OMT for Ribs and Thoracic Cage - Indiana Osteopathic Association

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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 C
7
.

2
nd

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:

1.
The body of T1 and no
transverse process

2.
The body of T1 and T2 and
no transverse processes

3.
The bodies of T1 and T2, and
the T1 transverse process

4.
The bodies of T1 and T2, and
the T2 transverse process

5.
The body of T2 and no
transverse process

NEUROVASCULAR STRUCTURES

Brachial plexus
passes between
anterior and middle
scalene muscles.


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
1
st

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

12
th

thoracic vertebra

subcostal

margin

xiphoid

process

RESPIRATION

The diaphragm is the primary muscle of
respiration. Innervated by phrenic nerve
(C
3
-
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 45
o

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 T
1
.
When T
1

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 1
st

rib Subluxation
.

Anteroposterior rib compression.


Lateral rib compression


Lateral Flexed rib (usually 2
nd

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.
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

1
st

and 2
nd

rib require special techniques

11
th

and 12
th

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
,

3
rd

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,
2
nd

Ed.
, Chapter 15, Rib Cage.