Download Rib Mobilizations Mobilizations

Certificate of Excellence (COE) Program
• Program delivered by the RMTAO
Certificate of Excellence In Assessment
Rib Mobilizations
• 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)
Presented by Aaron Rutter
PT, BScPT, FCAMPT, CAFCI
www.leadtheway.ca/continuingeducation/
Introduction
Course Objectives
• What conditions can you help by improving rib mobility?
• Registered Physiotherapist
• Certified Manual and
Manipulative
Physiotherapist
• Certified in Acupuncture
• Queen’s University
• RMTAO courses
• 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?
1
Rib Cage
Anterior
Ribs
• Do you treat the rib cage with your shoulder impingement patients or
patients with decreased arm elevation?
Jugular (suprasternal) notch
Rib
Manubrium
Sternomanubrial joint
(sternal angle)
Sternum
Costocartilage
Sternocostal joint
Xiphisternal joint
Xiphoid process
Costochondrium
Costochondrial joint
• 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 Cage
Posterior
Thoracic Vertebrae
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
Vertebral body
Superior articular process
Transverse process
Costovertebral joint
Costotransverse joint
Intervertebral foramina
Costovertebral joint of rib below
Inferior articular process
Spinous process
2
Ribs
Rib Ligaments
Anterior longitudinal ligament
Superior costotransverse ligament
(rib to TP above)
Radiate ligament
Intra-articular ligament
1st rib
Head of rib
Neck of rib
Tubercle of rib
Angle of rib
Typical rib
Posterior Thorax
(deep)
Rib Ligaments
Radiate ligament
(head of rib to vertebral body & disc)
Intra-articular ligament
(head of rib to vertebral body)
Costotransverse ligament
(neck of rib to TP at same level)
1.
2.
3.
4.
5.
6.
Semispinalis
Rotatores
Levatores costarum longus & brevis
External intercostals
Multifidus
Quadradus lumborum
Lateral costotransverse ligament
(tubercle of rib to TP at same level)
3
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 Physiol
Ther 1995; 18(1):34-7.
Thorax Palpation
Thorax Palpation
• Facilitated Segment
• T1-12 spinous processes
• T1-12 z-joints
• Pilomotor reflex
• Feel for local (1-2 levels) vs global (4-5 levels) muscle tension
• Facilitated segment
• 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
• 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
4
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
Rib Function
• Support/protect the viscera
• Muscle attachment
• Motion
• Breathing, ROM
• Ribs 1-6 ant to TP
• Ribs 7-10 ant/sup to TP
• Ribs 11-12 don’t touch TP
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
Costotransverse Joint Pain
Nociceptive 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
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
•
•
•
•
•
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
Chronic pain due to sensitization of the nervous system, lowered pain
threshold
5
Left 3rd Costotransverse Joint Nociceptive Pain
Right T7 Peripheral Neurogenic Pain
Radiates around towards sternum
in intercostal space
T7
Visceral Pain
Key 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
6
Flattened Thoracic Spine
Observations
Scoliosis
Dowager’s Hump
• Lateral curvature of spine
• Structural vs nonstructural
• Always named for the convex
side
• Example
• Right thoracic
• Left lumbar
• Results from postmenopausal
osteoporosis
• Multiple compression fractures
causing excessive kyphosis and
an associated scoliosis
7
Scheurmann’s Disease
• Disturbance in normal
development of endplates due
to Schmorl’s nodes
Pigeon Chest
(pectus carinatum)
• Sternum projects forward and
downward
• Increased thoracic kyphosis,
onset usually in 2nd decade in
males
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
8
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 costochondral
joints
AROM
Thorax ROM
Movement
Flexion
Extension
Side bend
Rotation
Chest Expansion
(xiphoid process)
ROM
20-45 degrees
25-45 degrees
20-40 degrees each way
35-50 degrees each way
3-7.5 cm
Big variation in the amount of motion between individuals
Is movement symmetrical?
Do they meet the minimum amount of motion?
Thorax ROM
Flexion
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
9
Thorax ROM
Extension
Thorax ROM
Rotation
Thorax ROM
Side Bend
Thorax ROM
Alternative Position: Rotation
10
Thorax ROM
Alternative Position: Rotation
AROM
flexion
L rotation
R rotation
L side bend
R side bend
extension
Thorax ROM
Chest Expansion
Thorax ROM
Breathing
• pump handle (ribs 1-6)
• bucket handle/lateral costal expansion (ribs 7-10)
11
Thorax ROM
Breathing
• Usually want to minimize pump handle breathing and
improve bucket handle (lateral costal) and diaphragmatic
breathing
Costotransverse Joint
Costovertebral 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
12
Costotransverse Joint
Osteokinematics
Movement
Right Costotransverse Joint
Osteokinematics
Ribs
• Anterior Rotation
Thoracic flexion
Thoracic extension
Thoracic SB
Thoracic Rot
• Posterior Rotation
Inspiration
Expiration
Combined Motions
• Thoracic flexion/right rotation
Combined Motions
• Thoracic left rotation/right side bend
• Thoracic flexion/left rotation
• Thoracic right rotation/left side bend
• Thoracic extension/right rotation
• Thoracic extension/left rotation
These combined motions match z-joint motion as well
These combined motions can help differentiate
rib restriction from z-joint restriction
13
Combined Motions
Flexion Quadrants
Combined Motions
Extension Quadrants
Combined Motions
Side 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 midrange
14
Costotransverse Joint
Arthrokinematics (Joint Glide)
Movement
Thoracic flex
Thoracic ext
Thoracic SB
Ribs 1-6
Ribs 7-10
Right Costotransverse Joint
Arthrokinematics (Joint Glide)
• Superior Glide/PMS
• Inferior glide/ALI
Thoracic Rot
Inspiration
Expiration
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
15
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 Glides
Ribs 1-6
• Superior Glide (end feel?)
16
Joint Glides
Ribs 1-6
Joint Glides
Rib 1
• Inferior Glide (end feel?)
• Inferior Glide (end feel?)
Joint Glides
Ribs 7-10
Joint Glides
Ribs 7-10
• PMS (end feel?)
• ALI (end feel?)
Indirect Technique
17
Joint Glides
Ribs 1-12
Distraction in Sitting
• Anterior glide/distraction (end feel?)
Towel position
• Tests all of the costotransverse and costovertebral ligaments
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
Right 6th Rib
Posterior Rotation Stiffness
• ROM Findings
• Joint Glide Findings
• Combined Movement Findings
• Fixated joints respond well to distraction
mobilizations
18
Left 8th Rib
Anterior Rotation Stiffness
Left 2nd Rib
Fixation
• ROM Findings
• ROM Findings
• Joint Glide Findings
• Joint Glide Findings
• Combined Movement Findings
• Combined Movement Findings
Anterior Costal Joints
Anterior Costal Joints
• Rib 1: synarthrosis
• Costochondral Joints
• manubrocostal
• Ribs 2-6: synovial
• sternocostal
• Where rib attaches to costocartilage
• Located approximately 1 inch lateral to the sternum
• Feel for where the bone changes to cartilage
• Ribs 7-10: fibrous
• attach indirectly to sternum through costochondrium
• Ribs 11-12: do not attach to sternum
• floating
19
Common Pathologies
• Fractures/stress fractures
• Manubrium, sternum, ribs, costocartilage
Joint Glides
Anterior Costal Joints
• Inferior glide (end feel?)
• 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 Glides
Anterior Costal Joints
• Superior glide (end feel?)
Joint Glides
Anterior Costal Joints
• Posterior glide (end feel?)
20
Thorax Stretching
1. Combined motions
Right side bend/left rotation
Left side bend/right rotation
Thorax Stretching
3. Tennis ball
• Lean up against tennis ball on wall (chin
retraction)
• Causes distraction of the costotransverse
joint
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
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
21
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 deweights off chair which applies an inferior glide
to rib
Thorax Stretching
Thorax Stretching
7. 1st rib (inferior glide)
7. 1st rib (inferior glide)
22
Review
Thank you
• 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
• For future courses visit www.leadtheway.ca/continuingeducation/ or
email me at [email protected]
• Posterior rotation/lateral costal expansion
• Inferior glide/ALI
• Stabilization exercises for patients with reoccurrences of
stiffness/fixations
23