Rib

cage diagnosis

Inhalation Exhalation PrimaryMotion

Dysfunction Dysfunction
1stRib 1stribsmovewell 1stribsmovewell Pumphandle
whenpatientinhales whenpatientexhales
(bothcomeup),but (bothgodown),but
oneribdoesnot oneribdoesnot
movewellwhen movewellwhen
patientexhales(one patientinhales(one
isstuckup) isstuckdown)
Upperribs(ribs13) Ribsmovewellwhen Ribsmovewellwhen Pumphandle
patientinhales(both patientexhales(both
comeup),butonerib godown),butone
doesnotmovewell ribdoesnotmove
whenpatientexhales wellwhenpatient
(oneisstuckup) inhales(oneisstuck
down)
Middleribs(ribs47) Ribsmovewellwhen Ribsmovewellwhen Pumpandbucket
patientinhales(both patientexhales(both handle
comeup),butonerib godown),butone
doesnotmovewell ribdoesnotmove
whenpatientexhales wellwhenpatient
(oneisstuckup) inhales(oneisstuck
down)
Lowerribs(ribs810) Ribsmovewellwhen Ribsmovewellwhen Buckethandle
patientinhales(both patientexhales(both
comeup),butonerib godown),butone
doesnotmovewell ribdoesnotmove
whenpatientexhales wellwhenpatient
(oneisstuckup) inhales(oneisstuck
down)
Rib11 11thribsmovewell 11thribsmovewell Calipermotion(move
whenpatientinhales whenpatientexhales posteriorinferiorin
(comesposterior (comesanterior inhalationand
inferior),butonerib superior),butonerib anteriorsuperiorin
doesnotmovewell doesnotmovewell exhalation)
whenpatientexhales whenpatientinhales
(stuckposteriorlyand (stuckanteriorlyand
Copyright2013NewYorkInstituteofTechnologyCollegeofOsteopathicMedicine
DepartmentofOsteopathicMedicine
 inferio
orly) superriorly)
th
Rib12 12 ribsmovewe ell 12thrribsmoveweell Calipermotion(m move
whenpatientinhaales whennpatientexh hales posteeriorinferiorrin
(come esposterior (comeesanterior inhalationand
or),butonerib
inferio superrior),butonerib anterriorsuperiorrin
doesnnotmovewe ell doesnotmovew well exhalation)
whenpatientexhaales whennpatientinh hales
(stuckkposterior (stuckkanteriorlyand
inferio
orly) superriorly)

Figure11sstribdiagnosishandplacementt

Figure2Upperribdiagnosis

Middleribdiagno
Figure3M osis Figure4Midddleribdiagnosissalternatehand
dpositioning

Copyrightt2013NewYorkInstitute
eofTechnolo
ogyCollegeoffOsteopathiccMedicine
DepartmeentofOsteop
pathicMedicin ne
Figure5Lo
owerribdiagnosis

Figure6Riibs11and12diagnosis

Briefdesscription:Diaagnosisoftheeribsshouldaassessthefirsstribs,upperr(13ribs),m
middle(47rib
bs),
lower(81
10ribs),ribs1
11and12.Motionoftheffirstribsanduupperribsareeprimarilypu
umphandle,
middleisamixofpummpandbucketthandle,whilethelowerrribsaremostlybuckethan ndle.Ribs11aand
12areuniqueinthattheyhavecalipermotion.IItisalsoimpoortanttodeteerminethekeeyribofa
onfortreatm
dysfunctio ment.Ininhalaationdysfunctions,thekeyyribisthebo
ottomrib.Ineexhalation
dysfunctio
ons,thekeyrribisthetoprib.

Look(ob
bservation):Observethepatientsbreaathingandlo okforanyscarsormarks.

Copyrightt2013NewYorkInstitute
eofTechnolo
ogyCollegeoffOsteopathiccMedicine
DepartmeentofOsteop
pathicMedicin ne


First rib diagnosis

Physicianposition:Sitattheheadofthetable

Patientposition:Supine

Handpositioning:Toassessthefirstrib,contactitbelowtheclaviclewherethefirstribjoinsthe
sternum,abovetheclavicleontheanteriorsuperioraspectoftheribandontheposterioraspectofthe
firstribinthetrapezius.

Technique:

1. Placeyourhandssothatyouhavea3pointcontactonthefirstribbilaterally(thumbs
ontheposterioraspectoftheribinthetrapezius,indexfingersontheanteriorsuperior
aspectjustabovetheclaviclesandthemiddlefingersattheattachmentofthefirstrib
onthesternum).
2. Addacompressiveforceontheribsandfeelforwhichishardertospringon.Thisribis
stuckupininhalation.
3. Youcanalsotestmotionwithrespirationbyhavingthepatientinhaleandexhalewhile
youhaveyour3pointcontact.Feelfortheribstomoveupininhalationanddownin
exhalation.
4. Tonamethedysfunction,determinethefreedom.(Ex.Bothmovewellininhalation,but
onexhalationtherightfirstribstaysstuckup.Thiswouldbearightfirstribinhalation
dysfunction.)

Move(motiontesting):
Activemotiontesting:

1. Havethepatientinhaleandexhalewhileyoumaintaina3pointcontactonthefirstrib.

Passivemotiontesting:

1. Springontheribbycompressingdown.Thesidewithmoreresistancetothisspringing
isstuckupininhalation.

Othernotes:Thefirstribissmallandlikeacollar.Itisoftenverytendertopalpation.

Copyright2013NewYorkInstituteofTechnologyCollegeofOsteopathicMedicine
DepartmentofOsteopathicMedicine


Rib 110 diagnosis

Physicianposition:Standtoeithersideofthepatient

Patientposition:Supine

Handpositioning:Toassesspumphandlemotion,placeyourhandsparallelandjustlateraltothe
sternum.Toassessbuckethandlemotionoftheupper(13)ribs,placeyourhandshorizontalunderthe
clavicle.Toassessbuckethandlemotionofthemiddle(47)andlower(810)ribs,placeyourhandsover
thecostalmarginandlateralaspectsoftheribcage.

Technique:

1. Placeyourhandssothattheyareparallelandjustlateraltothesternumintheregionof
ribs13.
2. Havethepatientinhaleandexhalewhilefeelingforapumphandlemotion.
3. Nowmoveyourhandssothattheyarehorizontalandjustundertheclaviclestoassess
forbuckethandlemotion.
4. Again,havethepatientinhaleandexhalewhilethistimefeelingforbuckethandle
motion.
5. Placeyourhandssothattheyareparallelandjustlateraltothesternumintheregionof
ribs47.
6. Havethepatientinhaleandexhalewhilefeelingforapumphandlemotion.
7. Nowmoveyourhandssothattheyareonthelateralaspectsoftheribcage.(Handswill
bepartlyinthemidaxillaryline.)
8. Again,havethepatientinhaleandexhalewhilethistimefeelingforbuckethandle
motion.
9. Placeyourhandssothattheyareparallelandjustlateraltomidlineintheregionofribs
810.
10. Havethepatientinhaleandexhalewhilefeelingforapumphandlemotion.
11. Nowmoveyourhandssothattheyareonthecostalmarginoftheribcage.(Handswill
beoverthecostalmarginandfingersouttothelateralaspectsoftheribcage.)
12. Again,havethepatientinhaleandexhalewhilethistimefeelingforbuckethandle
motion.
13. Todiagnosisthedysfunction,nameforthefreedomofmotion.(Ex.Ribs47are
symmetricalonexhalation,butoninhalationtherightribs47arestuckdown.This
wouldbearightribs47exhalationdysfunction.)

Move(motiontesting):

Activemotiontesting:

1. Havethepatientinhaleandexhalewhileyoucheckbothpumphandleandbucket
handlemotion.
2. Assessthisinall3regions(upper,middleandlowerribs).


Copyright2013NewYorkInstituteofTechnologyCollegeofOsteopathicMedicine
DepartmentofOsteopathicMedicine
Passivemotiontesting:

1. Compresstheribcageandtrytomoveitfromlefttoright.Feelforanygeneral
restrictionsofmovement.

Othernotes:Themotionoftheribsvariesbetweenpumpandbuckethandlemotionasyoumovefrom
thetoptothebottomoftheribcage.Theupper(13)ribsareprimarilypumphandlemotion,middle(4
7)ribsarebothandlower(810)ribsareprimarilybuckethandle.Thekeyribofthedysfunctionis
importantfortreatmentandisdetermineasfollows:forinhalationdysfunctionsitisthebottomrib,for
exhalationdysfunctionsitisthetoprib(mnemonicisBITE=bottom,inhalation;top,exhalation).

Copyright2013NewYorkInstituteofTechnologyCollegeofOsteopathicMedicine
DepartmentofOsteopathicMedicine
11th and 12th rib diagnosis:
Physicianposition:Standtoeithersideofthepatient

Patientposition:Prone

Handpositioning:Placeyourhandssothatyourindexfingerandthumbareoverthe11thribs
bilaterallyandthen12thribsbilaterally(eachribisdiagnosedseparately).

Technique:

1. Placeyourhandsoverthe11thribsbilaterallyandtrytocontactasmuchoftheribas
possible.
2. Havethepatientinhaleandexhale.Feelforaposteriorinferiormotiononinhalation
andanteriorsuperiormotiononexhalation.
3. Nowplaceyouhandsoverthe12thribsbilaterally.Again,trytocontacttheentirerib
withyourthumbandindexfinger.
4. Havethepatientinhaleandexhale.Feelforaposteriorinferiormotiononinhalation
andanteriorsuperiormotiononexhalation.
5. Todiagnosisthedysfunction,nameforthefreedomofmotion.(Ex.Rib11moves
posteriorinferiorbilaterally,buttherightrib11doesnotmoveanteriorsuperior.Thisis
arightrib11inhalationdysfunction.)

Move(motiontesting):

Activemotiontesting:

1. Whilemaintainingyourcontactonribs11or12,askthepatienttoinhaleandexhale.

Passivemotiontesting:

1. Checkthemotionofribs11and12whilethepatientrelaxesandbreathesnormally.

Othernotes:Ribs11and12arefloatingribsanddonotattachtotheanteriorportionoftheribcage.
Ribs11and12havecalipermotion,theymoveposteriorinferiorwithinhalationandanteriorsuperior
withexhalation.Theseribscanbefoundbywalkingyourhandsupfromtheiliaccrestsuntilyouhit
boneandthenwalkingyourfingersanteriorlytomakesuretheyarenotattachedtotheribcage
anteriorly.Alternatively,youmaywalkyourfingersdownthemidaxillarylineuntilyougettotheendof
theribcageandthenwalkyourfingersposteriorlytofindtheribs.Ribs11and12areoftentenderto
palpation.

Copyright2013NewYorkInstituteofTechnologyCollegeofOsteopathicMedicine
DepartmentofOsteopathicMedicine