Let’s talk about Ribs

Written by Kento Kamiyama PT, DPT

In today’s post, lets talk about the ribs in relation with other areas of the body.  When we look at the thorax, as a physical therapist we commonly think about the thoracic spine and not the ribs.  We are almost taught to look at those as separate entities which I believe is not a great way to think considering the amount of articulation involved with the thoracic spine and ribs.

However, if you look at the close relationship the ribs have on the thorax along with other areas in the body, it is hard to ignore them.

Once I had a better understanding about the roles of the ribs on our cardiovascular, neurological and musculoskeletal system, I realized I was missing something pretty significant in the early parts of my PT career.

The 12 ribs (1-7 true, 8-10 false, 11-12 floating) protect the lungs and heart from external forces and have a role in respiration.  Due to its role in respiration many muscles have attachments to the ribs:

Example Muscles include:

Inspiratory:  scalenes, sternocleidomastoid, pectorals minor/major, serratus anterior, serratus posterior superior, external intercostals, iliocostalis, longissimus, diaphragm, etc.

Expiratory:  Rectus abdominus, Internal/External Oblique, Tranversus Abdominis, Quadratus lumborum, serratus posterior inferior, tranversus thoracic, etc

I’m sure I’m missing some here but this is a good majority of it.

Whenever a muscle is connected to the ribs it is considered either a primary breathing muscle or a accessory breathing muscle.  Both primary and accessory muscles have important function during breathing.  During relaxed breathing it is recommended to utilize the primary breathing muscles (i.e.- diaphragm) instead of the accessory breathing muscles (ie- pec minor, SCM, scalenes).  The accessory muscles are their for ‘accessory’ reasons such as helping the individual get more air in during activities that need more oxygen.  However, in the clinic, I often see strategies where we use our accessory muscles more than the primary breathing muscles even during a relaxed state.

Rib Mechanics 101 

During inspiration, with good mechanics the diaphragm descends from its dome shape and the lower rib go through a bucket handle effect in a more transverse dimension and the upper ribs expand more in a anterior posterior dimension.   During expiration, the ribs go down back to its original position and allowing the diaphragm to dome back up.

Unfortunately, what I tend to see a lot is more of a pump handle effect on all the ribs for many of the clients which can lead to rib flares.  This leads to increased externally rotated and protracted ribs which can decrease its ability to depress the ribs during expiration and to expand laterally and posteriorly during inspiration.

This, unfortunately leads to poor diaphragm efficiency secondary to poor rib positioning.  The postural restoration institute will call this having a poor zone of apposition.  As shown below, if you keep this up, the rib will continue to flare and when you attempt to perform diaphragmatic breathing you might just be using accessory muscles since the diaphragm is already in a disadvantaged length/position.   Not only can this lead to inefficient diaphragmatic breathing, it can consistently lengthen the abdominals leading to inefficient abdominal strength.  This is when one might be chest breathing OR abdominal breathing with a strong rib flare.  This, unfortunately will not be good diaphragmatic breathing.  (I was going to find one in youtube but I’m not here to call anyone out here).

When this happens a myriad of things can happen where it can affect:

• Poor scapular/shoulder movements – Eric Cressey has a nice example of rib flare with shoulder movements here
• Back pain or poor intrinsic core function – Kolars has a nice article about back pain and diaphragmatic breathing.
• Neck/Hip/Foot/Thoracic Spine dysfunction –  Linda Joys Lee’s work is nice example
• Hip dysfunction – A nice article from PRI.
• Pelvic Floor Dysfunction- a quick clip from Dr. Kathy Dooley on diaphragm and pelvic floor function along with exercises to release it.

From a movement standpoint, when a thorax is protracted and externally rotated, it could loose its mobility in all three planes.  When a thorax is intact, the movements primarily allow transverse plane followed by lateral bending with significantly less flexion/extension moments (Watkins et al 2005, Willems et al 1996).  To repeat, when your ribs are flared, the diaphragm tends to flatten and you lose your ability to inhale through your diaphragm efficiently.  To use the diaphragm efficiently it is essential to have good rib positioning along with abdominal opposition to maintain good diaphragm dome shape (Postural Respiration Manual) .

Hence, just because an individual is abdominal breathing, it does not necessarily mean one is utilizing the diaphragm well to inhale.  If you see a rib flare and lack of rib movement laterally and posteriorly during inhale and poor rib internal rotation and depression during exhale, they still might be inefficiently utilizing the diaphragm and utilize the accessory muscles to breathe.

So….how do we improve good rib movement?  Here are some points (but not comprehensive) that I’ve learned that has helped:

•  Exhale long.  Either utilize a balloon, straw to get the exhale going to allow the ribs to go down and back.  Remember, you want to see some rib movements here.
• For those that can’t shut their back/rectus abdominis during exhale, utilize a ‘sigh’ type of breathe to shut down first
• After the exhale, hold your breathe for a couple seconds to allow the diaphragm to dome a little more
• When inhaling, try not to force the inhale and inhale silently.  Let the air in naturally.  When you force the inhale that tends to tap into the sympathetic system and the ribs tends to have a harder time expanding the way it needs to.
• Imagine your inhale or ‘air’ going into your mid/low back (or feel it expanding) while your abdominal muscles are opposing
• Alternate the ribs opening/closing.  Meaning learn how to bring one rib down while the other opens.  This happens with transverse and frontal plane motion such as gait.  Use alternating arm reaches as an example.  I just found a gem of Connor Ryan doing a demonstration of alternating arm reach.

Once the breathing mechanics are improved, now the questions are how are their ribs positioned or moving during:

• Neck movements?
• Scapular/Shoulder movements?
• T/S mobilization exercises?
• Core exercises?
• Hip movements?
• Gait?

Once you realized a certain area of the ribs not moving, it could have affects to all the movements above.

Hope this helps stir up some ideas.  Happy Holidays!!

Supplementary Videos:

Bill Hartman on thorax/rib position for scapular stability

Bill Hartman on an example of good rib position for scapular exercises

Zac Cupples talks about pelvis movement on how it can shortened certain areas of the pelvis tissues.  This is important when you can see how the ribs have an affect on pelvis positioning

Dr Kathy Dooley showing the immense connections of the diaphragm to organs

References:

Lee LJ.  The Thoracic Ring Approach- A New View of the Thorax.  N0. 145, Winter 2013, In Touch Journal, an official publication of Physic First, the Journal for Physiotherapists in Private Practice (UK).

Liebenson, C. Rehabilitation of the Spine: A Practitioners Manual (2007).

Postural Respiration Manual Notes from Postural Restoration Institute

Watkins R 4th, Watkins R 3rd, Williams L, Ahlbrand S, Garcia R, Karamanian A, Sharp L, Vo C, Hedman T. Stability provided by the sternum and rib cage in the thoracic spine.  Spine (Phila Pa 1976) 2005; 30(11):1283-1286