apply caudad tension. Pt rotates head away from side of dysfunctional rib and places the forearm of the side of the dysfunction over his/her forehead.

Supine, Direct: Muscle Energy (4821 Supine, Direct: Muscle Energy (4821.22B) “Pump Handle” Exhalation SD (Ribs 2-10) Physician places other hand over the patient’s elbow and forearm Pt applies a contractile force against the physician’s hand Contraction is held for 3-5 second, while physician offers isometric counterforce Physician allows tissue to relax, and takes up the slack with the caudad hand at the rib angle to the new restrictive barrier Repeat x 2 and recheck

SUpine, Indirect: Respiratory Cooperation (4821 SUpine, Indirect: Respiratory Cooperation (4821.22c) “Pump Handle” Exhalation SD (Ribs 2-10) Pt is seated, with physician on side of dysfunction. Contact dysfunctional rib: Posterior: inferior margin of the angle of dysfunctional rib. Anterior: interspace above dysfunctional rib. Lateral: Both thumbs contact rib shaft along the mid-axillary line.

SUpine, Indirect: Respiratory Cooperation (4821 SUpine, Indirect: Respiratory Cooperation (4821.22C) “Pump Handle” Exhalation SD (Ribs 2-10) Postion the hands on the highest rib with pt rotating head and body away to free the rib head from the demifacets Use both hands simultaneously to move both the posterior angle and anterior end of the rib in the direction of exhalation to the point of balanced ligamentous tension Instruct patient to “exhale deeply and hold your breath as long as you can” Repeat x 2 and recheck

Practice One up/One down

Rib Exhalation Bucket Tissue texture changes and tenderness in the intercostal muscles at the mid-axillary line or posteriorly over the rib angles. Shaft approximates the rib below Intercostal space is wide above, greatest at the mid-axillary line. Upper edge of shaft prominent. Shaft may move slightly downward on expiration. Shaft does not move on inspiration. Usually a deep ache or pain with respiration.

Supine, Direct: Muscle Energy (4822 Supine, Direct: Muscle Energy (4822.22A) - “Bucket Handle” ExHalation SD Ribs 4-10 Pt supine, with doctor on side of dysfunction. Physician hooks fingers of caudad hand over superior margin of the angle of the dysfunction rib or the lower rib of a group and applies caudad/lateral tension. Pt rotates head away from side of dysfunctional rib and places the forearm of the side of the dysfunction over his/her forehead. Supine. This time we want to think about moving the S/D rib(s) off of the lower ribs. CONTACT UPPER ASPECT OF SUPERIOR RIB ANGLE OF LESIONED RIB with FINGER PADS By placing the patient into the “fainting” position on the side of S/D, we can utilize muscle attachments to help us lift the offending ribs. Rotating the patient’s head away allows movement at the rib/vertebral articulation Doc maintains resistance on pt. elbow/forearm Patient provides contractile force, us per usual ME protocol.

Supine, Direct: Muscle Energy (4822 Supine, Direct: Muscle Energy (4822.22A) - “Bucket Handle” ExHalation SD ribs 4-10 Physician places other hand over the patient’s elbow and forearm. Patient is instructed to apply a contractile force against the physician’s hand. Contraction is held for 3-5 second, while physician offers isometric counterforce. Physician allows tissue to relax, and takes up the slack with the caudad hand at the rib angle to the new restrictive barrier (Inferior, lateral force). Repeat x 2 and recheck The patient’s contractile force is directed as follows: upper ribs (ribs 2-4) towards the contralateral (opposite side) nipple middle ribs (ribs 5-7) towards the contralateral ASIS lower ribs (ribs 8-10) towards the ipsilateral (same side) hip

Contractile Force Vector The patient’s contractile force is directed as follows: Towards the contralateral (opposite side) nipple for upper ribs (ribs 2-4) Pectoralis minor m. Towards the contralateral ASIS for middle ribs (ribs 5-7) Serratus anterior m. Towards the ipsilateral (same side) hip for lower ribs (ribs 8- 10) Latissimus dorsi m.

Pectoralis Minor Pectoralis minor

Serratus Anterior Origin: outer aspects of upper 8 to 10 ribs Inserts: anterior surface of vertebral (medial border of scapula Action draws scapula forward & laterally; rotates scapula in raising arm

Latissimus Dorsi Origin: Sp of Vertebrae T7 to S3, thoracolumbar fascia, iliac crest, lowere four ribs inferior angle of scapula Intserts: floor of intertubercular of humerus in bicipital groove Adducts, extends, rotates arms medially.

Scalenes Scalenus anterior Origin: transverse process of 3rd to 6th cervical vertebrae Inserts scalene tubercle of 1st rib Raises ist rib bends neck forward and rotates to opposite side Scalenus Medius Origin: TP of ist 6 cevical vertebra; Inserts upper surface of 1st rib Raises 1st rib bends neck to same side Scalenus Posterior Oriigin: transverse process of 4th to 6th rib Inserts: outer aspect of 2nd rib Raises 1st & 2nd rib bends neck to same side. Scalenus Minimus Origine tp 7th cerv vertebrae Inserts 1st rib & Pleura Tenses dome of the pleura

Supine, Direct: Muscle Energy (4822 Supine, Direct: Muscle Energy (4822.22B) - “Bucket Handle” Exhalation SD (Ribs 2-3) Pt is seated with physician standing behind patient. Physician contacts shaft of the rib below the dysfunctional rib in the mid-axillary line with the fingers of his/her caudad hand. Physician uses other hand to side bend and rotate away from side of dysfunctional rib. Again axilla provides access to the expiratory SD rib ****NOTE: the rib contacted is the rib below the SD rib! How to grasp it? MID AXILLARY LINE Position patient? Why?_rotation away frees demifacet. Doc uses other hand to position head and neck to free SD rib head & maximize pull or the muscles Muscles activated by patient?______ Do you think that the scalenes may also be involved with rib 2 exhalation S/D muscle energy techniques? YES

Supine, Direct: Muscle Energy (4822 Supine, Direct: Muscle Energy (4822.22B) - “Bucket Handle” Exhalation SD (Ribs 2-3) Pt. instructed to “pull your head to the side against my hand” while physician offers isometric counterforce for 3-5 seconds. After patient relaxes for 2-3 seconds, physician takes up slack with the hand at the mid-axillary line to the new restrictive barrier. Repeat x 2 and recheck

Practice One up/One down

Atypical ribs Rib 1 (thoracic inlet indirect covered block 2 ME covered later) Rib 11-12 (inhalation ME Kimberly 140, exhalation ME Kimberly 141)

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