1. Rib Cage Technique List

2. Transverse Axis (Pump Handle)

3. Supine-direct method-respiratory force
Diagnosis: Ribs 2-10 inhalation, pump handle
Patient is supine and the physician stands at the head of the table
Physician contacts the dysfunctional rib or the lowest rib of the group with the lateral margin of his/her thumb on the superior aspect of the rib
Physician slides the other hand under the patient with the fingers hooked under the inferior margin of the posterior angle of the dysfunctional rib and cradles the patient’s head on his/her forearm
Physician lifts patient’s head and upper thorax into flexion to the barrier and applies cephalad tension on the posterior angle of the rib
Patient is instructed “take a deep breathe and then let it all out forcibly”. The physician’s anterior hand carries the anterior portion of the dysfunctional rib caudad and holds the rib at the new restrictive barrier
Steps 4-5 are repeated several times until the dysfunctional area releases (average is 3 times)
Recheck
Note: When you inhale, the anterior end of the rib elevates. The posterior end depresses. When you exhale, the anterior end depresses and the posterior end elevates. In this case, the patient’s anterior end is stuck upwardly so therefore the posterior end is downward. This is why when the patient exhales, we want to push downward on the anterior end which is the direction it should go when we exhale.

4. Supine-indirect method-respiratory force
Diagnosis: Ribs 2-10 inhalation, pump handle
Patient is supine and the physician sits on the side of dysfunction
Physician hooks the fingers of his/her cephalad hand over the superior margin of the angle of the dysfunctional rib or the lower rib of a group
Physician’s caudad hand is in the interspace below the dysfunctional rib and the thumb is at the mid-axillary line
Physician uses 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
Patient is instructed “inhale deeply and hold your breath as long as you can” while the physician makes minor adjustments in position to maintain ligamentous balance
Recheck
Note: When the patient inhales, the anterior end moves superiorly so the physician is going to further that motion by pushing up as well. The physician is going the way it likes to go.

5. Supine-direct method-muscle energy (isometric)
Diagnosis: Ribs 2-10 exhalation, pump handle
Patient is supine and the physician stands or sits on the side of the dysfunction
Physician hooks the fingers of his/her caudad hand over the superior margin of the angle of the dysfunctional rib or the highest rib of a group and applies caudad tension
Patient turns his/her head away from the dysfunctional rib and places the forearm on the side of the dysfunction over his/her forehead
Physician places his/her cephalad hand over the patient’s elbow and forearm
Patient is instructed “pull your elbow toward your chest” or “pull your elbow toward your belly button” whichever effort puts the most muscle tension on the dysfunctional rib, while the physician offers isometric counterforce
Physician has the patient maintain the force long enough to sense that the patient’s contractile force is localized at the dysfunctional segment (typically 3-5 seconds)
Patient is instructed to gently cease the directive force and the physician simultaneously ceases his/her counterforce
Physician waits for the tissues to relax completely (about 2 seconds) and then takes up the slack with the cuadad hand at the rib angle to the new restrictive barrier
Steps 5-8 are repeated until the best rib motion is obtained (average is 3 times)
Recheck
Note: The patient’s posterior end is stuck upward and the anterior end is stuck downward. Hence, the physician pulls the posterior end downward.

6. Supine-indirect method-respiratory force
Diagnosis: Ribs 2-10 exhalation, pump handle
Patient is supine and the physician sits on the side of the dysfunction
Physician passes his/her posterior hand under the patient and contacts the inferior aspect of the angle of the involved rib with the lateral margin of the index finger
Physician places the lateral margin of the index finger of the anterior hand on the superior aspect of the dysfunctional rib at the mid-clavicular line
Physician uses both hands to simultaneously move the rib angle and anterior end in the direction of exhalation to the point of balanced ligamentous tension
Patient is instructed “take a deep breath. Now let it out and hold it out as long as you can” The physician adjusts tension as needed to maintain ligamentous balance
Steps 4-5 are repeated several times until the dysfunctional area releases
Recheck

7. What goes which way?
Anterior part of the rib moves superiorly when you inhale. Anterior part of the rib moves inferiorly when you exhale. The posterior part of the rib moves opposite of the anterior part of the rib.

8. Which rib do I treat?
If you have a EXHALATION dysfuction, you treat the most SUPERIOR rib. If you have a INHALATION dysfuction, you treat the most INFERIOR rib. For example, a patient has a group exhalation dysfunction of ribs 3-5, you should then treat rib 3.

9. Anterior-Posterior Axis (Bucket Handle)

10. Supine-direct method-ME (isometric)
Diagnosis: Ribs 4-10 inhalation, bucket handle
Patient is supine and the physician stands at the head of the table, toward the side of the dysfunction
Physician slides one hand under patient from able 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 midaxillary line with the web between the thumb and index finger of the caudad hand
Patient is lifted into forward bending and sidebending toward side of the dysfunctional rib until the restrictive barrier is reached
Patient is instructed “Bend your body to the other side” The physician has the patient maintain the force long enough to sense the patient’s contractile force localized at the dysfunctional rib (typically 3-5 seconds)
Patient is instructed to gently cease the directive force and the physician simultaneously ceases his/her counterforce
Physician waits for the tissues to relax completely (about 2 seconds) and then takes up the slack with the caudad hand to the new restrictive barrier
Steps 5-7 are repeated until the best rib motion is obtained (average is 3 times)
Recheck
Note: The lateral part (shaft) of rib moves slightly upward on inspiration and restricted on expiration. In this case, there is a restriction in the rib moving downward . It is stuck up. By forward bending and sidebending, it will force the rib to go downward.

11. Seated-direct method-muscle energy (isometric)
Diagnosis: Rib 2 or 3 inhalation, bucket handle
Patient sits and the physician stands behind the patient
Physician contacts the shaft of the dysfunctional rib in the mid axillary line with the fingers of his/her caudad hand
Physician uses the other hand to position the head and neck into sidebending and rotation away from the dysfunctional rib to free the head from its demifacets
Patient is instructed “pull your head to the side against my hand” while the physician offers isometric counterforce
Physician has the patient maintain the force long enough to sense that the patient’s contractile force is localized at the dysfunctional rib (typical 3-5 seconds)
Patient is instructed to gently cease the directive force and the physician simultaneously ceases his/her counterforce
Physician waits for the tissues to relax completely (about 2 seconds) and then takes up the slack with caudad hand at the mid-axillary line to the new restrictive barrier
Steps 4-7 are repeated until the best rib motion is obtained (average is 3 times)
Recheck

12. Supine-direct method-muscle energy (isometric)
Diagnosis: Ribs 4-10 exhalation, bucket handle
Patient is supine and the physician stands on the side of the dysfunction
Physician uses his/her caudad hand to grasp the rib angle of the dysfunctional rib and pull it inferiorly and laterally
Patient turns his/her hand away from the dysfunctional rib and places the forearm on the side of the dysfunction over his/her forehead
Physician places his/her other hand on the patient’s elbow
Patient is instructed “pull your elbow toward your chest” or “pull your elbow toward your belly button” or “pull your elbow toward your hip” whichever effort puts the most muscle tension on the dysfunctional rib
Physician has the patient maintain the force long enough to sense that the patient’s contractile force is localized at the dysfunctional rib (typical 3-5 seconds)
Patient is instructed to gently cease the directive force and the physician simultaneously ceases his/her counterforce
Physician waits for the tissues to relax completely (about 2 seconds) and then takes up the slack with caudad hand at the rib angle to the new restrictive barrier
Steps 5-8 are repeated until the best rib motion is obtained (average is 3 times)
Recheck
Note: Lateral part (shaft) of rib moves slightly downward on expiration and restricted on inspiration.

13. Seated-direct method-muscle energy (isometric)
Diagnosis: Rib 2 or 3 exhalation, bucket handle
Patient sits and the physician stands behind the patient
Physician contacts the shaft of the rib below the dysfunctional rib in the mid-axillary line with the pad of one or more fingers
Physician’s other hand sidebends and rotates the patient’s neck away from the dysfunctional rib to free the rib head from the demifacets and to maximize the pull of the scalene muscles on the dysfunctional rib
Patient is instructed “pull your head to the side against my hand” while the physician offers isometric counterforce
Patient is instructed to gently cease the directive force and the physician simultaneously ceases his/her counterforce
Physician waits for the tissues to relax completely (about 2 seconds) and then takes up the slack with the caudad hand at the mid-axillary line to the new restrictive barrier
Steps 4-6 are repeated until the best rib motion is obtained (average is 3 times)
Recheck

14. Bucket Handle Movements in Dysfunction
Inhalation Dysfunction Shaft of rib moves slightly UPWARD on INSIPRATION and RESTRICTED in EXPIRATION
Exhalation Dysfunction Shaft of ribs moves slightly DOWNWARD on EXPIRATION and RESTRICTED in INSPIRATION.

15. How to memorize the atypical ribs
Atypical ribs have 1s and 2s Rib 1 Rib 2 Rib 11 Rib 12 Sometimes Rib 10

16. Practice Question
Ribs 6-9 on the right are restricted with inhalation, which statement correctly describes the diagnosis and treatment?
Inhalation dysfunction and treatment should be directed at rib 9
Exhalation dysfunction and treatment should be directed at rib 9
Inhalation dysfunction and treatment should be directed at rib 6
Exhalation dysfunction and treatment should be directed at rib 6
Bonus: which muscle would be used to correct this somatic dysfunction?
D, serratus anterior