Presentation on theme: "Indiana Osteopathic Association"— Presentation transcript:
1Indiana Osteopathic Association RIB CAGEJOHN G HOHNER, DO, FAAODepartment of Osteopathic Manipulative MedicineChicago College of Osteopathic MedicineMidwestern UniversityMAY 4, 2012
2OBJECTIVES1. 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
15ANATOMY OF THE THORACIC REGION Costovertebral JointsThe head of the first rib does not contact C7.2nd and below ribs contact the superior hemi-facet plus theinferior hemi-facet of the vertebra above.Rib 11 and 12 articulate with the side of the vertebral body.
19ANATOMY Costochondral Joints There is a section of cartilage between a rib and the sternum.Costosternal junctionCostochondral junction
20CLASSIFICATION Cartilage Ribs 1-7 "true ribs" attach to sternum Ribs "false ribs" attach via cartilageRibs 11, 12 "floating"
21The second rib attaches to: The body of T1 and no transverse processThe body of T1 and T2 and no transverse processesThe bodies of T1 and T2, and the T1 transverse processThe bodies of T1 and T2, and the T2 transverse processThe body of T2 and no transverse process
22NEUROVASCULAR STRUCTURES Brachial plexus passes between anterior and middle scalene muscles.
23Intercostal: artery, vein, nerve pass along inferior surface of rib. Autonomics: sympathetic ganglia and chain lie just anterior to ribsIntercostal: artery, vein, nerve pass along inferior surface of rib.
24THORACIC 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
28RESPIRATIONThe 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 gassesFluid movement: venous return, lymphatic return
29MOTION 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.
30MOTION OF THE RIBS DURING INHALATION AND EXHALATION
31PUMP 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).
33BUCKET 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.
36AXIS OF RIB MOTIONThe 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.
38AXIS OF RIB MOTIONThe 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.
39WHAT 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.
40WHAT ABOUT RIBS ?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).
41RIB SOMATIC DYSFUNCTION Rib dysfunctions are grouped into two categories:Respiratory rib dysfunctionsStructural rib dysfunctions
42RESPIRATORY 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.
43RESPIRATORY RIB DYSFUNCTION Respiratory Rib Terminology (named for direction of freer motion)1. Exhalation (exhaled) rib = restriction of inhalation2. Inhalation (inhaled) rib = restriction of exhalation3. Elevated rib/depressed rib
44STRUCTURAL RIB DYSFUNCTION Structural Ribs tend to exhibit restrictions of motion associated with thoracic cage restriction/dysfunction.Inhalation/exhalation is notthe basic motion restriction.
47GROUP RIB DYSFUNCTIONFor 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
48GROUP RIB DYSFUNCTIONFor 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.
50MECHANICAL 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 thepattern.
51PRINCIPLES 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.
52PRINCIPLES 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.
53PRINCIPLES 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.
54TREATMENTTreat thoracic spine component first (unless you are using counterstrain or indirect). Treat structural ribs before respiratory rib dysfunction1st and 2nd rib require special techniques11th 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.
55TREATMENTAvoid 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.
56Case 1 24 yo male Resolving URI Still coughing Pain in right side, worse with inhalationNo local rash, lungs clear
57Case 2 Upper back and right shoulder pain, radiating to right arm Neuro intact, lungs clear, distal CMS intactPositive Adson’s
58Case 323 yo femaleProgressive cough, DOE, generalized chest wall painThorough normal cardiac and pulmonary workup, except for drop in pulse ox with exertionChronic back painPoor chest wall excursion
59SUGGESTED READINGFoundations of Osteopathic Medicine, rd Edition, Chapter 39, Thoracic Region & Rib Cage.An Osteopathic Approach to Diagnosis and Treatment, DiGiovanna and Schiowitz, pp ,Greenman, Principles of Manual Medicine, 2nd Ed., Chapter 15, Rib Cage.