I was fortunate to be one of two teaching assistant for Ann sleeper this weekend. The other TA was Harminder Sihota. We had a good laugh at Ann and her funny sounding voice (she was battling a tickle in her throat).
Structural rib problems are often overlooked by many therapists. Often people that have a diffuse non-specific pain in there back is often a rib problem. This is were the person knows where the pain is but can't seem to put their finger directly on it.
Common symptoms of a structural rib dysfunction are:
- "poke in the back", chest and breast pain
- Pain in the neck (especially upper ribs)
- Pain in the shoulder and arm; decreased ROM especially ribs 1 and 2, Thoracic Outlet Syndrome symptoms
- Breathing issues
- Circulatory issues
- Lymphatic issues
- Autonomic balance (can even show up as focus, digestion etc)
- Low back pain. Rib 12: everybody meets here.
Other common symptom include sympathetic irritations. Remember that the sympathetic chain ganglia are running along the anterior of the vertebra where the rib heads join the vertebrae. This can be like the "Wheel of Missfortune". You don't really know what kind of autonomic issue you might end up with when you have a rib problem or if you will have a sympathetic problem. Keep an eye out for rib dysfunctions when you see autonomic problems.
Its always good reviewing anatomy and the movement that the ribs make. Typical ribs: ribs 3-10 have 5 joints per side. Yes 5! There are 3 in the front and 2 in the back. In the front there is the piece of chondral cartilage between the sternum and the bone of the rib. This gives us the sternocondral joints and the costocondral joints. In the back the rib joins to the vertebral body of the level it is named for and the vertebral body above by demi facets and also to the transverse process of the vertebrae it's named for.
The ribs are flexible and have a great deal of motion available to them. We look for 2 distinct movements when we are assessing the ribs. We look for pump handle and bucket handle movements. It is easier to palpate the pump handle movement from the front and the bucket handle movement on the lateral aspects of the ribcage.
Realizing that the ribs are so flexible and mobile we come to the conclusion that there must be multiple ways they become dysfunctional. Ann's course covers what the ribs will possibly do:
- anterior and posterior rib subluxations;
- external and internal torsions;
- superior subluxations of the top rib 1;
- superior lateral rib flexion (bucket bail dysfunction);
- lateral rib compression;
- anteriorposterior rib compression;
- inhalation and exhalation restrictions of rib 11 and 12.
- costocondral and sternocondral
- sternomanubrial joints
We also covered the clavicle too.
- Sternalclavicular joint
- Acromioclavicular joint
It was a 2 1/2 day course and on the last day patients came in for the students to practice on. I think this is such a valuable opportunity for the students. It helps to get the order of things solid in their minds and get confirmation from the instructors about what is happening. Sometimes it is difficult to justify the extra time of work to do this but the result is you end up "owning" the material and integrating it into your practice right away.
I have been treating the ribs for over 20 years and it is always nice hearing the stories from Ann and Harminder to give me even more experience of what patients go through trying to find relief for problems caused by ribs. I was also happy to see a full course of people that have learned to treat these overlooked areas. Their practices will get busier and the clients will be happy.
I greatly encourage you to look into becoming skilled at Muscle Energy Technique (MET) especially for the ribs and sacrum. Go to Ann's website: annsleeper.com.
