Rib dysfunctions: inhaled vs exhaled ribs, key ribs, and muscle energy

A rib dysfunction is named for the breathing phase the rib prefers. An inhaled rib (inhalation dysfunction) is held up: it moves into inhalation easily and stops early when the patient breathes out. An exhaled rib (exhalation dysfunction) is held down: it breathes out easily and stops early on the way in. When a group of ribs is involved, you treat one key rib: the bottom rib of an inhaled group, the top rib of an exhaled group.

Rib anatomy that matters

• True ribs (1 to 7) reach the sternum through their own cartilage. False ribs (8 to 10) join the cartilage above. Floating ribs (11 and 12) end free.
• Typical ribs are generally 3 to 9. Ribs 1, 2, 11 and 12 are atypical, and rib 10 is often counted as atypical too.
• Ribs 1 to 10 meet the spine at two joints: the costovertebral joint (head of the rib) and the costotransverse joint (tubercle), and the axis of rib motion runs through them. Ribs 11 and 12 have no tubercle, so they only have the costovertebral joint.
• The scalenes attach to ribs 1 and 2, which is why those ribs matter for both breathing and the thoracic outlet.

How ribs move

The motions overlap, especially in the middle ribs. Each name marks the dominant pattern.

Inhaled or exhaled?

The motion lag makes the diagnosis. Pain with one phase of breathing, a prominent rib or a tender point supports the diagnosis but never makes it alone.

Examining the ribs

1. Place your hands symmetrically over the ribs: near the midclavicular line for pump handle motion (upper ribs) and near the midaxillary line for bucket handle motion (lower ribs).
2. Have the patient breathe in and out deeply while you compare sides.
3. The side or level that stops moving first is restricted. If it stops early on exhalation, the rib is inhaled; if it stops early on inhalation, it is exhaled.
4. Find the extent of the group, then pick the key rib with BITE.

Reading the intercostal spaces

A widened or narrowed space has two possible explanations, and motion testing decides between them.

Example: a widened sixth space with poor inhalation in the ribs below it points to an exhaled seventh rib, the top of an exhaled group.

Muscle energy for exhaled ribs

An exhaled rib needs to move into inhalation. For ribs 1 to 10, the muscle in the table attaches to the rib (or, for the lats, to the lower ribs) and draws it into inhalation as it contracts; ribs 11 and 12 move out and back rather than up, and are treated with the quadratus lumborum and breathing assistance. Bring the rib to its inhalation barrier, have the patient contract against your equal resistance for 3 to 5 seconds, relax, take up the slack, repeat and recheck. A common posterior contact is the rib angle, with a gentle pull toward the feet that levers the front of the rib up.

Muscle energy for inhaled ribs

An inhaled rib needs to go down, so breathing does the work (respiratory assistance).

1. Flex the patient's head and trunk enough to localize to the key rib (the bottom rib of the group). For bucket handle ribs, add sidebending toward the treated side.
2. Contact the top edge of the key rib in front.
3. The patient breathes out fully while you follow the rib down; hold it there while the patient breathes in.
4. Repeat, then recheck.

Rib HVLA in brief

For ribs 2 to 10, the fulcrum usually sits at the rib angle rather than the transverse process. In a common supine method, a thrust vector toward the feet (caudad) at the posterior angle treats exhaled ribs, and one toward the head (cephalad) treats inhaled ribs. A seated first-rib method uses sidebending toward and rotation away, with a down-and-in thrust on the rib. Localization and contraindication screening matter more than any single mnemonic.

Counterstrain for ribs

• Anterior rib points (AR1 to AR10), linked to exhaled ribs: AR1 just below the clavicle at the first rib's sternal end, AR2 on the second rib near the midclavicular line, and AR3 to AR10 on their ribs near the anterior axillary line. Position: flexion, sidebending and rotation toward the point.
• Posterior rib points (PR1 to PR10), linked to inhaled ribs: PR2 to PR10 at the rib angles, positioned in slight flexion with sidebending and rotation away. PR1 sits near the first costotransverse joint and uses slight extension, sidebending away and rotation toward.

See counterstrain for the method and every region.

The thoracic outlet

The nerves and vessels to the arm pass through three tight spaces. Each provocative test traditionally targets one of them.

The Roos test (elevated arm stress test) has the patient hold both arms up and open and close the hands repeatedly, watching for symptoms.

Frequently asked

What is the difference between an inhaled and an exhaled rib?

An inhaled rib is held up and cannot fully breathe out, so exhalation is restricted. An exhaled rib is held down and cannot fully breathe in, so inhalation is restricted. Each is named for the phase it prefers.

Which rib is the key rib?

In a group of inhaled ribs, the bottom rib. In a group of exhaled ribs, the top rib. The mnemonic is BITE: bottom for inhalation, top for exhalation.

Which muscle do you use for muscle energy on rib 1?

The anterior and middle scalenes. The patient lifts the head against resistance. Rib 2 uses the posterior scalene with the head turned away.

What is pump handle versus bucket handle motion?

Pump handle motion, mainly ribs 1 to 5, lifts the front of the rib and deepens the chest front to back. Bucket handle motion, mainly ribs 6 to 10, lifts the side of the rib and widens the chest.

How long do you hold a rib counterstrain point?

Board review keys 120 seconds for rib tender points, compared with about 90 seconds for most other points.