Thoracic spine and rib osteopathy

Last updated: September 27, 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

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

Bones

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

Osteopathic landmarks

Vertebral prominence: C7
Spine of the scapula: T3
Inferior angle of the scapula: T7
Level of the 12^th rib: T12

Ribs

Costovertebral joints and ligaments Bones and ligaments of the sternoclavicular and sternocostal joints Vertical lines used in topographic anatomy of the thorax Palpable landmarks of the thorax Bony structures of the thorax Positional changes of the thorax and diaphragm during breathing

Bones

See “ribs” in the article on the chest wall.

Osteopathic landmarks

T1: just superior to the clavicle
T3: sternal notch
Posterior rib angles
Midclavicular line
Midaxillary line

Motion

Upper division (ribs 1–5)
- Pump-handle motion
- Anterior-posterior diameter increases during inhalation
Lower division (ribs 6–10)
- Bucket-handle motion
- Transverse diameter increases during inhalation
11^th and 12^th ribs
- Caliper motion
- Down and out motion during inhalation

Rib motions

Rib dysfunctions

Diagnosis

Ribs can be restricted in motion during inhalation or exhalation
They are diagnosed via static examination based on the motion of a rib or group of ≥ 2 adjacent ribs (some institutions teach a group of ≥ 3 adjacent ribs).
Within a group of dysfunctional ribs, a key rib is identified, which represents the major restrictor.

	Inhalation dysfunctions	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	Restriction in rib motion during inhalation

BITE: Bottom rib, Inhalation; Top rib, Exhalation

Static examination

Position: seated or supine
Procedure
1. Palpate ribs in accordance with their primary motion.
  - Rib 1
    - Motion: pump-handle
    - From the head of the table, place your index fingers and thumbs on the anterior and posterior aspect of the 1^st rib, respectively.
  - Ribs 2–5
    - Motion: pump-handle
    - From the head of the table, place the hypothenar eminences on the sternum.
  - Ribs 6–10
    - Motion: bucket-handle
    - From the side of the patient, grasp the chest wall on the midclavicular line just below the pectoralis muscles.
    - Lower ribs can also be palpated from the midaxillary line.
  - Ribs 11–12
    - Motion: caliper
    - From behind the patient, place your hands at the level of the 11^th or 12^th rib.
2. Identify inhalation versus exhalation dysfunction.

Treatment

Consists of either muscle energy or HVLA
Thoracic spinal dysfunctions should be treated first.
Each rib is treated individually.
In group dysfunctions, treatment begins with the key rib.

Inhalation dysfunctions

Muscle energy

Treated via three mechanisms:
1. Begins with the most inferior rib
2. Utilizes flexion to the level of the rib to relax muscles holding the rib in inhalation
3. Inferior traction on the anterior aspect of the affected rib

Exhalation dysfunctions

Muscle energy

Treated via four mechanisms:
1. Begins with the most superior rib
2. Inhalation
3. Movement of the head, elbow or arm against equal resistance
  1. Rib 1: anterior and middle scalenes
  2. Rib 2: posterior scalenes
  3. Ribs 3–5: pectoralis minor
  4. Ribs 6–8: serratus anterior
  5. Ribs 9–11: latissimus dorsi
  6. Rib 12: quadratus lumborum
4. Inferior traction on the posterior aspect of the affected rib

High-velocity low-amplitude

Treated similarly to thoracic spinal dysfunctions
Rib 1 and ribs 2–10 are treated differently.

Rib inhalation dysfunction

Rib 1

Muscle energy

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 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.

High-velocity low-amplitude

Position: prone
Procedure
1. Place 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 thoracic spine).
5. Bring the patient's head away from the affected rib.
6. Ask patient to inhale.
7. At the end of exhalation, apply a downward thrust through the thenar eminence.
8. Relax.
9. Reassess.

Ribs 2–5

Muscle energy

Position: supine
Procedure
1. Place palm on the superior aspect of the costal cartilage of the affected rib and apply inferior force.
2. Flex patient's head until motion is felt at the affected rib.
3. Ask 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.

High-velocity low-amplitude

Position: supine with examiner on the opposite side of the dysfunction
Procedure
1. Perform myofascial technique.
2. Have the patient cross the 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 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.

Ribs 6–10

Muscle energy

Position: supine
Procedure
1. Place palm on the lateral aspect of the affected rib and apply inferior force.
2. Flex and side bend the patient's head and torso until motion is felt at the affected rib.
3. Ask 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

High-velocity low-amplitude

See high-velocity low-amplitude treatment for ribs 2–5.

Rib exhalation dysfunction

Ribs 1–2

Muscle energy

Position: supine
Procedure
1. Grasp affected rib angle underneath patient.
2. Apply inferolateral traction.
3. Place the dorsal aspect of the patient's ipsilateral wrist onto their forehead.
4. Ask patient to inhale while you continue to apply inferolateral traction.
5. Ask patient to hold their breath for 3–5 seconds while bringing their head up against equal resistance.
6. Relax for 5 seconds.
7. Re-engage barrier and repeat

Muscle Energy Pump Handle Rib 1

Ribs 3–5

Muscle energy

Position: supine
Procedure
1. Grasp affected rib angle underneath the patient.
2. Apply inferolateral traction.
3. Abduct the patient's ipsilateral shoulder.
4. Ask patient to inhale while you continue to apply inferolateral traction.
5. Ask patient to hold their breath for 3–5 seconds while bringing their elbow upward against equal resistance.
6. Relax for 5 seconds.
7. Re-engage barrier and repeat.

Muscle Energy Pump handle ribs 2 5

Ribs 6–9

Muscle energy

Position: supine
Procedure
1. Grasp affected rib angle underneath the patient.
2. Apply inferolateral traction.
3. Abduct the patient's ipsilateral shoulder and elbow to 90 degrees with their wrist facing upward.
4. Ask patient to inhale while you continue to apply inferolateral traction.
5. Ask patient to hold their breath for 3–5 seconds while pushing their arm upward against equal resistance.
6. Relax for 5 seconds.
7. Re-engage barrier and repeat.

Muscle Energy Bucket Handle Ribs

Ribs 10–12

Muscle energy

Position: supine
Procedure
1. Grasp affected rib angle underneath the patient.
2. Apply inferolateral traction.
3. Abduct the patient's ipsilateral shoulder to about 180 degrees.
4. Ask patient to inhale while you continue to apply inferolateral traction.
5. Ask patient to hold their breath for 3–5 seconds while abducting their elbow against equal resistance.
6. Relax for 5 seconds.
7. Re-engage barrier and repeat.

Muscle Energy Rib 10 Caliper Ribs 11 12

Thoracic spine dysfunction

Diagnosis

Thoracic spinal segments can exhibit type 1 dysfunctions or type 2 dysfunctions.
- See “Fryette's principles” in the article on general osteopathic principles for more information.
Dysfunctions are diagnosed via static examination of individual segments based on the rule of threes.

Rule of threes

The comparative superficial spinous processes are used to locate the deeper and often difficult to palpate transverse processes.
Rule of threes separates the thoracic vertebrae into 3 distinct groups, each with a different relationship between the spinous and transverse processes.
The level of a thoracic spinous process and its corresponding transverse process is dependent on the region of the thoracic spine.
Anatomical landmarks are used to identify thoracic spinal segments (e.g., inferior angle of scapula: T7).
Accurate identification is required to adequately treat spinal segment somatic dysfunctions.

Thoracic vertebrae	Transverse process location	Example
T1–T3 & T12	At the same level as the spinous process	T2 transverse process is at the level of the T2 spinous process.
T4–T6 & T11	Halfway between its spinous process and the one above	T5 transverse process is halfway between the T5 spinous process and the T4 spinous process
T7–T9 & T10	At the level of the spinous process above	T9 transverse process is at the level of the T8 spinous process

Thoracic vertebrae

Transverse process location

Example

T1–T3

T12

At the same level as the spinous process

T2 transverse process is at the level of the T2 spinous process.

T4–T6

T11

Halfway between its spinous process and the one above

T5 transverse process is halfway between the T5 spinous process and the T4 spinous process

T7–T9

T10

At the level of the spinous process above

T9 transverse process is at the level of the T8 spinous process

Static examination

Position: prone
Procedure
1. Palpate each transverse process of the thoracic spine.
2. Identify each posterior transverse process.
3. Evaluate flexion or extension component.
  - On each segment with a posterior transverse process, roll your fingers up (to induce flexion) and down (to induce extension).
    - Transverse processes become more symmetrical when the spinal segment is placed into its freedom of motion (e.g., rolling your fingers up to check for flexion component causes the transverse processes to become more symmetrical → flexion dysfunction).
      - If a non-neutral component exists, a type 2 dysfunction is present.
    - If transverse processes on each side do not become more symmetrical with either movement, a type 1 dysfunction is most likely present.
      - A type 1 dysfunction can only be present if three or more adjacent segments are involved.

Thoracic Spine - Diagnosis

Treatment

Type 1 thoracic (group curve) dysfunction (T1–T10)

Muscle energy

Position: seated
Procedure
1. Stand on the side of the convexity (side of rotated segments).
2. Monitor apex of the curve.
3. Place the apex of the group curve into its side bending and rotational barriers.
4. Ask patient to side bend 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.

Type 2 thoracic dysfunctions (upper segments: T1–T4)

Muscle energy

Position: seated
Procedure
1. Stand opposite of the posterior transverse process.
2. Monitor rotated segment.
3. Place the segment into its flexion or extension, side bending, and rotational barriers.
4. Ask 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

High-velocity low-amplitude

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

Upper Thoracic - HVLA Lower Thoracic - HVLA

Type 2 thoracic dysfunctions (lower segments: T5–T12)

Muscle energy

Position: seated
Procedure
1. Stand opposite of the posterior transverse process.
2. Monitor rotated segment.
3. Place the segment into its flexion or extension, side bending, and rotational barriers.
4. Ask patient to side bend 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

High-velocity low-amplitude

Same as type 2 thoracic dysfunctions of the upper segments

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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