Rib

cage diagnosis

1stRib

Upperribs(ribs13)

Inhalation
Dysfunction
1stribsmovewell
whenpatientinhales
(bothcomeup),but
oneribdoesnot
movewellwhen
patientexhales(one
isstuckup)
Ribsmovewellwhen
patientinhales(both
comeup),butonerib
doesnotmovewell
whenpatientexhales
(oneisstuckup)

Middleribs(ribs47)

Ribsmovewellwhen
patientinhales(both
comeup),butonerib
doesnotmovewell
whenpatientexhales
(oneisstuckup)

Lowerribs(ribs810)

Ribsmovewellwhen
patientinhales(both
comeup),butonerib
doesnotmovewell
whenpatientexhales
(oneisstuckup)

Rib11

11thribsmovewell
whenpatientinhales
(comesposterior
inferior),butonerib
doesnotmovewell
whenpatientexhales
(stuckposteriorlyand

Exhalation
Dysfunction
1stribsmovewell
whenpatientexhales
(bothgodown),but
oneribdoesnot
movewellwhen
patientinhales(one
isstuckdown)
Ribsmovewellwhen
patientexhales(both
godown),butone
ribdoesnotmove
wellwhenpatient
inhales(oneisstuck
down)
Ribsmovewellwhen
patientexhales(both
godown),butone
ribdoesnotmove
wellwhenpatient
inhales(oneisstuck
down)
Ribsmovewellwhen
patientexhales(both
godown),butone
ribdoesnotmove
wellwhenpatient
inhales(oneisstuck
down)
11thribsmovewell
whenpatientexhales
(comesanterior
superior),butonerib
doesnotmovewell
whenpatientinhales
(stuckanteriorlyand

PrimaryMotion
Pumphandle

Pumphandle

Pumpandbucket
handle

Buckethandle

Calipermotion(move
posteriorinferiorin
inhalationand
anteriorsuperiorin
exhalation)

Copyright2013NewYorkInstituteofTechnologyCollegeofOsteopathicMedicine
DepartmentofOsteopathicMedicine

Rib12

inferio
orly)
th
12 ribsmovewe
ell
whenpatientinhaales
(come
esposterior
inferio
or),butonerib
doesn
notmovewe
ell
whenpatientexhaales
(stuckkposterior
inferio
orly)

superriorly)
12thrribsmoveweell
whennpatientexh
hales
(comeesanterior
superrior),butonerib
doesnotmovew
well
hales
whennpatientinh
(stuckkanteriorlyand
superriorly)

Calipermotion(m
move
posteeriorinferiorrin
inhalationand
anterriorsuperiorrin
exhalation)

Figure11sstribdiagnosishandplacementt

Figure2Upperribdiagnosis

Middleribdiagno
osis
Figure3M

Figure4Midddleribdiagnosissalternatehand
dpositioning

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eofTechnolo
ogyCollegeoffOsteopathiccMedicine
Departme
entofOsteop
pathicMedicin
ne

Figure5Lo
owerribdiagnosis

Figure6Riibs11and12diagnosis

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

Look(ob
bservation):Observethepatientsbreaathingandlo okforanyscarsormarks.

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eofTechnolo
ogyCollegeoffOsteopathiccMedicine
Departme
entofOsteop
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