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

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 There is a section of cartilage between a rib and the sternum. Costosternal junction Costochondral junction

CLASSIFICATION Cartilage Ribs 1-7 "true ribs" attach to sternum Ribs 8-10 "false ribs" attach via cartilage Ribs 11, 12 "floating"

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.

Intercostal: artery, vein, nerve pass along inferior surface of rib. 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 2-5). (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. 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.