Thoracic spine and rib osteopathy

Last updated: December 16, 2023

Summary

The thoracic spine, composed of 12 segments, is the longest subsection of the vertebral column. Each segment has an articulation with a rib, giving rise to an important relationship between structure and function in this region. Therefore, somatic dysfunction in the thoracic spine will affect the rib cage, and somatic dysfunction in the rib cage will affect the thoracic spine. While this region is of major importance to respiration and circulation (including lymphatic flow), its functional capacity is also important in relation to the autonomic nervous system due to the location of the sympathetic chain ganglia. Treatment involves articulatory techniques, muscle energy, and high-velocity low-amplitude.

Anatomy

Thoracic spine

See “thoracic vertebrae” in the article on the vertebral column.

Vertebral column Structure of the spinal cord Thoracic vertebra (T9)

Rule of threes

Definition: a method used to identify the position of the thoracic transverse processes relative to the respective spinous processes
Description
- The rule of threes separates the thoracic vertebrae into four groups of three vertebrae, each group with a different relationship between the spinous and transverse processes.
- Transverse processes
  - Protrude laterally
  - Located on the same level as the vertebrae they are attached to
- Spinous processes
  - Protrude posteriorly and inferiorly
  - Depending on the region of the thoracic spine, the spinous processes may or may not be on the same level as its corresponding transverse processes and vertebral body.

Overview of the rule of threes
Thoracic vertebrae	Spinous process location	Example
T1–T3	At the same level as the transverse process	T2 spinous process is at the level of the T2 transverse process.
T4–T6	One half segment below the corresponding transverse process	T5 spinous process is halfway between the T5 and T6 transverse processes
T7–T9	At the level of the transverse process below	T9 spinous process is at the level of the T10 transverse process
T10	Same as T7–T9	T10 spinous process is at the level of the T11 transverse process
T11	Same as T4–T6	T11 spinous process is halfway between the T11 and T12 transverse processes
T12	Same as T1–T3	T12 is at the the level of the T12 transverse process.

Anatomical landmarks of the thoracic spine

Anatomical landmarks can be used to identify thoracic spinal segments.

Anterior
- Sternal notch: T2
- Sternal angle: T4
- Xiphoid process: T9
Posterior
- Vertebral prominence: C7
- Spine of the scapula: T3
- Inferior angle of the scapula: T7

Thoracic anatomical landmarks Bony structures of the thorax Palpable landmarks of the thorax Vertical lines used in topographic anatomy of the thorax

Ribs

There are 12 pairs of ribs separated by intercostal spaces (ICSs)
Types
- True ribs: ribs 1–7
- False ribs: ribs 8–10
- Floating ribs: ribs 11–12
- Typical ribs: ribs 3–10
- Atypical ribs: 1–2, 11–12
For more information, see “Rib cage” in the “Chest wall” article.

The parts of a typical rib include: the head, neck, tubercle, angle, and body of the rib (shaft)

Costovertebral joints and ligaments Bones and ligaments of the sternoclavicular and sternocostal joints

Muscles used during respiration

Primary muscles
- Diaphragm
- Intercostal muscles (external, internal, and subcostal)
Secondary muscles
- Scalenes: assist in the elevation of ribs 1–2
- Pectoralis minor: assists in the elevation of ribs 3–5
- Anterior and posterior serratus: assists in the elevation of ribs 6–8
- Quadratus lumborum: assists in the motion of rib 12
- Latissimus dorsi: assists in the elevation of ribs 9–10
For more information, see “Musculature” in the “Chest wall” article.

Muscles of the chest wall Anatomy of the intercostal muscles Transversus thoracis muscle Trapezius and serratus anterior muscles Latissimus dorsi muscle and teres major muscle Pectoral, subclavius, and coracobrachialis muscles Positional changes of the thorax and diaphragm during breathing

Thoracic spine and rib motion

Thoracic spine motion

Main motions: rotation, sidebending, flexion, and extension
Rotation has the greatest range of motion in the thoracic spine.
The thoracic spine follows Fryette laws. See “General osteopathic principles.”
The direction of the body of the vertebra indicates which direction the vertebra is rotated.

Rotation is the thoracic spine's main motion. The direction of rotation corresponds to whichever transverse process is more posterior. 1st and 2nd Fryette’s Laws Range of motion of the spine

Rib motion

Ribs typically move superiorly during inhalation and inferiorly during exhalation.

Types of rib motion
- Pump-handle motion
  - The anterior rib portion moves superiorly during inhalation and inferiorly during exhalation, while the posterior rib portion remains relatively unchanged
  - The anterior-posterior diameter increases during inhalation
  - Ribs 1–5 primarily exhibit this movement
- Bucket-handle motion
  - The lateral portion moves superiorly during inspiration and inferiorly during exhalation, while the anterior-posterior rib portions remain relatively unchanged
  - Transverse diameter increases during inhalation
  - Ribs 6–10 primarily exhibit this movement
- Caliper motion
  - The anterior portion moves laterally during inhalation and medially during exhalation, while the posterior rib portion remains unchanged
  - Down and out motion during inhalation
  - Ribs 11–12 primarily exhibit this movement

All ribs exhibit different degrees of these motions based on their position within the ribcage.

Rib motions

Thoracic spine dysfunctions

The thoracic spinal segments can exhibit type 1 dysfunctions or type 2 dysfunctions.

Examination of thoracic somatic dysfunctions

Procedure
1. Assess for rotation in a neutral position by palpating the transverse processes on each side of the segment being examined.
2. Assess asymmetry of the segment in flexion.
3. Assess asymmetry of the segment in extension.
Interpretation
- If a transverse process is more posterior on one side of a segment, this indicates rotation in that direction.
- If the asymmetry resolves in flexion or extension, this is the direction of ease.
  - Nonneutral dysfunction
  - Type 2 somatic dysfunction (Fryette's second law applies)
- If the asymmetry does not resolve in flexion or extension
  - Neutral dysfunction
  - Type 1 somatic dysfunction (Fryette's first law applies)

Examples

T7 NS_RR_L
- Type 1 somatic dysfunction
- The asymmetry does not change during extension or flexion of the thoracic spine.
- There is restriction in left sidebending (direction of ease is to the right).
- In a neutral position, the left transverse process of T7 is more strongly palpable than the right transverse process (this asymmetry is due to rotation to the left).
T7 ER_RS_R
- Type 2 somatic dysfunction
- In a neutral position, the right transverse process of T7 is more strongly palpable than the left transverse process (this asymmetry is due to rotation to the right).
- There is a restriction in left sidebending (direction of ease is to the right).
- During extension of the thoracic spine, the asymmetry resolves (intensifies during flexion).

Thoracic Spine - Diagnosis

Rib dysfunctions

Overview

Overview of rib dysfunctions
	Rib inhalation dysfunctions	Rib exhalation dysfunctions
Diagnosis	Rib or group of ribs is restricted during exhalation	Rib or group of ribs is restricted during inhalation
Key rib	Bottom-most rib within the group of ≥ 2 adjacent ribs	Top-most rib within the group of ≥ 2 adjacent ribs
Outcome	Restriction in rib motion during exhalation Pump handle Anterior portion of the rib moves superiorly during inhalation and does not move inferiorly during exhalation Increased AP diameter of the rib cage Anterior narrowing of the intercostal space above the dysfunctional rib Bucket handle Lateral portion of the rib moves superiorly and does not move inferiorly as much during exhalation Increased transverse diameter of the rib cage Lateral Narrowing of the intercostal space above the dysfunctional rib Caliper: ribs do not come closer and move anteriorly during exhalation	Restriction in rib motion during inhalation Pump-handle Anterior portion of the rib moves inferiorly on exhalation and does not move superiorly during inhalation Decreased AP diameter of the rib cage Anterior narrowing of the intercostal space below the dysfunctional rib Bucket handle Lateral portion of the rib moves inferiorly on exhalation and does not move superiorly during inhalation Decreased transverse diameter of the rib cage Lateral narrowing of the intercostal space below the dysfunctional rib Caliper: ribs do not separate and move posteriorly during inhalation

BITE: Bottom rib, Inhalation; Top rib, Exhalation

Rib dysfunctions are also named according to their position of ease.

Examination of rib dysfunctions

Rib dysfunctions are diagnosed via static examination (i.e., palpation)
- Based on the motion of a rib or group of ≥ 2 adjacent ribs (group dysfunction)
- In rib group dysfunctions, a key rib needs to be identified to treat the dysfunction accordingly.
Key rib: represents the rib causing the group dysfunction
- Rib inhalation dysfunctions
  - The key rib is the lowest rib, restricting the full range of motion of the ribs above during exhalation
  - E.g., inhalation dysfunction in ribs 4–7, rib 7 is the key rib
- Rib exhalation dysfunctions
  - The key rib is the uppermost rib, restricting the full range of motion of the ribs below during inhalation
  - E.g., exhalation dysfunction in ribs 3–5, rib 3 is the key rib

Static examination

Position: seated or supine; prone for ribs 11–12
Procedure: palpate ribs and assess them according to their primary motion
- Rib 1–2: standing on the head of the table, place your index fingers and thumbs on the anterior and posterior aspect of the 1^st rib, respectively (at the sternoclavicular junction)
- Ribs 3–5: standing on the head of the table, place the hypothenar eminences on the sternum (at the midclavicular line) and palpate the anterolateral aspect of the ribs.
- Ribs 6–10
  - Standing next to the patient, grasp the chest wall on the midclavicular line just below the pectoralis muscles, and palpate the lateral aspects of the ribs.
  - The lower ribs can also be palpated from the midaxillary line.
- Ribs 11–12: standing behind the patient, place your hands at the level of the 11^th or 12^th rib shafts

Muscle energy treatment

General

Thoracic spinal dysfunctions should be treated first.
Each rib is treated individually.
In group dysfunctions, treatment begins with the key rib.

Thoracic spine dysfunction

T1–T10 group curve (Type 1 thoracic dysfunction)

Position: seated
Procedure
1. Stand on the side of the convexity (side of rotated segments).
2. Monitor the apex of the curve.
3. Place the apex of the group curve into its sidebending and rotational barriers.
4. Ask the patient to sidebend toward the opposite side against your equal resistance for 3–5 seconds.
5. Relax for 5 seconds.
6. Re-engage barrier and repeat.
7. Reassess.

Upper segments: T1–T4 (Type 2 thoracic dysfunction)

Position: seated
Procedure
1. Stand opposite of the posterior transverse process.
2. Monitor rotated segment.
3. Place the segment into its flexion or extension, sidebending, and rotational barriers.
4. Ask the patient to rotate the head toward its freedom of motion against your equal resistance for 3–5 seconds.
5. Relax for 5 seconds.
6. Re-engage barrier and repeat.
7. Reassess.

Subboccipital Release

Lower segments: T5–T12) (Type 2 thoracic dysfunction)

Position: seated
Procedure
1. Stand opposite of the posterior transverse process.
2. Monitor rotated segment.
3. Place the segment into its flexion or extension, sidebending, and rotational barriers.
4. Ask the patient to sidebend the torso toward its freedom of motion against your equal resistance for 3–5 seconds.
5. Relax for 5 seconds.
6. Re-engage barrier and repeat.
7. Reassess.

Lower Thoracic Spine - ME

Rib inhalation dysfunction

Various muscle energy techniques may be used to treat rib inhalation dysfunctions.

Group inhalation dysfunction

Treated via three mechanisms:
- Begin with the most inferior rib.
- Utilize flexion to the level of the rib to relax muscles holding the rib during inhalation.
- Use inferior traction on the anterior aspect of the affected rib.

Pump-handle group inhalation dysfunction

Position: supine
Procedure
- Place one hand on the anterior aspect of the key rib.
- Flex the patient caudally.
- Palpate the dysfunctional rib.
- Ask the patient to take a deep breath.
- Hold their breath at the end of their exhalation for 3–5 seconds.
- On exhalation follow the rib shaft with your hand.
- Adjust towards the new restrictive barrier.
- On inhalation resist the rib's inhalation motion.
- Repeat steps 3–5
- Reassess.

Bucket-handle group inhalation dysfunction

Position: supine
Procedure
- Place one hand on the anterior aspect of the key rib.
- Sidebend the patient.
- Palpate the dysfunctional rib.
- Ask the patient to take a deep breath.
- Ask the patient to reach for their knee on the affected side and hold their breath at the end of their exhalation for 3–5 seconds.
- On exhalation follow the rib shaft with your hand.
- Adjust towards the new restrictive barrier.
- On inhalation resist the rib's inhalation motion.
- Repeat steps 3–5
- Reassess.

Rib 1

Position: supine
Procedure
1. Place finger pads onto the superior aspect of the 1^st rib (supraclavicular fossa) and apply inferior force.
2. Flex the patient's head until motion is felt at the 1^st rib (relaxes scalenes).
3. Ask the patient to take a deep breath.
4. Upon exhalation, follow the rib inferiorly (into its barrier).
5. Upon inhalation, resist the upward motion of the 1^st rib.
6. Repeat for 3–4 breaths.
7. Reassess.

Ribs 2–5

Position: supine
Procedure
1. Place the palm on the superior aspect of the costal cartilage of the affected rib and apply inferior force.
2. Flex the patient's head until motion is felt at the affected rib.
3. Ask the patient to take a deep breath.
4. Upon exhalation, follow the rib inferiorly (into its barrier).
5. Upon inhalation, resist the upward motion of the affected rib.
6. Repeat for 3–4 breaths.
7. Reassess.

Ribs 6–10

Position: supine
Procedure
1. Place palm on the lateral aspect of the affected rib and apply inferior force.
2. Flex and sidebend the patient's head and torso until motion is felt at the affected rib.
3. Ask the patient to take a deep breath.
4. Upon exhalation, follow the rib inferiorly (into its barrier).
5. Upon inhalation, resist the upward motion of the affected rib.
6. Repeat for 3–4 breaths.
7. Reassess.

Muscle Energy Bucket handle ribs 6 10 inhalation dysfunction

Rib exhalation dysfunction

Various muscle energy techniques, which typically engage the same muscles, may be used to treat rib exhalation dysfunction.
The affected rib determines the muscle(s) being targeted during treatment (i.e., activated by the patient).

Overview
Ribs	Target muscles
1	Anterior and middle scalenes
2	Posterior scalene
3–5	Pectoralis minor
6–8	Serratus anterior
9–10	Latissimus dorsi
11–12	Quadratus lumborum

Muscle energy

Rib 1–2
- Muscles
  - Rib 1: anterior and middle scalenes
  - Rib 2: posterior scalene
- Position: supine with the dorsal wrist of the affected side across the forehead
- Procedure
  1. Ask the patient to inhale while you grasp the angle of rib 1 underneath the patient and apply inferolateral traction.
  2. Ask the patient to hold their breath and raise their head toward the ceiling against an equal resistance for 3–5 seconds.
  3. Relax and repeat 3-5 times before retesting improvement of motion.
Ribs 3–5
- Muscle: pectoralis minor
- Position: supine with the dorsal wrist of the affected side across the forehead
- Procedure
  1. Ask the patient to inhale while you grasp the angle of the affected rib underneath the patient and apply inferolateral traction.
  2. Ask the patient to hold their breath and move the elbow of the affected side toward the opposite anterior superior iliac spine (ASIS) against an equal resistance for 3–5 seconds.
  3. Relax and repeat 3-5 times before retesting improvement of motion.
Ribs 6–8
- Muscle: serratus anterior
- Position: supine with the dorsal wrist of the affected side across the forehead
- Procedure
  1. Ask the patient to inhale while you grasp the angle of the affected rib underneath the patient and apply inferolateral traction.
  2. Ask the patient to hold their breath and push the arm of the affected side anteriorly against an equal resistance for 3–5 seconds.
  3. Relax and repeat 3-5 times before retesting improvement of motion.
Ribs 9–10
- Muscle: latissimus dorsi
- Position: supine with the dorsal wrist of the affected side across the forehead
- Procedure
  1. Ask the patient to inhale while you grasp the angle of the affected rib underneath the patient and apply inferolateral traction.
  2. Ask the patient to hold their breath and adduct the arm of the affected side against an equal resistance for 3–5 seconds.
  3. Relax and repeat 3-5 times before retesting improvement of motion.
Ribs 11–12
- Muscle: quadratus lumborum
- Position: supine or prone with the torso and lower extremities side bent away from the affected side
- Procedure
  1. Ask the patient to inhale while you grasp the angle of the affected rib and apply inferior and posterior traction to the pelvis.
  2. Ask the patient to hold their breath and lift their ASIS of the affected side toward the ipsilateral shoulder against an equal resistance for 3–5 seconds.
  3. Relax and repeat 3-5 times before retesting improvement of motion.

High-velocity low-amplitude treatment

Thoracic spine dysfunction

Position: supine, with the examiner on the opposite side of the dysfunction
Procedure
1. Perform myofascial technique.
2. Have the patient cross their arms over their chest
3. Push elbows down and tuck under your abdomen while maintaining downward pressure.
4. Lift the patient's head and torso toward you.
5. Flex, rotate, and sidebend away.
6. Place the thenar eminence over the posterior transverse process (or just medial to the posterior rib angle).
7. Ask the patient to fully inhale and exhale.
8. Slowly isolate the segment by rolling the patient over your hand.
9. Apply a downward thrust through the posterior segment using your weight.
10. Reassess.

The physician stands opposite the side of rotation, therefore sidebending the trunk away for a type 1 somatic dysfunction and toward for a type 2 somatic dysfunction.

Upper Thoracic - HVLA Lower Thoracic - HVLA

Rib inhalation dysfunction

Different HVLA techniques may be used to treat rib inhalation dysfunctions.

Rib 1

Position: prone
Procedure
1. Place the thenar eminence over the posterior rib.
2. Bring the patient's ipsilateral arm cephalad to cup their chin.
3. Apply an anterior pressure onto the posterior rib.
4. Bring the patient's elbow superiorly (help flatten the thoracic spine).
5. Bring the patient's head away from the affected rib.
6. Ask the patient to inhale.
7. At the end of exhalation, apply a downward thrust through the thenar eminence.
8. Relax.
9. Reassess.

Ribs 2–10

Position: supine, with the examiner on the opposite side of the dysfunction
Procedure
1. Perform myofascial technique.
2. Have the patient cross their arms.
3. Push elbows down and tuck under your abdomen while maintaining downward pressure.
4. Lift the patient's head and torso toward you.
5. Place the thenar eminence over the posterior rib angle.
6. Ask the patient to fully inhale and exhale.
7. Slowly isolate the rib by rolling the patient over your hand.
8. Apply a downward thrust through the posterior rib angle using your weight.
9. Reassess.

Rib exhalation dysfunction

Different HVLA techniques may be used to treat rib exhalation dysfunctions.

Rib 1

Position: supine, with the examiner at the head of the table
Procedure
1. Sidebend the head and neck towards the side of the dysfunctional rib.
2. Rotate the head and neck away.
3. Place the 1^st MCP on the tubercle of rib 1.
4. Ask the patient to take a deep breath.
5. At the end of exhalation, apply a downward thrust through the thenar eminence.
6. Reassess.

Ribs 2–10

Position: supine, with the examiner on the opposite side of the dysfunction
Procedure
1. Have the patient cross their arms.
2. Place the thenar eminence over the posterior rib angle.
3. Using the free hand, lift the patient's torso and sidebend away from the dysfunctional rin.
4. Ask the patient to fully inhale and exhale.
5. At the end of exhalation, apply a downward thrust toward your thenar eminence.
6. Reassess.

Facilitated positional release treatment

Thoracic spine

Position: seated with the examiner on the side of the dysfunction
Procedure:
1. Monitor dysfunction at the transverse process of the segment with the contralateral hand.
2. Place the ipsilateral arm in front of the patient's shoulders so that the forearm is on the patient's contralateral shoulder and the axilla rests on the patient's ipsilateral shoulder.
3. Ask the patient to sit up straight until extension is palpated at the segment level (i.e., neutral positioning).
4. Add a compressive force, with the arm pushing downward into the patient's thoracic spine.
5. While maintaining compression, place the segment into a position of ease.
6. Hold for 3–5 seconds.
7. Relax.
8. Reassess.

The treatment sequence of FPR can be remembered as “neutral, compress, ease.”

References

Destefano L. Greenman's Principles of Manual Medicine. Wolters Kluwer Law & Business ; 2015
Nicholas A. Atlas of Osteopathic Techniques. LWW ; 2015

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