A brief look at assessing rib function
Essentials of assessment
Written by David a. Zulak, ma, rmt
Obviously, “testing rib function, requires an understanding of how ribs function.” The image below nicely summarizes how ribs have been classically organized.
Ribs 1 (plural to denote pairs) is unique in several ways. It articulates with T1 alone. It attaches to the manubrium, just below the sternoclavicular joint. Third, it is a flat bone, set transversely, with the broadest portion facing superior-inferiorly and the thin edges lateral and medial. This broad shelf provides attachment for the scalenes, and traveling across its superior surface is the neurovascular bundle to supply the arm. Ribs 1 (along with ribs 2) and the manubrium are also referred to as the thoracic inlet/outlet.
Rib 2 motions (elevation and depression) are best felt anteriorly just prior to its articulation with the manubrium-sternum.
Place an index finger on each rib 2 and have the client breathe deeply, then normally, as you follow the motions.
Another joint to consider, before we move on, is the cartilaginous joint between the manubrium and sternum. As the sternal complex rises on inhalation the manubrium rises superiorly and anteriorly.
The sternum will of course follow superiorly, but the lower end of the sternum is not allowed to move anteriorly as much, due to the lower ribs. Hence there is a slight hinge motion at the sterno-manubrial joint.
This motion can be palpated by placing one finger above and one finger below the joint as the client breathes. We should feel a springiness if we simultaneously push on the manubrium and the sternum into the chest slightly.
This motion of the manubrium and the sternum requires that we keep in mind the affect that the shoulder girdle will have on the motions of the ribs.
The sternoclavicular joint, being the only boney bridge between the upper limb and the axial skeleton, is not just important to keep in mind for proper clavicular motions during shoulder movements.
It also requires us to keep any present shoulder dysfunction in mind, when we look at rib/respiration problems. A fixed or restricted SC joint will affect the motion of the ribs, (amount/quality of motion and direction of movement/lines of tension).
A quick scan of respiration during the testing of shoulder dysfunctions could be useful to gain the information required to help the client back to full function.
Let’s look at the quick scanning of rib motion:
Scanning rib motions during respiration are often done supine. We need to divide the rib cage into three sections. Placing your hands on the anterior surface of the upper 3 ribs available (ribs 2-4) for palpation you would expect to feel the ribs elevate anteriorly and superiorly. This motion is compared to a pump handle as the motion is seen as primarily happening in an up and down motion.
Palpating ribs 5 to 10 on their lateral sides (i.e., under the Serratus Anterior), we can feel the motion of the proverbial bucket handle. This latter motion shows that the ribs move primarily in a ‘lateral excursion’ or swell laterally.
Palpation of ribs 7 through 10 can be done anterior – laterally – still being bucket handle motion. Here you are palpating over a lot of the cartilaginous portion of the lower ribs. A soft spring motion can supply feed back about the soft springiness that should be found there.
It is not contraindicated, if pain free, to rhythmically alternate pushing gently posterior-medially seven to 10 times, as this loosens the lower ribs and intercostals muscles, if tight. Not a bad massage for the internal organs as well – helping to move along fluids, nutrients, and gastric products etc. Especially good for sedentary patients!
To conclude our quick scan: palpate the motion of ribs 11 and 12. Now position the client in prone. This is the best position to palpate ribs 11 and 12. Have the patient place their hands at their back (if possible, or at their waist). This internal rotation of the shoulder helps the scapula to move laterally out of the way for palpation of the ‘rib angles’. Place your hands over these ribs, you should feel them move posteriorly on inhalation: moving as a pair of callipers or ice-thongs.
When palpating true rib angles, note; the quality of motion when compressed, subjective responses of the patient, and also note if one or two ribs (angles) seem more anterior or posterior than others. Compare to your lateral palpation, where those ribs may be ‘bulging’ laterally. Check the intercostals spacing: Are they equal bilaterally? …seem too close on one side or the other? … too large a gap between two on one side?
For more information on the assessment (and treatment planning) of the thoracic region consider participating in the Comprehensive Orthopaedic Assessment ™ (COA) courses that David teaches through the Canadian Institute of Manual Therapies (CIMT). Information and video clips are available at www.cimt.biz.com