Ribs and Diaphragm 11/12

Question 1

muscles of inspiration

Answer 1

Principal:

• external intercostals (elevate ribs, increasing width of thoracic cavity)
• interchondral part of internal intercostals also elevates ribs
• Diaphragm: dome descend, thus increasing vertical dimesion and elvates the lower ribs

Accessory:

• sternocleidomastoid - elevates sternum
• Scalenes: anterior, middle, posterior: elevate and fix upper ribs
• Quadratus lumborum
• Serratus anterior (if patient is laying down)
• Pectoralis
• sternocleidomastoid
• Lat Dorsi
• Serratus post superior

Question 2

Muscles of Expiration

Answer 2

Quiet breathing:

• expiration results from passive recoil of lungs and rib cage

Active breathing:

• internal intercostals except interchondral part: lower ribs
• Abdominals (depress lower ribs, compress abdominal contents, thus pushing diaphragm up)
• Rectus abdominis, external oblique, internal oblique, transversus abdominus, serratus posterior inferior, transversus thoracis

Question 3

Nerves

Answer 3

the SNS chain: post ganglionic SNS fibers or preganglionic splanchnics to viscera are right near internal portino of rib head.

Thus rib dysfunctions can dramatically affect SNS tone

Question 4

What are types of motion of Respiration?

Answer 4

1-5: pump handle

• Transverse processes of upper thoracics extend lateral = a largely transverse axis
• palpated best anteriorly
• anteroposterior motion

6-10: bucket handle

• Transverse processes of lower thoracics angle back posteriorly = a more AP axis is created
• palpated best laterally
• up and down motion seen in lateral aspect
• increases transverse diameter

11-12: caliper

• Antero-medial and postero-lateral motion

Question 5

What pierces diaphragm where?

Answer 5

Inferior Vena Cava: T8

Esophagus: T10

Aorta: T12

Question 6

Diaphragm motion

Answer 6

Inhalation

• Contracts down into the abdomen
• Central tendon becomes a fixed point
• Fibers of the diaphragm use as an insertion point

Apertures

• Vena caval opening dilates
• Esophageal hiatus contracts

Exhalation

• Relaxation superiorly into the thorax

Question 7

What are the ribs?

Answer 7

True ribs: attach directly to sternum: 1-7

False ribs: 8-10

Floating ribs: 11-12

Typical ribs: 2-9 have double (demifacets) connection with vertebral bodies

Atypical: 1,10,11,12: one facet

1 – most curved, flat, no angle or groove, single facet with vertebral body
2 – demifacets with T1 & T2 bodies
10 – single facet with T10 body
11 & 12 – no tubercles, tapered ends, single facets with bodies

Question 8

inhaled vs. exhaled ribs

Answer 8

defined in direction of preferred motion

inhaled rib= up in front, down in back

• exhalation dysfunction
• Prominent anteriorly, divot posterior, resists exhalation
• holds up ribs above - keeps them from moving down on exhalation

exhaled = up in back, down in front

• Prominent posteriorly, divot anteriorly, resists inhalation
• inhalation dysfunction
• holds down ribs below - keeps them from moving up in inspiration

Question 9

Rib landmarks

Answer 9

Rib 1
Anteriorly at manubrium

Rib 2
Anteriorly at sternal angle (aka Angle of Louis)

Rib 6

usually at level of inferior border of sternum

Rib 3
Posteriorly with T3 at the spine of the scapula

Rib 7
Posteriorly with T7 at the inferior angle of the scapula

Rib 12
Superior to the iliac crest

Question 10

vertebra landmarks

Answer 10

T2
Suprasternal notch

T4
Sternal angle

T9
Xiphoid process

L3-4
Umbilicus

Question 11

articulation of rib

Answer 11

all ribs articulate with two places on the thoracic vertebrae - the head of the rib articulates with vertebral body/bodies, and the rib tubercle articulates with the transverse process. The angulation between these two contact points determines the primary motion of the rib

• the ribls angle inferiorly from the thoracic vertebrae in the back, so the costal attachment of each rib is inferior to the rib head

Question 12

Rules of Three

Answer 12

• can be used to find ribs posteriorly, knowing that they attach inferiorly to the thoracic vertebrae

T1-T3: spinous process at same level as transverse process

T4-6: Spinous processis half step below transverse process

T7-9: Spinous process full step below transverse process

T10: full step

T11: half step

T12: same level

Question 13

Upper Ribs

Answer 13

Ribs 1-5 “pump handle’

• angulation of rib head and tubercle is more transverse- creating motion in the saggital plane anteriorly around the transverse axis (though more posterior)
• motion best monitored on patients chest parasternally
• ribs are named for its freedom of motion: if rib 1 has greater motion in inhalation, and stops and does not exhale - then it would be called an inhaled rib

Question 14

Lower Ribs

Answer 14

Ribs 6-10 - **“bucket handle” **

• the angle of the rib head and tubercle in the lower ribs is more anteroposterior than the the upper ribs
• this creates motion in the coronal plane- with an AP axis
• greatest amount of motion is in the coronal plane laterally - therefore assesment is best when hands a placed on the lateral aspect of the rib cage: with fingers angled posteriosuperiorly, following the ribs

Question 15

Floating ribs

Answer 15

ribs 11-12

do not attach anteriorly to the costal cartilage, display caliper motion (slight bucket motion as well): posteriorly, on inhalation they move laterally, and on exhalation they move medially

• motion is best monitored when patient is in prone position, place thumbs on transverse processes of T11 or T12 bilaterally and wrap your index fingers around the patients torso following the contour of the ribs,

Question 16

Sternal movment during respiration

Answer 16

with inhalation: sternal angle of louis moves anteriorlyand superiorly, which is allowed by movment of the sternal body and manubrium

Sternum can rotate and sidebend

Question 17

Group rib dysfunctions and the key rib

Answer 17

often you will find group inhalation/exhalation

group of inhaled ribs: (bottom rib is problem) When a single rib is inhaled “up in front, down in back” it acts as a wall to hold a number of ribs above it “up” and not allow them to go into exhalation

group of exhaled rib: (top rib is the problem) key rib is most superior rib in the group “down in fron, up in back” - thereby holding ribs below it “down”

BITE: bottom inhaled, top exhaled

Question 18

TP of Anterior ribs

Answer 18

Anterior Ribs (AR1-10)

Location: midclvicular to midaxillary

patient seated

Inital position: physicians foot (opposite of affected rib) on table with pateitn’s opposite side arm draped over leg. Flexion, slight sidebending and rotation of torso towards affected rib

Involved muscles: external, internal, innermost intercostals, serratus anterior

Question 19

TP for posterior ribs

Answer 19

PR1-12

location: rib angles

patient position: seated

initial position: physicians foot (same side as affected rib) on table with pateitn’s same side arm draped over your leg. Slight extension, sidebending and rotation away from affected rib

involved muscles: external, internal, innermost intercostals, lat dorsi, rhomboids

Question 20

MET for exhaled Rib 1 dysfunctions

Answer 20

Considerations: for exhaled ribs, the physician utilizes the accessory muscles of inhalation to correct the somatic dysfunction. for tib one, the physician will utilie ipsilateral anterior and middle scalene muscles

For right Rib 1 exhaled

place patients right forearm on their forehead, monitor the posterior aspect of rib 1 on the right. instruct the patient to hold their breath in deep inhalation. - while inhaling have patient flex their head and neck while you provide isometric counterforce

Question 21

MET for Exhaled Rib 2 dysfunction

Answer 21

Considerations: for exhaled ribs, the physician utilizes the accessory muscles of inhalation to correct for the SD. For rib 2, physician utilizes the ipsilateral posterior scalene muscle

Rib 2 dx: exhaled on right

standing on right of patient, turn patient’s head about 45 degrees to the left. Place patients right forearm on their forehead, monitor posterior superior aspect of rib two on the right. instruct patient to hold their breath in deep inhalation while flexing their head and neck against your isometric force.

Question 22

MET for exhaled rib 3-5

Answer 22

consideration: use acc. muscles of inhalation to correct for SD. Ipsilateral pectoralis minor muscle

Dx: Rib4 exhaled on right

stand on patients dysfunctional side: contact pateitns right elbow with cephalad hand, monitor the posterior superior aspect of rib 4. abduct the right arm, instruct patient to hold inhlaation, while trying to bring their right elbow toward their left hip.

Question 23

MET for exhaled Rib 6-10 dysfunctions

Answer 23

considerations: utilize acc. muscle of inhalation to correct for SD. for ribs 6-10 use ipsilateral serratus anterior muscle

Dx: rib 8 exhaled

stand on dysfunction side of patient

contact pateitn right forearm with cephalad hand, monitor the posterior superior aspect of rib 8. abduct the right arm until motion is palpated at rib 8, instruct patient to hold their breath in deep inhalation while trying to adduct their shoulder against isometric force

Question 24

MET for exhaled rib 11-12 dysfunction

Answer 24

consideration: utilize quadratus lumborum to correct for dysfu;nction of caliper ribs. The difference for the inhaled technique and exhaled technique is the hand placement on the posterior aspect of the rib.

Rib 12 exhaled on left.

physician stands on opposite side to dysfunction

patient is prone, with their left arm reaching over their head to the right (causing sidebending away from the exhaled rib)

Monitor motion over the posterior-medial aspect of rib12 with cephalad hand. Contact pateitnts left ASIS, simultaneously apply a posterior pressure to ASIS and an anterior pressure to rib 12. While maintaining deep inhalation instruct patient to pull their left hip to the table (contracting left quadratus lumborum)

Question 25

MET for inhalation Rib 1-5 dysfunction

Answer 25

Considerations: first five ribs are predominantly pump handle (more motion anteriorly than laterally) - therefore treatment may be more effective if flexion is used to localize initially and sidebending

Dx.rib 2 inhaled on the right

physician stand sat head of table

monitor anterior aspect of second rib with right hand. flex patients head and neck until motion is palpated at rib 2 (place knee underneath the pateints head and neck to help support weight). sidebend pateitn head to the right, have them hold their breath in deep exhalation - instruct patient to extend their head and neck against your leg

Question 26

MET inhaled rib 6-10

Answer 26

Consdierations: ribs 6-10 have bucket handle motion (more laterally than anteriorly) - thereore treatment may be more effective if sidebending used to localized initially and flexion is used for fine tuning: treat bottom rib in group inhalation dysfuction

dx. rib 8 inhaled on the right - stand on the dysfunction side of the patient

monitor the superior, lateral aspect of rib, sidebend patients neck and shoulders to right until motion is palpated at rib 8 - slightly flex the patient , instruct patient to hoold their breath in deep exhalation - instruct pateitn to return to neutral psotion (inducing extension and left sidebending) against your isometric force

Question 27

MET for inhaled rib 11-12 dysfunction

Answer 27

Quadratus lumborum is utilized to correct SD of caliper ribs. The difference between the inhaled tech. and exhaled is the hand placement on posterior aspect of rib. for inhalation dysfunction, your hand is placed more laterally on the rib, over the rib angle

dx. rib 12 inhaled on left
position: stand on opposite side of dysfunction

pateitn prone with left arm reaching toward their toes

monitor motion over lateral aspect of rib 12- contact patients left ASIS. apply posterior pressure to ASI and an anterolateral pressure to rib 12, have patient holde breath in deep exhalation - have them pull their left hip to the table.

Question 28

MET for diaphragm dysfunction

Answer 28

dx. right hemi-diaphragm restrcited in inhalation

place hands over lower six ribs, apply slight compressive force down to level of diaphragm - take diaphragm to feather edge by inducing sidebending and rotational motions. instruct pateint to hold breath in inhalation while you resist the downward movment of the diaphragm with your thumbs. instruct patient to exhale, following the motion of the diaphragm through rexhalation taking up the slack.

Question 29

Diaphragm MFR/ “osteopathic hug”

Answer 29

stand behind the patient. have pateitn slump forward, and contact the anterior costal margin, place fingerpads underneath anterior costal margin . apply slight compression and use your body to move patient into sidebending, rotation and flexion/extension

Question 30

Supine Rib raising

Answer 30

considerations: this technique may be done over the thoracic and lumbar spine and SI joints to effect the sympathetic chain ganglia
dx. increased sympathetic tone or spinal facilitation

place both hands underneath the patient’s back and contact the rib tubercles/costotransverse articulation with fingerpads, apply gentle anterolateral pressure with fingerpads

Question 31

Seated Rib raising

Answer 31

considerations: this technique may be done over thoracic and lumbar spine and SI joints to effect the sympathetic chain ganglia

instruct patient to cross their arms in front of them, and to lean forward resting their forearms on your chest. apply gentle anterolateral pressure bilaterally at the rib tubercles.

Question 32

Where does repiratory diaphragm attach

Answer 32

Attaches to the Xiphoid process and 6 lower ribs along costal arch anteriorly

Attaches to the T/L junction, vertebral bodies of L1-L3, and rib 12 posteriorly

Attachments

• Right crus to L1,2,3,(4)
• Left crus to L1,2,(3)
• Arcuate ligaments
• Xyphoid process (sternal origin)
• Ribs 6-12 (costal origin)

inferior connections of diaphragm:

• Quadratus Lumborum
• Psoas Major
• Attaches to the same area as crus
• Psoas minor
• Transversus Abdominis
• External/Internal Oblique
• Ant. Longitudinal Ligament

Question 33

What structures pass through diaphragm, where?

Answer 33

Inferior Vena Cava (T8)
Esophagus (T10)
Descending Aorta / lympatic duct (T12)

 Greater, Lesser, and Least Thoracic Splanchnic Nerves (from lateral sides of the crus
 Sympathetic Chain (under medial arcuate lig)

Question 34

Where do the sympathetic chain ganglia lie?

Answer 34

Lie anterior to rib heads of ribs 1-12
Continues to sacrum lying anterior to the transverse processes of Lumbar vertebrae.
Manipulated by contacting with rib heads through stimulation or inhibition, with the ultimate goal of balancing sympathetic tone.

Question 35

important OPP history dates

Answer 35

Born on August 6, 1828
The banner of Osteopathy was unfurled on June 22, 1874
The term was coined by “an old country doctor” named Andrew Taylor Still, DO, MD, in 1889
Started the first school in Kirksville in 1892 named the American School of Osteopathy