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Rib Rib Rib Rib MobilizationsMobilizationsMobilizationsMobilizations

Presented by Aaron Rutter

PT, BScPT, FCAMPT, CAFCI

www.leadtheway.ca/continuingeducation/

Certificate of Excellence In AssessmentCertificate of Excellence In AssessmentCertificate of Excellence In AssessmentCertificate of Excellence In Assessment

Certificate of Excellence (COE) Program

• Program delivered by the RMTAO

• Certificate of Excellence in Assessment

• CMTO and RMTAO member

• Complete 10 RMTAO run assessment courses over a 5 year period

• Pass each course’s examination with a minimum 70% (multiple choice quiz)

Introduction

• Registered Physiotherapist

• Certified Manual and Manipulative Physiotherapist

• Certified in Acupuncture

• Queen’s University

• RMTAO courses

Course Objectives

• What conditions can you help by improving rib mobility?

• What is normal lateral costal expansion?

• How do you assess and treat joint stiffness or fixations of the ribs?

• How do you distract a rib?

• What home exercises can you give to improve pain, ROM and function in the thoracic spine and ribs?

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Ribs

• Do you treat the rib cage with your shoulder impingement patients or patients with decreased arm elevation?

• Do you treat the rib cage with your mid to lower c-spine OA patients?

• Do you treat the rib cage with your WAD I/II patients or patients with acute neck pain?

Rib CageAnterior

Jugular (suprasternal) notch

Rib

Manubrium

Sternomanubrial joint

(sternal angle)

Sternum

Costocartilage

Sternocostal joint

Xiphisternal joint

Xiphoid process

Costochondrium

Costochondrial joint

Rib CagePosterior

Scapula

Transverse processes

Spinous processes

Ribs

Ribs 1-6 ant to TP

Ribs 7-10 ant/sup to TP

Ribs 11-12 don’t touch TP

Thoracic Vertebrae

Vertebral body

Superior articular process

Transverse process

Costovertebral joint

Costotransverse joint

Intervertebral foramina

Costovertebral joint of rib below

Inferior articular process

Spinous process

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Ribs

1st rib

Typical rib

Head of rib

Neck of rib

Tubercle of rib

Angle of rib

Rib Ligaments

Anterior longitudinal ligament

Superior costotransverse ligament

(rib to TP above)

Radiate ligament

Intra-articular ligament

Intra-articular ligament

(head of rib to vertebral body)

Lateral costotransverse ligament

(tubercle of rib to TP at same level)

Radiate ligament

(head of rib to vertebral body & disc)

Costotransverse ligament

(neck of rib to TP at same level)

Rib LigamentsPosterior Thorax(deep)

1. Semispinalis

2. Rotatores

3. Levatores costarum longus & brevis

4. External intercostals

5. Multifidus

6. Quadradus lumborum

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Sympathetic Chain

• Sympathetic Nervous System

T4 Syndrome

• Facilitation of the nervous system at the T4 level caused by a mechanical dysfunction

• Costotransverse joint, facet joint, disc

• Diffuse arm pain

• Diffuse arm and hand numbness and tingling

• Glove like, no dermatomal pattern

• Upper back stiffness

• DeFrance GG, Levine LJ. The T4 syndrome. J Manipulative PhysiolTher 1995; 18(1):34-7.

Thorax Palpation

• Facilitated Segment

• Pilomotor reflex

• Skin temperature is cool

• Sudomotor reflex

• Increased skin drag or resistance

• Peau d’orange

• Skin rolling/squeezing, change in texture/colour of skin

• Trophedema

• Non pitting edema that persists (skin denting)

• Wheel response

• Scratch test: lack of vascular response

• Indicates an area of sympathetic nervous system facilitation

Thorax Palpation

• T1-12 spinous processes

• T1-12 z-joints• Feel for local (1-2 levels) vs global (4-5 levels) muscle tension• Facilitated segment

• T1-12 transverse processes

• Ribs 1-12 posteriorly• Costotransverse joint

• Jugular (suprasternal) notch

• Manubrium

• Sternal angle

• Sternum

• Xiphoid

• Ribs 1-6 anteriorly• Manubrocostal, sternocostal and costochondral joints

• Ribs 7-10 anteriorly• Costochondrium

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Ribs

• Typical rib articulates with its own vertebrae and TP as well as the vertebrae above and disc between

• Ribs 1, 11 and 12 articulate only with their own vertebrae

• Ribs 11 and 12 do not articulate anteriorly with the costochondrium or their TP. They are floating ribs

• The ribs make the thoracic spine the mechanically stiffest and least mobile region of the spine

• Ribs 1-6 ant to TP

• Ribs 7-10 ant/sup to TP

• Ribs 11-12 don’t touch TP

Rib Function

• Support/protect the viscera

• Muscle attachment

• Motion

• Breathing, ROM

Thorax Pain

1. Nociceptive• Pain from any structure that has nerve supply (articular, myofascial,

ligamentous, disc, dura etc) • Costotransverse joint pain stays localized• Mechanical pain from somatic structures is by far the most common

type of thorax pain

2. Neurogenic• Neural tissue inflammation, compression etc• Pain, weakness and paraesthesia in intercostal space of level affected

3. Visceral• Pain referral from internal organs

4. Central• Chronic pain due to sensitization of the nervous system, lowered pain

threshold

Costotransverse Joint PainNociceptive Pain

• Young BA et al. Thoracic costotransverse joint pain patterns: a study in normal volunteers. BMC Musculoskeletal Disorders 2008, 9:140.

• Innervated by the lateral branch of the primary dorsal ramus and also has connections to the sympathetic nervous system at the corresponding level and the level above

• Ipsilateral

• Localized, no referral to chest

• 3.3/10

• Deep dull ache, pressure sensation

• Rarely does it refer above or below, but if it does it goes a maximum of 2 levels

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Left 3rd Costotransverse Joint Nociceptive Pain Right T7 Peripheral Neurogenic Pain

T7

Radiates around towards sternum

in intercostal space

Visceral PainKey Thorax Subjective Questions

• Cord signs and symptoms

• Disc signs and symptoms• Pain on cough/sneeze/valsalva

• Cancer history• Bony metastasis to spine

• Breast, bronchus, bowel, prostrate, thyroid, kidney, lymphoma

• Pancoast tumour

• Visceral symptoms• Pain with breathing, shortness of breath

• Chest pain with exertion

• Bladder/Bowel

• GI problems

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Observations

Flattened Thoracic Spine

Scoliosis

• Lateral curvature of spine

• Structural vs nonstructural

• Always named for the convex side

• Example

• Right thoracic

• Left lumbar

Dowager’s Hump

• Results from postmenopausal osteoporosis

• Multiple compression fractures causing excessive kyphosis and an associated scoliosis

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Scheurmann’s Disease

• Disturbance in normal development of endplates due to Schmorl’s nodes

• Increased thoracic kyphosis, onset usually in 2nd decade in males

Pigeon Chest (pectus carinatum)

• Sternum projects forward and downward

Funnel Chest(pectus excavatum)

� Sternum is pushed posteriorly by an overgrowth of the ribs

Barrel Chest

• Sternum projects forward and upward increasing the anterior/posterior diameter

• Common in chronic lung diseases

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Thorax Observations

• Spinal curves/posture• kyphosis (apex about T7-8), scoliosis

• increased, normal, decreased

• Muscle bulk/tension• Posterior

• UFT, MFT, LFT, LS, Rhomboids, ES, LD, QL, multifidi

• Anterior• RA, EO, IO

• Scars (bypass surgery etc)

• Bump/lump at manubrocostal, sternocostal or costochondraljoints

Thorax ROM

Big variation in the amount of motion between individuals

Is movement symmetrical?

Do they meet the minimum amount of motion?

Movement ROM

Flexion 20-45 degrees

Extension 25-45 degrees

Side bend 20-40 degrees each way

Rotation 35-50 degrees each way

Chest Expansion

(xiphoid process)

3-7.5 cm

AROM

Thoracic Spine• Flexion: elbows towards belly button

• Extension: lift arms and chest• Side bend: shoulder towards hip

• Rotation: twist to the right and left

• Clear joints above and below• Cervical and lumbar spine, shoulder

Clinical Tidbits

• Do in sitting to stabilize pelvis

• Cross arms, one underneath each other or hands behind neck

• May need to stabilize the lumbar spine

• Add overpressure if client has full and pain free AROM

Thorax ROMFlexion

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Thorax ROMExtension

Thorax ROMSide Bend

Thorax ROMRotation Thorax ROM

Alternative Position: Rotation

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Thorax ROMAlternative Position: Rotation

AROM

flexion

extension

R rotation

R side bend

L rotation

L side bend

Thorax ROMChest Expansion

Thorax ROM

Breathing

• pump handle (ribs 1-6)

• bucket handle/lateral costal expansion (ribs 7-10)

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Thorax ROM

Breathing

• Usually want to minimize pump handle breathing and improve bucket handle (lateral costal) and diaphragmatic breathing

Costotransverse JointCostovertebral Joint

Costotransverse (CT) Joint

Synovial

Modified ovoid (rib convex, transverse process concave)

Joint between articular facet of posterior aspect of rib tubercle and the articular facet on the anterior aspect of the transverse process

Costovertebral (CV) Joint

Synovial

Modified ovoid (rib convex, vertebrae concave)

Joint between head of rib and vertebral body

Clinically unable to test costovertebral joint, as is too deep

Biomechanics

• Osteokinematics

• How the bone moves in space

• Range of motion

• Arthrokinematics

• How the bone moves relative to the one it is attached to

• Joint glide

Costotransverse Joint Osteokinematics

• The rib can only perform two motions

• Anterior rotation

• Posterior rotation

• Palpate rib using web space of hand (thumb and index finger) on each side

• Feel for rib movement as perform physiological movements

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Costotransverse JointOsteokinematics

Movement Ribs

Thoracic flexion

Thoracic extension

Thoracic SB

Thoracic Rot

Inspiration

Expiration

Right Costotransverse Joint Osteokinematics

• Anterior Rotation

• Posterior Rotation

Combined Motions

• Thoracic flexion/right rotation

• Thoracic flexion/left rotation

• Thoracic extension/right rotation

• Thoracic extension/left rotation

These combined motions match z-joint motion as well

Combined Motions

• Thoracic left rotation/right side bend

• Thoracic right rotation/left side bend

These combined motions can help differentiate

rib restriction from z-joint restriction

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Combined MotionsFlexion Quadrants

Combined MotionsExtension Quadrants

Combined MotionsSide Bend and Opposite Rotation

Costotransverse Joint Arthrokinematics (Joint Glide)

• The rib can only perform two motions

• Ribs 1-6 (pump handle)

• Superior glide

• Inferior glide

• Ribs 7-10 (bucket handle)

• Post/med/sup glide (PMS)

• Ant/lat/inf glide (ALI)

• Palpate transverse process and rib at same level

• Feel for rib movement relative to transverse process as perform physiological movements through mid-range

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Costotransverse JointArthrokinematics (Joint Glide)

Movement Ribs 1-6 Ribs 7-10

Thoracic flex

Thoracic ext

Thoracic SB

Thoracic Rot

Inspiration

Expiration

Right Costotransverse JointArthrokinematics (Joint Glide)

• Superior Glide/PMS

• Inferior glide/ALI

Clinical Tidbit

• Anterior rotation produces a superior glide (ribs 1-6) or PMS glide (ribs 7-10)

• Posterior rotation produces an inferior glide (ribs 1-6) or ALI glide (ribs 7-10)

Passive Motion of the Costotransverse Joint

• Use less movement than you think, lumbar spine must stay stable

• Palpate rib relative to transverse process at same level

• Watch and feel

• IT EITHER MOVES OR IT DOESN’T

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Passive Motion of the Costotransverse Joint

Arm Placement

Passive Motion of the Costotransverse Joint

When to right of patient perform

• R rot while palpating on R (post rot on R)

• R rot while palpating on L (ant rot on L)

When to left of patient perform

• L rot while palpating on L (post rot on L)

• L rot while palpating on R (ant rot on R)

May also feel passive motion of upper ribs with cervical motions and arm elevation

May also feel passive motion of ribs through other single plane motions or combined movements

Joint Glides

• Use thumbs to assess

• Use hypothenar eminence (pisiform) to treat

• Be as close to costotransverse joint as possible

• Let patient’s arms hang over side of bed to protract scapula, gives you more room to work with

• IT EITHER MOVES OR IT DOESN’T

Joint GlidesRibs 1-6

• Superior Glide (end feel?)

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Joint GlidesRibs 1-6

• Inferior Glide (end feel?)

Joint GlidesRib 1

• Inferior Glide (end feel?)

Joint GlidesRibs 7-10

• PMS (end feel?)

Indirect Technique

Joint GlidesRibs 7-10

• ALI (end feel?)

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Joint GlidesRibs 1-12

• Anterior glide/distraction (end feel?)

• Tests all of the costotransverse and costovertebral ligaments

Distraction in Sitting

Towel position

Stiffness versus Fixations

• With stiffness will have positive passive mobility and passive accessory testing only for the direction that is stiff

• With a fixation all of your passive mobility and passive accessory testing should be positive

• Fixated joints respond well to distraction mobilizations

Right 6th RibPosterior Rotation Stiffness

• ROM Findings

• Joint Glide Findings

• Combined Movement Findings

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Left 8th RibAnterior Rotation Stiffness

• ROM Findings

• Joint Glide Findings

• Combined Movement Findings

Left 2nd RibFixation

• ROM Findings

• Joint Glide Findings

• Combined Movement Findings

Anterior Costal Joints

• Rib 1: synarthrosis

• manubrocostal

• Ribs 2-6: synovial

• sternocostal

• Ribs 7-10: fibrous

• attach indirectly to sternum through costochondrium

• Ribs 11-12: do not attach to sternum

• floating

Anterior Costal Joints

• Costochondral Joints

• Where rib attaches to costocartilage

• Located approximately 1 inch lateral to the sternum

• Feel for where the bone changes to cartilage

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Common Pathologies

• Fractures/stress fractures

• Manubrium, sternum, ribs, costocartilage

• Slipping rib syndrome

• Joint fixations

• Subluxations (palpable bump)

• Joint stiffness

• Costochondritis

• No swelling visible

• Tietze syndrome

• Swelling visible

• Gregory PL et al. Musculoskeletal problems of the chest wall in athletes. Sports Med 2002; 32(4): 235-250.

Joint GlidesAnterior Costal Joints

• Inferior glide (end feel?)

Joint GlidesAnterior Costal Joints

• Superior glide (end feel?)

Joint GlidesAnterior Anterior Anterior Anterior Costal JointsCostal JointsCostal JointsCostal Joints

• Posterior glide (end feel?)

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Thorax Stretching

1. Combined motions

� Right side bend/left rotation

� Left side bend/right rotation

Thorax Stretching

2. Mobilizations with movement (belt)

• Place belt at level of dysfunction

• Apply an anterior force (distraction) with belt

• Perform appropriate combined or physiological motion

Thorax Stretching

3. Tennis ball

• Lean up against tennis ball on wall (chin retraction)

• Causes distraction of the costotransversejoint

Thorax Stretching

4. Extension over a foam roller

• Place foam roller at level of dysfunction

• PPT

• Chin retraction

• Arm elevation

• Causes distraction and posterior rotation of ribs

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Thorax Stretching

5. Thorax extension on wall

• PPT

• Chin retraction

• Arm abduction and ER up wall

• Causes posterior rotation of ribs

• Concentrate on inspiration

Thorax Stretching

6. Chin retraction over towel

• Sitting with back against wall

• Place firmly rolled towel/tennis ball at level of dysfunction to stabilize rib

• Chin retraction

• Gentle push through feet so buttock slightly de-weights off chair which applies an inferior glide to rib

Thorax Stretching

7. 1st rib (inferior glide)

Thorax Stretching

7. 1st rib (inferior glide)

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Review

• Ant rot and sup/PMS glide are the same motion

• Post rot and inf/ALI glide are the same motion

• Use combined motions to test and treat

• Improve rib mobility into extension

• Posterior rotation/lateral costal expansion

• Inferior glide/ALI

• Stabilization exercises for patients with reoccurrences of stiffness/fixations

Thank you

• For future courses visit www.leadtheway.ca/continuingeducation/ or email me at aaronjrutter@gmail.com