1. Rib Review

2. Objectives
To review the basic function and anatomy of the typical and atypical ribs To review the manual diagnosis of somatic dysfunction of the ribs Review the Autonomic innervations

3. Dermatomes C5 – Clavicles T4 – Nipples T7 – Xiphoid process
T10 – Umbilicus
T12 – Inguinal or groin regions

4. Typical Ribs Ribs 3 to 9 are considered “Typical Ribs” They have:
1. Head that articulates with the corresponding vertebra and the one above.
2. Tubercle that articulates with the corresponding transverse process
3. Neck
4. Angle
5. Shaft
Nerve and arteries lie under the shaft of the rib

5. Question #1
A typical rib will have all of the following landmarks EXCEPT?
A) Tubercle
B) Tuberosity
C) Head
D) Neck
E) Angle B
This is question 7 from ch 3 of savarese

6. Tubercle/facet for articulating with same numbered transverse process
Two demifacets
Articulate with:
same vertebra
the one above
Tubercle/facet for articulating with same numbered transverse process
Know that the typical ribs all have demifacets in the head of the rib, that articulate with the vertebrae above and the vertebrae that it is named for
Ex. If this is the 8th rib  will be with T7 and T8
Costal groove - nerve and vessels

7. Question #2
Which one of the following statements concerning the thoracic vertebral attachments of ribs 6-9 is true?
A) Ribs 6-9 attach to T6-T10
B) Ribs 6-9 attach to T6-T9
C) Ribs 6-9 attach to T5-T9
D) Ribs 6-9 attach to T5-T10
This is question 12 from savarese ch 3

8. COSTOVERTEBRAL JOINTS
6th RIB T6
COSTOTRANSVERSE JOINTS

9. Thoracic Apertures: Inlet versus Outlet
The thoracic cavity communicates with the neck and upper limb through the superior thoracic aperture also known as the (boney) thoracic inlet
Trachea, esophagus, major vessels and nerves pass through here
Lymphatic drainage for the whole body drains into the venous system immediately posterior to the medial end of the clavicle and 1st rib
Sibson’s fascia
6.5 x 11 cm in the adult, sloping antero-inferiorly just like the ribs do
Boundaries of Anatomic Thoracic Inlet:
Posterior by T1 vertebra
Laterally by medial margins of 1st ribs and costal cartilages
Anteriorly by superior/posterior border of manubrium
Inferiorly, the thoracic cavity communicates with the abdomen through the anatomic thoracic outlet, closely associated with the abdominal diaphragm.
The “functional” thoracic inlet is a concept that is considered osteopathically to evaluate and treat lymphatic drainage: It includes thoracic segments 1-4, ribs 1 and 2 bilaterally and the manubrium (Kuchera Osteopathic Principles and Practice p 81)

10. Thoracic Inlet: Fascia
The cervicothoracic (diaphragm) fascia covers the thoracic inlet.
It is the deep fascia of the scalenus muscle group
Including variably fibrous bands, this fascia inconsistently includes muscle fibers from scalenus minimus. This fascial covering of the superior dome of the lung is also referred to as Sibson’s Fascia (Grey’s Anatomy)
Sibson’s Fascia
Cervicothoracic Fascial Diaphragm
Final area for obstruction of 2 great lymphatic ducts

11. Thoracic Inlet & Outlet
Greenman P. Principles of Manual Medicine. P 262

12. Anatomical Thoracic Inlet
Functional Thoracic Inlet T1
1st Ribs
Sternal Manubrium
T1-T4
Ribs 1 & 2
Manubrium
Know this

13. Diaphragm Thoracic Cage Dimensions Attachments Innervation
Vertical diameter
Lateral diameter
AP diameter
Attachments
Xiphoid process
Lower six ribs
L1,2,3
Innervation
C3,4,5 (Phrenic n.)
KNOW:
IVC  T8
Esophagus  T10
Aorta  T12
Where it comes through the diaphragm (if you cannot remember this remember your vowels “A-E-I-O-U” use the A – aorta, E – esophagus, I – IVC for the order to remember this
Right Crus – L1-3
Left Crus – L1 – 2 attachment

14. Diaphragmatic Function
Pressure Gradients
Inhalation
Exhalation
Venous Return
Lymphatic Return
Fascial Considerations

15. Lymphatics
Extrapleural lymphatics drain to intercostal vessels, to axillary nodes and then to the right or left lymphatic duct
Pleural sac and lung tissues drain through the pretracheal nodes and then to the right lymphatic duct.
Basic medical and osteopathic research have proven that chronic lymphatic congestion with resultant poor oxygenation of the cells is associated with increased infection, increased mortality, increased healing time, and increased fibrosis and scarring if healing does occur.

16. Question #3
Which of the following groups of ribs are considered false?
A) Ribs 1-8
B) Ribs 7-10
C) Ribs 6-10
D) Ribs 8-10
E) Ribs 7-11
Rib 1  not a synovial joint
Rib 8 – 10  attach through costocondral
Rib 11 and 12  floating ribs

17. Question #4
Which of the following statements regarding ribs 6-9 is true?
A) All of the ribs are considered typical
B) All of the ribs are considered typical except rib 9
C) All of the ribs are considered atypical
D) All of the ribs are considered typical except rib 6
Question 10 from savarese ch 3

18. Rib Groups: Typical vs. Atypical
“Typical” Ribs:
Ribs 3-9
All display both transverse axis (pump handle) and AP axis (bucket handle) motion
Upper ribs prefer pump handle
Lower ribs prefer bucket handle
“Atypical” Ribs
Ribs 1,2, 10, 11-12
10 is atypical because the head of the rib is not a demifacet
He said you will never be asked this though

19. Rib Groups: True, False and Floating
True ribs – 1-7
False ribs – 8-10
Floating ribs – 11,12
Ribs 1-7
Ribs 8-10
Ribs 11,12

20. Atypical Ribs
Functionally ribs 1,2, 10, 11 and 12 are considered atypical ribs
- Rib 1 is short, strong, and very curved
- Rib 2 is typical except for a large tuberosity that allows it to attach to serratus anterior
- Rib 11 and 12 do no have tubercles and do not attach to the sternum/costal cartilage
- Rib 10 is considered atypical because it only articulates with only thoracic vertebrae 10.
Rib 1 also only attaches to T1 and is not a synovial joint like the rest
(I think)

21. Other Naming Conventions
Anatomically, the typical Ribs can be divided into three major groups:
“True Ribs” – ribs 1-7 that articulate directly with the sternum/manumbrium
“False” or “Vertebral-Chondral Ribs” – ribs 8 thru 10 that merge into a single cartilaginous mass that attaches to the sternum
“Floating Ribs” – ribs 11 and 12 that do not articulate with cartillage or bone anteriorly

22. Question #5
Which of the following groups of ribs are considered atypical?
A) Ribs 1,2,3,11,12
B) Ribs 1,2,3,12
C) Ribs 1,3,12
D) Ribs 1,2,11,12
E) Ribs 1,2,12

23. Rib 1 Type: Atypical Primary Motion: Elevation and Depression
Muscles Used to Treat Dysfunction: Anterior Scalene and Middle Scalene
Know the muscles used to treat
Important for thoracic outlet syndrome (subclavian v and a as well as brachial plexus)

24. Rib 2 Type: Atypical Primary Motion: Pump Handle
Muscles Used to Treat Dysfunction: Posterior Scalene
Know the muscles used to treat
This also has a tuberosity that attaches to the serratus anterior

25. Question #6
Which one of the following statements concerning the motion of ribs 6-9 is true?
A) All of the ribs primarily move in a pump-handle motion
B) All of the ribs primarily move in a bucket-handle motion
C) All of the ribs move primarily in a caliper motion
D) All of the ribs primarily move in a pump-handle motion, except rib 9 which moves primarily in a bucket-handle motion
E) All of the ribs primarily move in a bucket-handle motion except rib 6 which moves primarily in a pump-handle motion
2 – 5 pump handle
Feel this best the furthest away from the axis (transverse axis…along the posterior axis of the vertebral attachment of the rib aka spinotransverse axis) so the front
4 – 6 combined
5 – 10 bucket handle
- Feel this best the furthest away from the axis (AP axis…from the sternum to the thoracic vertebrae aka costosternal axis)  so laterally
11 – 12 capiler motion
This is a vertical axis

26. Pump Handle and Bucket Handle Axes
The angle between the spinous process and the transverse process (spinotransverse angle) decreases as you move down the thoracic spine
When the more superior ribs elevate, their movement expands the ribcage in an A/P direction
Pump handle  transverse axis
When the more inferior ribs elevate, their movement expands the ribcage in a lateral direction.
Bucket handle  AP axis

27. Transverse Axis “Pump Handle” Motion
Occurs more predominately in upper ribs
Primarily Ribs 1-5
Occurs around a functional transverse axis
Axis passes through the posterior tubercle and the head of the rib
Increases AP diameter of rib cage

28. Pump Handle Motion As Inspiration occurs:
Anterior Rib head moves cephalad (superiorly)
Posterior rib head moves caudad (inferiorly)

29. Rib moving into inspiration in transverse “Pump Handle” axis

30. Rib moving into expiration in transverse “Pump Handle” axis

31. Resting Position

32. Inhalation

33. Bucket Handle Motion Increases transverse diameter of the rib cage
Occurs predominantly in the lower ribs
Primarily Ribs 6-10
Occurs around a functional anteroposterior (line AB) or longitudinal axis
Axis passes through the posterior tubercle and the anterior end of the rib
Increases transverse diameter of the rib cage
Anterior end of the rib is located medial to the breast tissue, along the midclavicular line when feeling for pump handle ribs, and feel along the midaxillary line for bucket handle ribs

34. Bucket Handle Motion
The intercostal space separates during inhalation and narrows during exhalation
motion is best palpated at the mid-axillary line
Anterior and posterior ends of the axis act as pivots
The rib shaft is the handle of the bucket

35. Inhalation Somatic Dysfunction
Think “Stuck in Inhalation”
Rib is “stuck” in the inspiratory phase of the respiratory cycle
Anterior rib head has moved superiorly, while the posterior head has moved inferiorly
A group that doesn’t drop with exhalation (inhalation SD) may be blocked by the most inferior rib
You could say you have a “stuck up” rib – get it? Ha ha.
^ seriously Klosterman?!
In a group of ribs like this treat key rib  the bottom rib

36. Inhalation S/D: Rib(s) restricted in moving to exhalation position

37. Muscles Used for Inhalation Rib Somatic Dysfunction
Scalenes
Pectoralis Minor
Serratus Anterior
Latissimus Dorsi
Quadratus Lumborum
Intercostales
Diaphragm
Acts Upon
….Ribs 1-2
….Ribs 3,4,5,(6)
….Ribs 6,7,8,9,10
….Ribs 9,10,11,12
….Rib 12 Indirectly
….Forced Exhalation
….Ribs 6-12
Creating valsava while using abdominal muscles also acts upon forced exhalation

38. Muscles of Rib 1 & Rib 2

39. Muscles of Ribs 3 to 8

40. Muscles of Ribs 9 & 10

41. Muscles of Ribs 11 & 12

42. Question #7
All of the following are secondary muscles of respiration (during inhalation) except?
A) Scalenes
B) Pectoralis minor
C) External intercostal
D) Quadratus lumborum
E) Latissumus dorsi
External intercostals are for expiration only

43. Exhalation S/D a.k.a. Expiratory Lesion
Think “Stuck in Exhalation”
Rib is “stuck” in the expiratory phase of the respiratory cycle
Anterior rib head has moved inferiorly, while the posterior head has moved anteriorly
a group that doesn’t rise with inhalation (exhalation SD) is often due to most superior rib “pinning other down”
Treat the most superior rib in a group of dysfunctional ribs

44. Exhalation S/D: Rib(s) restricted in moving to Inhalation position

45. Exhalation Somatic Dysfunction
Inhalation Somatic Dysfunction

46. Question #8
In a pt with chest wall tenderness, rib 5 has limited inhalation motion around an AP axis. The best statement that describes the SD of rib 5 is?
A) The shaft of rib 5 will approximate the shaft of rib 4 at the mid clavicular line
B) Rib 5 will feel more prominent anteriorly
C) The shaft of rib 5 will approximate the shaft of rib 6 in the mid-axillary line
D) Rib 5 has a pump-handle exhalation SD
E) The angle of rib 5 will feel more prominent
This is not a good question
C treats it as a bucket handle, D treats it as a pump handle…it could be either

47. Caliper motion Primary motion of ribs 11 and 12
Imagine that the left and right ribs 11 and 12 are your thumb and index finger pinched together. As you inhale they move farther apart (unpinch), and as you exhale, they pinch together.

48. Treatment Tip
When treating an inhalation somatic dysfunction (“stuck in inhalation”)
Treat the lowest rib of the group of ribs that is restricted
When treating an exhalation somatic dysfunction (“stuck in exhalation”)
Treat the highest rib of the group of ribs that is restricted

49. Question #9 + 10
A 25 y/o male comes to your office complaining of R sided thoracic pain. The pain started after a fall at work 1 week ago. The pain is worse with maximum inhalation. Motrin 4x per day helps. X-rays in the office reveal no frx and the EKG shows normal sinus rhythm. On exam, you notice that ribs 6-9 are restricted with inhalation, therefore you suspect a rib SD. Which of the following statements correctly describes the dx and tx?
Exhalation SD

50. Question #9 A) Inhalation SD and tx should be directed at rib 9
B) Exhalation SD and tx should be directed at rib 9
C) Inhalation SD and tx should be directed at rib 6
D) Exhalation SD and tx should be directed at rib 6

51. Question #10 Which muscle would be used to correct this SD using ME
A) Anterior scalene
B) Posterior scalene
C) Pectoralis minor
D) Serratus anterior
E) Latissimus dorsi
To engage pec minor (3-5, sometimes 6) have pt prone and put their hand on the side of dysfunction on their forehead like the are going to faint, and have them do ME towards the contralateral ASIS
To engage serratus anterior (6-10) have have pt prone and put their hand on the side of dysfunction on their forehead like the are going to faint, and have them do ME anteriorly
To engage the Lat (9-12) have pt prone and put their hand on the side of dysfunction on their forehead like the are going to faint, and have them do ME towards the ipsilateral ASIS

52. Rib Dysfunctions and the Nervous System
Rib 1 dysfunction can compress the cervical plexus
Thoracic outlet syndrome
Each rib has a nerve associated with it
The sympathetic chain ganglion lie anterior to the rib heads
What you treat with rib raising

53. Rib Dysfunctions and the Sympathetic Nervous System

54. Thoracic Sympathetic Innervations
T1 – T Head and Neck
T1 – T Heart
T2 – T Lungs
T2 – T Esophagus, Upper Extremities
T11 – L Lower Extremities
T5 – T Greater Splanchnic Nerve (ex. Stomach, part of the Duodenum, Liver, Gallbladder, Spleen, part of the Pancreas)
T10 – T Lesser Splanchnic Nerve (part of the Duodenum, Jejunum, Ileum, part of the pancreas, Ascending Colon, Proximal 2/3 of the Transverse Colon)
T11 – L Least Splanchnic Nerve (distal 1/3 of transverse colon, Descending Colon, Sigmoid Colon, and Rectum)
T Appendix
T10 – T Kidneys, Upper Ureters
T12 – L Lower Ureters
T11 – L Bladder
Know this well

55. Question #11
Which OMT is the method of choice when attempting to enhance arteriolar lung perfusion and reduce autonomic hyperactivity associated with pneumonia?
A) The occipital decompression
B) ME of C3-5
C) The thoraco-abdominal diaphragm release
D) HVLA to T2-4
E) Rib raising
Video cut off

56. Osteopathic Treatment

57. Question #12
In a pt with neck and upper thoracic pain, you notice that the fifth cervical vertebrae is extended and rotated right. Ribs 1-5 on the L lag behind with deep inspiration. The thoracic vertebrae, T1-5 have a lateral convexity to the right. The transverse processes of these vertebrae are posterior on the right, except for T3 which has a posterior transverse process on the L. Which of the following statements is true regarding dx and tx.
Here is what information this question gives you:
C5 – ERrSBr
Rib 1 – 5 = exhalation somatic dysfunction
T1,2,4,5 = NSBLRR
T3 = non neutral RLSBL

58. Question #12
A) The above pt has an exhalation SD, and initial tx should be directed to rib 1
B) T3 is SLRR and the pt would be asked to rotate their torso to the right wen correction this SD using ME (direct) technique
C) The pt has an inhalation SD and HVLA thrust can be directed at the rib angle of rib 5 to correct this SD
D) C5 will resist translation to the right while the head is in the flexed position. Therefore the head should be placed in the flexed SL and RL position for a direct ME technique
E) T1-5 are NSLRR. These vertebrae should be placed in R sidebending and L rotation when using a direct tx

59. Question #13
While examining a child, you notice a SD of rib 5 on the right. The rib seems to lag with inhalation and move easily into exhalation. Which of the following is the best statement regarding the 5th rib?
A) This pt will have limited cephalad motion of rib 5 at the mid-axillary line
B) This pt will have a TP in the pectoralis minor muscle
C) This pt will display a winging of the scapula
D) The 4th thoracic vertebrae is non-neutral SRRR
E) The 4th thoracic vertebrae is non-neutral SLRL

60. Questions #14-15
A 83 y/o female with severe COPD is having dyspnea. You evaluate her costal motion with deep breath while your hands are over her chest wall. You find limited ROM of ribs 2-6 on the left during expiration. A 5 degree levoscoliosis involving the T2-6 segments is present

61. Question #14 This type of palpatory assessment is called
A) Inherent respiration motion testing
B) Gross motion testing
C) Segmental motion testing
D) Vertebral motion testing
E) Passive motion testing

62. Question #15
The most effective initial tx that would restore costal motion would be directed at?
A) Rib 2
B) Rib 6
C) Thoracic vertebrae – more correct
D) Thoracic inlet
E) Anterior scalene
This is a bad question, but you should always treat the T spine before ribs, so go with C