The Thinking Practitioner Podcast:
Episode 56: Working with Rib Issues

Til Luchau:

Hi, I'm Til Luchau. When I was looking for a publisher for a book I wanted to write, I was fortunate to have ended up with two offers. One, from a large international media conglomerate and the other from Handspring, a small publisher in Scotland, run by four great people who love great books and who love our field. To this day, I'm glad I chose to go with Handspring, as not only did they help me make the books I wanted to share, the Advanced Myofascial Techniques series, but their catalog has emerged as one of the leading collections, a professional level books written, especially for body workers, movement teachers, and all professionals who use movement or touch to help patients achieve wellness.

Whitney Lowe:

Hi, and I'm Whitney Lowe, and Handspring's move to learn webinars are free 45 minute broadcasts featuring their authors, including one with you Til, so head on over to their website @handspringpublishing.com to check those out. And be sure to use the code TTP at checkout for a discount. Thanks again so much, Handspring. All right, sir, here we are once again, recording this just after the new year. And then an interesting start to the new year, certainly for you guys out there in Colorado, a very challenging time there, so glad to hear that you're safe and sound after the wildfire disaster.

Til Luchau:

The wildfire just on December 30th was right here, and the count is still being tallied, but looks like almost a thousand homes burned-

Whitney Lowe:

Wow, man.

Til Luchau:

... within a mile of our place, so it was quite a big deal, quite a shock. And we, what a thing, Whitney, there's so many fires and so many people that have been affected by this, but to have it come that close and to have gone through the evacuation process of saying, we're saying goodbye to our house, but then to wake up the next day, it's a really, and be back still in our house, back there and everything's and our little sphere normal again, but then just over the Ridge, there's people that have lost everything.

Whitney Lowe:

It happens so quickly and it really, it's one of those things that people reflect on a great deal of recognizing what's valuable and what's, when you have to make those decisions in a split second. We've had to do that before too with fire evacuations. What are you going to try to save in just a few minutes? Really makes you think about a lot of things.

Til Luchau:

Of course. The first thing I went for was my box set of Thinking Practitioner recordings.

Whitney Lowe:

Of course, because that is irreplaceable.

Til Luchau:

That's right. It was a powerful process going through that, so letting it go. good to be here.

Whitney Lowe:

We're glad you're here. We're glad you're safe and everything, so we're going to start off the new year right.

Til Luchau:

Thank you. How are you doing?

Whitney Lowe:

Doing all right. We had a nice relaxing turnover to the year here, and are ready to get started and get going on some new adventures this year, so that's where we are.

Til Luchau:

Looking forward to being part of those and hearing about those as they come forth.

Whitney Lowe:

Alrighty. Well, what are we talking about today?

Til Luchau:

Let's talk about ribs, rib cages, rib issues, and hands on work.

Whitney Lowe:

That's something interesting we haven't delved into yet here, so that sounds exciting.

Til Luchau:

It's a topic that a lot of soft tissue therapists don't spend a lot of time thinking about, or maybe don't even have a lot of training in, but it is one of my favorite topics. Partly because it's the most recent full training we've recorded, and it's also the subject of a training coming up and I'll say some more about that toward the end, coming up starting the beginning of February. But it's remarkable to get into the mindset of working with the rib and rib cage. And it's just so much I have to say about it, I'm looking forward to talking to you about it. Where do you want to start?

Whitney Lowe:

Well, I'm curious. I want to touch base with, first of all, with something that you just said a moment ago. Because this was called to my attention both as I was doing some preparation for this episode, and also just thinking through training processes in our field, in other fields, why is it that we don't talk about the ribs a whole lot? We don't hear a whole lot about them. There's not a lot of stuff in PubMed. When I went digging around, looking for some things, interesting stuff, I didn't see a whole lot of things in there.

Til Luchau:

No, there's not.

Whitney Lowe:

And you don't hear about people focusing on rib cage issues a great deal in many of the training programs that are around in our field and also in many other fields as well. I found the same thing, a couple of the articles that I was looking at were saying, this is an area that doesn't get a lot of attention in medical practice, for example, and I thought, it's odd. It's interesting. This is the housing for our vital internal organs

Til Luchau:

Most vital organs, that's right. I wonder if it's because, at least for the soft tissue perspective, if it's because they're bones, and their joints don't move a lot. We usually think, and I'm going to get into how they move, but we think of it as a bone, and we think of ourselves as soft tissue people. And I'm also thinking that when they're broken, there's not a lot, unless they're really fractured, there's not a lot that's done for them in a medical sense other than trying to keep someone comfortable and immobile enough to let them heal. Pretty trouble free except when they're not, because when they're not, then you hurt, or some super important functions like breathing, or impaired, things like that.

Whitney Lowe:

I broke a rib a couple years ago in a snowboarding accident and man, coughing, sneezing and laughing for about six weeks was not fun.

Til Luchau:

Not good.

Whitney Lowe:

It was not fun.

Til Luchau:

I didn't know you were a shredder.

Whitney Lowe:

I wasn't, that's why I broke my rib! When I was young, I used to skateboard all the time and thought, well, I'm going to try doing the snowboarding thing, because it looks like it'd be a good transition of motor skills. And I've gone a couple times with it and I have a lot of fun doing it. I didn't do enough to get good at it, but I just took a spill one time and fell down, and my elbow was tucked right into my torso, so it just slammed it in there, all my body weight, and broke my rib, and...

Til Luchau:

Oh boy. It took about six weeks you said, to feel-

Whitney Lowe:

It did.

Til Luchau:

... something like normal?

Whitney Lowe:

It did.

Til Luchau:

Well, you know how a snowboarder introduces himself to you, don't you?

Whitney Lowe:

Oh boy, I don't know. I'm ready to hear that though.

Til Luchau:

Sorry dude.

Whitney Lowe:

That's about it.

Til Luchau:

That's a skier joke. I'm a skier, so we tell snowboarding jokes, of course, but snowboarding's pretty great, and it's also easier on the knees than skiing, although higher incidents of neck injuries in snowboarders.

Whitney Lowe:

So I was trying to evaluate, which of those injuries would I be willing to sustain that might keep me away from doing work and stuff like that? I thought, well, do I want to wrench my knees and torque my MCL and do that on skis, or do I want to just take a spill and hit my upper body with snowboarding? I did a little bit of both, and they're both fun.

Til Luchau:

We take our risks, we pay the price, but then, so ribs, tell us about, maybe tell us about some rib anatomy?

Whitney Lowe:

So let's start our exploration at the base level here. And we'll talk a little bit about structure first, and then we'll get into some things about function, dysfunction, challenges, problems, and what we think we can do with this. So just as a reminder, I'm sure you all touched based on this in your entry level training, but just as a reminder here's what we're talking about here. We have 12 pairs of ribs, one-

Til Luchau:

Sorry to interrupt already.

Whitney Lowe:

All right.

Til Luchau:

We should mention the handout, because we're going to put an outline of this in the handout.

Whitney Lowe:

Why don't you tell us about that?

Til Luchau:

Just, we're going to put it on our site. So wherever you found this, we'll try to put the URL for the handout in there, and just go get it.

Whitney Lowe:

That's more good details, and at the end maybe you can tell us a little bit more about what's in there, and we'll get into it, so thank you for reminding that. So 12 pairs of ribs, half on each side, and we have, they're divided oftentimes into three categories, the first being called true ribs. And these are going to be mostly the upper ones that have a connection directly with the sternum, so this is generally ribs one through seven. And you can, if you remember your anatomy pictures, that rib goes all the way around from the vertebral connection directly into the sternum on those first seven ribs. So a little bit different sometimes with that first rib, because it can have some other fibrous connections in there, especially with some of the anatomical variations that we have talked about before, and we'll get into again here. And then your next-

Til Luchau:

This is really, what you just said is so important to working with them that they connect both and back and they go around all the way to the front, key concept.

Whitney Lowe:

And we'll talk about that in some other functional explanations here a bit too. And down below that, the next three are sometimes called false ribs, which means they're not directly articulating with the sternum, but if you remember, they have fibrous connections that blend up into that larger bundle of connective tissue where rib seven comes over and attaches with the sternum. And then the last two are-

Til Luchau:

Wait a minute, so wait, why they're false, they're false ribs. They're pretending to be ribs, we say, because they don't articulate directly with the sternum. And you said connective tissue, that's interesting. Because, it's often taught as cartilage, isn't it?

Whitney Lowe:

Yeah, and I think I meant to say cartilage, but can we say connective tissue?

Til Luchau:

Yeah, we can use one of those.

Whitney Lowe:

But for clarification, it's good to say cartilage because there are conditions that are named and described in relation to the cartilage dysfunctions of those connections, so that's an important clarification.

Til Luchau:

That's right.

Whitney Lowe:

Cartilage connections. And then our last two are the two floating ribs that do not have connections with the sternum, so they're just out there in space. I ran across an interesting little tidbit trivia around this. You may have heard this, but there are, as in many things, there are anatomical variations unique to certain demographic groups and this-

Til Luchau:

Red state, blue state variations in ribs?

Whitney Lowe:

Yes, something like that. Actually not demographic, but what am I trying to say? Just-

Til Luchau:

I know what you mean exactly. I can use demographics, I was just giving you a hard time.

Whitney Lowe:

Local things, locally oriented things, but in Japanese people, there's a higher incidence of the 10th rib being a floating rib, believe it or not. Never heard that before.

Til Luchau:

Longer lumbar section essentially, that's really interesting.

Whitney Lowe:

So fascinating there. Back up to the first rib for just a second, we did mention that, we talked about this in our episode on thoracic outlet syndrome, the presence of something called a cervical rib. And that is a faulty extension of the transverse process of C7 that will curve around and connect in, have fibrous connections in with where the first rib is connecting in toward the sternum. So sometimes that is present in about half of a percent of the population we have found, or that's been the stats that I have come across a couple times in terms of the predominance of that cervical rib.

Til Luchau:

I've heard that too. And I've heard it is not always symptomatic, two to three times more likely to be symptomatic. So, but more symptomatic than people that don't have them, but not inevitably symptomatic either.

Whitney Lowe:

And an important distinction about that is also remembering, if you're working on somebody's scalene muscles, and you feel something really hard right down there-

Til Luchau:

Don't try to rub it out.

Whitney Lowe:

... it might not be a hypertonic tight muscle. It might be a cervical rib in there.

Til Luchau:

Nice.

Whitney Lowe:

Slightly greater predominance in females with that cervical rib also that's-

Til Luchau:

I did not know that.

Whitney Lowe:

So interesting little things there.

Til Luchau:

Back to the floating ribs, I'm remembering a little bit of trivia from the structural integration legacy. And I can't remember exactly what question she was asked, but Ida Rolf, again, the founder of that tradition was asked at some point, what was her favorite technique or what was her favorite part of the body, or if she could only do one thing, what would it be? Maybe it was, if she could only take one technique to a desert island, what would she take? But it was, her answer was the 12th rib.

Whitney Lowe:

Really? Interesting.

Til Luchau:

Out of her whole repertory of things, it was the 12th rib she says the one.

Whitney Lowe:

And, explanations of why, any ideas?

Til Luchau:

There have been numerous long-winded discussions about why she might have said that and what she meant. She left it as a riddle, I think, but it is really key. It's where the upper body meets the lower body in a lot of different ways. It's the back of the diaphragm, the diaphragm being such an important central structure. And when it's not open, neither is much else, really. You can say when things don't move or expand around that place, not much else says to. Those are just maybe some quick off the top of my head factors she might have been thinking about, but there might have been a whole lot more too.

Whitney Lowe:

All right, so fascinating stuff in there. And so, those are the main bones of the rib cage. And then of course, to tie those things together, especially on the posterior aspect, where the ribs are joining with the vertebral spine, there is a very intricate webbing of ligaments, very short, very small ligaments in there, but I came across this. I had no idea about the number of this. There's roughly somewhere in the neighborhood of 108 costovertebral ligaments in the thoracic spine, so lots of little connections there between portions of vertebral bodies and the ribs to hold them in position there.

Til Luchau:

And those are just the ones that have names probably. Because, if you've done a dissection, or you've done some cooking with meat, or you've seen the anatomical pictures, that whole region there where the ribs meet the spine is so fibrous, and so bound in with ligaments, like you said, but also lots of little muscular and fascial structures.

Whitney Lowe:

And a very important consideration for us to remember is, that means lots of richly innervated soft tissues in there that might be irritated and cause some of the pain sensations people may be feeling. So I think a number of things there to be thinking about with all those little, little bitty guys in there. And we got a bunch of muscles connecting along there too, to the rib cage, especially those that are helping to act on the spine, the paravertebral muscles. You mentioned the diaphragm earlier, what else we've got in there? Some other muscles, quadratus lumborum, you talked about the 12th rib and its importance, and then also...

Til Luchau:

Some of those ones that I listed there in the outline were things that I was brainstorming about what connects the ribs out into the appendices. Because, there's certainly the things that connect ribs to other ribs like intercostals, but we often don't think of them. You said, paravertebral, but the iliocostalis part of the erector group, that's a rib muscle, it's right in its name, iliocostalis, and it does a lot with ribs, or latissimus, or like you said, QL, is a rib muscle.

Whitney Lowe:

Any of those spinal muscle, ones that we don't think about a lot, serratus posterior superior, for example, other ones that are connecting in with those bodies of the ribs and, or also near the joints themselves and may certainly be playing a part in different types of pain complaints people may be having there, so some very important things to be thinking about. And you also mentioned one in here too, that I think a lot of people don't think about, this as a rib oriented muscle, even though it fans out across the ribs and it's a major appendicular muscle, and that's the serratus anterior, really critical player there. And it's spanning across a broad range of the whole rib cage, the lateral rib cage.

Til Luchau:

Well, and then pectoralis major in front, similar, spans and connect and minor as well. Now, for those of us who think in muscle terms that these names mean something, but if you don't think in muscle terms, a shorthand is just to think there's lots of big soft tissue structures that fan out, like said, onto the ribs, and connect them either to the axial spine or out in the case of some of those, out into the limbs as well. With the upper girdle in particular for the upper ribs, being something to think about as you're starting to aim for the ribs themselves, a progression in terms of a treatment model might or maybe should include some upper girdle work as well.

Til Luchau:

Because, the shoulder girdle is wrapped around the upper rib cage in such a way that it's impossible to separate them, so really thinking about upper ribs means thinking about pectoralis in front, and then up into the head and neck there's scalenes, rib muscles, like you said, on the upper rib or two, that really, the real upper ribs are really the base of the neck, the base of those guy wires or the scalenes that are helping to stabilize and mobilize the neck as well.

Whitney Lowe:

It's important to remember, so muscles like the scalenes, which we think about so often being neck muscles and acting on the neck, but they are really critical for inspiration and lifting the ribcage up, and that's a big factor with them.

Til Luchau:

Biting my tongue a little bit, because it's a rabbit hole, but it's the costal pleural ligaments, the little ligaments right up there at the top of the pleural dome that anchor, essentially anchor the top of the lungs to the ribs and to the vertebrae, are the other end of what the diaphragm pulls on. Diaphragm contracts and pulls downward, the ribs are, sorry, the lungs are anchored up to the upper ribs, so that they get stretched between the downward descending diaphragm and that anchor up at the top, essentially the base of the neck. That's what it pulls air in, because of those anchorings up there.

Whitney Lowe:

It's a fascinating process. And again, something I think we just don't tend to delve into as much in our world, so it's great to take a deeper look into this. So we're starting to-

Til Luchau:

Sorry, let me give honorable mention to the thoracolumbar fascia.

Whitney Lowe:

Oh, yes.

Til Luchau:

And pectoralis fascia, cervical fascia, brachial fascia, pleura fascia, this is like the credits rolling by, as we did all the names involved in the rib production. But sure, certainly there's fascial layers too that are very involved with rib mobility, and rib sensitivity, and rib structure.

Whitney Lowe:

And as we get into some of those tissues we start looking a little bit more closely at function, in terms of what is the rib cage's primary role, and what is it doing there? So of course, it makes sense that it's a primary factor in protecting the internal thoracic organs, some of our most vital organs, lungs, heart, everything that are up in the upper thoracic region there. And they're also, as you mentioned too here, assisting a great deal in that whole process of respirations. So they are providing both structure and also some capability for expansion and contraction of the lungs during the respiration process.

Til Luchau:

Did I say that? Did I say assistance in respiration? Was that me?

Whitney Lowe:

I think so.

Til Luchau:

Well, if I-

Whitney Lowe:

We were talking about the scalenes, and you were talking about the lungs and all that stuff, so...

Til Luchau:

I'm looking, I'm seeing that in our outline. I didn't know that was me, but if I had to riff on that a little bit, I would say the ribs are our springs too. We load them on the inhale. They expand a little bit, like if you imagine a C coming farther apart, and then when you let the air out, the ribs return to the original shape. So we're using the ribs, and they're springing, kinetic loading aspect as well for respiration.

Whitney Lowe:

That makes sense. So tell me some more about the move. You've got some other things in here about some movement things, tell me a little bit about that.

Til Luchau:

It's just so important. And it was a revelation for me to think about ribs moving in three dimensions. And you mentioned them being attached in the back and in the front, so it's front and spine and back. So let's actually do this with, if you just take an in breath and lift your arms above your head, like Diane McKowski would when she's starting a conversation with you, and then bring them down. If you just do that again, bring your arms up over your head. Your ribs are basically moving upwards with your arms. They're being pulled outward and upward. That motion is called, as you may know, bucket handle motion, where because they're attached in the back and the front, they swing outward from the middle like a bucket handle, like two bucket handles.

Whitney Lowe:

So let me clarify it again. So when you're saying they're swinging outward, meaning the whole rib cage is curving around toward the front as you do that, is that what you are saying?

Til Luchau:

No, thanks. Attached back in front. One rib, let's say, and as you lift your arm, it'll swing laterally, say the mid part of that handle, the middle part of the river will swing laterally, while those fixed points are relatively immobile. So it's like lifting the handle up on a bucket.

Whitney Lowe:

Got it. That makes sense.

Til Luchau:

That of course, in two sides, and then we have it all the way up and down, so you got a whole bunch of buckets going in both directions, so that's just one dimension too. The other dimension that's talked about often is pump handle, because it's like an up and down motion, and that's the tendency of your sternum, let's say, with a front side of the ribcage to drop and rise as you breathe. Try that a little bit, exhale lets your sternum drop a lot, as you can just curve over in your chair, whether you're listening to the podcast, seated or standing, you can just curl forward. And then, if you take a big in breath and let your sternum come up, go ahead and do that everybody. Your ribs are basically lifting in the front more than they're in the back. So do that a couple times and feel that, that's the pump handle motion of the ribs, the front side, the sternum going upwards and downwards in space with-

Whitney Lowe:

So if we're moving in that direction, and you've got this curved bone going from the spine back around to the sternum, is the entire curved bone moving forward, or is that curve opening up and expanding as the sternum rises and falls?

Til Luchau:

Well, that because you're inhaling, you're also expanding the curve. You're also, like I said, it's like a C shaped bucket handle. You're actually flattening the C as you inhale and lift in front as well. So all these are going on at once, absolutely.

Whitney Lowe:

So this seems like one of the places in the body where we have something that's pretty unusual, which is bones bending as part of their natural activity.

Til Luchau:

That's right.

Whitney Lowe:

So the flexibility of those bones to be able to do that seems like it's a pretty crucial part of normal function there.

Til Luchau:

So crucial. And then you talked about floating ribs, you could think about them all floating, in some ways they're all suspended between various soft tissues, soft structures to allow all these movements. And there's one more dimension too which is, if you just put your hands on the side of your ribcage, somewhere above your waist, on your thorax, and then twist from side to side, so you're moving now in a horizontal plane, that's caliper motion of the ribs, so that on the side that you're turning towards, say you're turning towards the right, your right ribs are opening in the front, away from the spine, and your left ribs are closing toward the spine.

Til Luchau:

And then you reverse it the other way, you twist the other way, that's the other possibility where the right side, right ribs are closing in the front, left side are opening in the front, so that movement of the horizontal plane like a caliper motion, or if you just arch your back and look upwards, that's all the ribs caliper, open in front, or if you curl forward and hunch, like you're working too late on your computer, all the ribs caliper forwards and close in front, so that's the horizontal plane movements. And we tend to, you can just imagine now that those rib motions are really important to posture, and to support, and to function, and to balance, certainly in standing, but definitely in seated positions as well. So they're relevant to all this time we spend on these devices now, and what we do there, and how the ribs are engaged or not engaged, how they're moving or not moving as we're doing these things.

Whitney Lowe:

And as you mentioned a moment ago about the different motions and the directions that we're moving to, just another point I want to call attention to, when we think about motion through the spine, that there's some significant differences in terms of what we should be seeing of where spinal motion occurs. So for example, throughout the entire spine, the majority of flexion and extension movements are occurring in the lumbar spine, whereas, the majority of our rotational movements are happening in the thoracic spine. And so, you get some of that during that flexion and extension, you'll get a little bit of that as you mentioned, shrinking down and expanding of the thoracic rib cage. But if the thoracic spine flexed and extended as much as the lumbar spine does, then it would be difficult, because your ribs would collapse in on each other.

Til Luchau:

Well, that's a good point. And the thoracic spine flexes and extends less because of the ribs.

Whitney Lowe:

Exactly.

Til Luchau:

Because it has a rib cage around it. It's a fun mental exercise though to imagine that your thoracic spine could flex and expand that much. But you could actually, you'd have to grow your sternum somehow. Your sternum would have to get longer in front. Most of us could use that. Most of us could use a little bit of that imagination, so that's a good point though, Whitney.

Whitney Lowe:

And remembering too that, despite the fact that we think of ourselves turning our torso, and you're turning your back, the majority of that rotational movement is occurring in that thoracic region where the ribcage is, and not in the lumbar spine.

Til Luchau:

Yes, thank you. So the twisting happens in the thoracics.

Whitney Lowe:

And of course, if you're interested in the anatomical minutia of that, that's a fascinating aspect of looking at the angular orientation of the facet joints of this spine that allows that, because in the spinal region they're more vertical allowing for sagittal plane movement. And as you move up the spine through the thoracic region, they start to slant more diagonally, allowing a lot more of that rotational movement, so that's a fascinating aspect of how those facet joints are associated too.

Til Luchau:

I love that stuff. And then the fact that the costovertebral joints, the ways that the ribs are knit in with all 108 thoracic costovertebral ligaments there, that really determines movement too that could restrict or allow movement in the thoracic spine, the ways the ribs relate to it. And so, it's it. And maybe I'm going to put this in the handout. There's some fun techniques of just using the entire rib or half of the rib cage, the whole rack of ribs on one side to move it against the spine to get that mobilization between the spine and the ribs can be a remarkable epiphany to feel movement there, to be able to breathe there.

Whitney Lowe:

All right, well what else?

Til Luchau:

Well, I got a question for you there. Do you think ribs go out? Where do you stand on that question?

Whitney Lowe:

I ponder this often, because when you look at them being so tightly bound with all these little ligaments in there, it seems like, well, that's a pretty firm connection, but at the same time, the articulation from a bony standpoint is really weak. It's just two vertical surfaces sitting against each other.

Til Luchau:

Shallow depression, no real socket.

Whitney Lowe:

So it looks like the kind of thing that they could do. So the thing that I find puzzling and interesting is that this particular type of problem doesn't get a lot of attention in many different medical fields of people that would be working with this kind of thing. Certain groups I think will focus on this a whole lot more, for example, chiropractors, osteopath, manipulative therapists, I think focus a lot more attention on this than some of the traditional medical practitioners.

Til Luchau:

The idea that a rib would be out of place, or sublux, or something like that, and that could be the cause of some pain.

Whitney Lowe:

So I certainly think that it does happen, and it can happen in certain instances. Now, one of the other things that I found fascinating in looking up some stuff about costovertebral dysfunctions, is that a lot of times when they are actually identified in traditional medical, Western medical practices-

Til Luchau:

Over a radiograph, or something, an x-ray or something-

Whitney Lowe:

Or a lot of times there's a paper that had about five different case studies of costovertebral dysfunction. And they basically in most of those cases were making their determination based on localized paraspinal, muscle spasm, exquisite tenderness at that particular junction of the rib without necessarily finding anything on the diagnostic studies. But they treated it with nerve blocks, and then the person got better in most cases after a relatively short period of time just with the nerve block alone, which means, so they didn't push something back in that might have been out, but there was significant rib head pain associated with some type of either malalignment, or subluxation where it was partially out and then went back in, or went out and came back in quickly.

Til Luchau:

If I follow, in these case studies, they were seeing people with painful rib heads right up there next to the spine. And there was a shape difference. Was there a topographical difference?

Whitney Lowe:

Yeah.

Til Luchau:

So this is a bump or something they go, traditionally, in some cases people describe it as a rib being out. There's a bump there you can feel. And they treated it not with "pushing the rib back in," but by blocking the nerve, blocking the sensation, and people got better?

Whitney Lowe:

Yeah.

Til Luchau:

Cool.

Whitney Lowe:

Now, those are just a couple of case studies that were reported in the literature. And I would be willing to bet that if you were a health professional that focused on this stuff, you would probably find those a lot more frequently. So, for example, just my sense is just from personal experience, that I tend to see this happen a lot more in the chiropractic field that they're a lot more focused on looking for that as a problem when people have those kinds of symptoms, and then look at this is the way that we're going to treat, is by some type of forced manipulative movement of the rib to put it back in position, and oftentimes it really works well.

Til Luchau:

It's the question I get asked, probably the single biggest question I get asked in the rib training, it's okay, so what do I do for a rib that's out? That question inevitably comes up and often more than once.

Whitney Lowe:

And what do you say? I'm curious what your perspective is on that?

Til Luchau:

I say, I dodge it a little bit, because it's a controversial idea. And in fact, like you said, it's really common and accepted as fact in some fields, and then in other fields like emergency medicine, they say that's not even a thing, or if it is, it's really rare. So there's a big controversy about the accuracy of that terminology. And so, what I say in response to that question, what do you do with a rib that's out? I say, I don't use that map. I don't debate that, that's a useful map in some circumstances or some approaches, but in my map I'm thinking about movement more than position anyway. And there's, sometimes you'll feel a bump there. The skeptics say that it's maybe sprained ligaments with some swelling or hardening, the believers say you're feeling the rib out of misalignment and that's the cause of the pain.

Til Luchau:

I just say I'm feeling for movement. I'm feeling for adaptability. And I'm also, so that's, I'm using my touch to restore movement, but I'm also using my touch to restore or normalize you could say the sensation, to restore normal sensation or normalized sensitivity. So if something's painful, there's a lot we can do with our touch to help ease that sensitivity, that protective response that pain is. And if it's immobile and in conjunction with that, then there's a lot we can do to help encourage movement, help the body be willing to move more.

Whitney Lowe:

And I think it's an important thing, a reminder to us in this instance in particular, but also in a number of other instances too, you don't really know if a person has a rib that's out just by palpation and some of those other clinical signs and symptoms, because what might appear to be the bump in the place where the rib might potentially be out, could be an anatomical anomaly of bone shape, and it just happens to be enlarged and there's tender soft tissues around there. So until you do a high tech diagnostic study and see a distance between the articulating surfaces that indicate that something is out of place, you don't know that for sure. And then once that diagnostic study gets done, it's not your job to do something about it anyway.

Til Luchau:

Out of scope you're saying, from a soft tissue therapist, and I would go even further. I would say, even if we did that study and saw differences in the joint spaces, there's still a debate about whether that's pathological or not. That still is just using a positional map on something that may be a sensation issue or a mobility issue. Anyway, that's another topic.

Whitney Lowe:

But you try to keep the attention focused on the client's experience, and dealing with things from movement enhancement, and getting mobility restored to functional levels.

Til Luchau:

The client's experience in terms of sensation in particular, and then the therapist's experience in terms of the mobility we feel. So those are the goals of my approach is to increase options for your movement and refine proprioception. It's not to get all the ribs in a straight row necessarily. It serves another purpose.

Whitney Lowe:

So while we're talking about those things, tell me a little bit more about, what other things might cause some of these ribs to lose their mobility, or have painful problems, things like that. What else are we looking at that's possible cause?

Til Luchau:

The big groupings of what causes ribs to be troublesome would be a loss in soft tissue adaptability, things get sprained, and scarred, and denser, you could say, or maybe the muscular tension, so it's a loss of soft tissue adaptability or nervous system sensitization, and the protection that comes with that. If you have a rib that's sensitive, then that cycles into that protective movement pattern, which is that vicious circle of lack of mobility, greater sensitivity, and then over time tissue changes perhaps, or movement pattern changes that are harder to get out of. So that's the cycle, but the things that can set that up, I pulled this list out of my slideshow and I see the first one I put on there is an unnatural sleep position. I'm giving the slideshow as I'm traveling around talking to people, so that's probably the first on my mind, getting off the plane and going to teach their class. I'm like going, okay, unnatural sleep position's number one. Coughing, sneezing, vomiting, you can break a rib coughing.

Whitney Lowe:

It's interesting.

Til Luchau:

A lot of the case studies out now about, we don't have a lot of data yet on COVID relationships to rib pain, there's a lot of reports of that. But a lot of them do seem to be tied to coughing. People can cough a lot with COVID sometimes, and that can be, it can strain the soft tissues, strain the different joints, sensitize them over time. Pregnancy's a big rib event. Life of a rib pregnancy figures large. Postural habits, just the way we're used to seating, standing, moving, will change the adaptability or sensitivity of a rib.

Whitney Lowe:

Do you think it changes rib position? The forward slumped, upper thoracic slumped postural position that the ribs adapt to that, or change position in relation to that?

Til Luchau:

I don't mean to be too fussy about this, but I think posture is position. That's what defines posture's position. So a slumped posture would be a change in rib position. Now, I don't think that's quite what you're asking. I think you were saying, is that persistent perhaps, or does that change the joint relationships or something?

Whitney Lowe:

Mm-hmm (affirmative).

Til Luchau:

And yeah, I think it does that too. We get used to the positions that we're in a lot, both our tissue gets used to it, and our brain gets used to it, and our desk set up gets used to it in all kinds of ways. Then there's the question of plasticity and how much is that changeable, all those kind of things. But anyway, you were going to say?

Whitney Lowe:

Just, I agree with you there that it seems like anytime when you're changing those positions for long periods of time, that's the functional position that somebody's in, so it's changing some things. But like you said, the other big question is how plastic, or solid, or lingering is that?

Til Luchau:

That's why I put habit in there too, I said, posture or habit. Not just posture, which is thought of to be a fixed thing that maybe you could improve through working on it, but habit, the ways we do things, the functional side of it as well, being a big piece of what shapes us and the shapes we take often as much habit as structure. So the other thing on the list, trauma, falls, injuries, surgeries, things that physically traumatize or injure the ribs and they're surrounding soft tissues, can definitely cause them to be sensitive over time. And then our old friends, stress, inactivity and disease will all show up as rib pain or rib dysfunction of various sorts.

Whitney Lowe:

So we'll talk about a few more of these potential pathological problems here that people have that are associated with ribs, and maybe also a little bit about what role we may play with some of them. So when we look at what causes the pain and pathology, some of the things that come to mind, you mentioned here a couple of things. What do we get on our list here of things?

Til Luchau:

Well, the show is getting into the realm of pathological descriptions. Maybe there's some of what your clients say coming into, what their complaints are that makes you think let's do this work. And certainly breathing restrictions is number one. It's just, either it could be as dramatic as a shortness of breath, but it could be just not seeing someone breathe much or difficulty taking a big breath when you ask them to.

Whitney Lowe:

I'm curious at what, if there's any research about this or what your thoughts are on it too, like a person who's not able to use their lungs to the full capacity that they did, for example, a smoker who's not probably expanding their lungs to the point that they could before they were smoking, if that maybe causes atrophy, loss of range of motion in the intercostal muscles, or difficulty in ever getting to be able to expand that again?

Til Luchau:

Well, you and many massage therapists being muscle people go, intercostals, me being a fascial structural guy says, pleural, fascia, the deep fascia around the ribcage, the wrappings around the intercostals, the bigger wrappers there, but all of those things probably changed through habit, and probably something like smoking, or inactivity, things that make us breathe less, or like your snowboarding story when you didn't breathe as much for six weeks. It probably changed all those things too. That took some time to either get used to and come back out of, or not as time goes on.

Whitney Lowe:

For sure.

Til Luchau:

Other than that, the other extreme would be COPD or something like that, where there's a serious breathing pathology that absolutely changes the physical quality of all those structures involved. But then also, our brain forgets, or keeps it, protects us from movement ranges that are uncomfortable, or threatening, or weird. So what else we got in there? The rib joint or soft tissue strain, sprain. That's one explanation for the rib out phenomena, just the soft tissue around there getting injured or sensitized. Did we cover what you wanted to say about costovertebral dysfunction?

Whitney Lowe:

I think we delved into a good bit earlier there, so we had that on our list of potential pathologies that we talked about a good bit with the whole rib out discussion, so I think we've touched on that there.

Til Luchau:

And then, costochondritis or TC syndrome, which is the sensitivity of, or inflammation, it's thought out to be, of the joints or the junctures between the ribs and the sternum and, or the sternum cartilage, and the costal cartilage and the sternum. That zone in there, when it gets really sensitive to touch it's called costochondritis. If it gets swollen and sensitive to touch it's called TC syndrome.

Whitney Lowe:

I was curious about that distinction, because costochondritis by its name essentially implies inflammation and irritation of those cartilage structures in there, and that's basically what's happening in the TC syndrome, so that seems like an ambiguous distinction there.

Til Luchau:

It's probably splitting hairs that may or may not need to be split. And the thing we all ask is, so what can we do about that when we see a client with that kind of swelling or tenderness right around the sternum? And there's a lot we can do to ease the experience of that. We don't get in there and poke on it generally though. That does seem to be an inflammatory condition that is aggravated by direct work, it's work that's too direct. So it's basically making sure someone's mobile and giving it some time. Now, if it goes on for a longer time, then we get into the inflammation discussion about unresolved inflammation and how do we work with that? And there's some different things to try.

Whitney Lowe:

But again, and always, I think there's a role for us in settling down nervous system responses and then enhancing overall movement. Things that don't necessarily have to mean that you go into the painful problem area and try to fix and do something to it.

Til Luchau:

Exactly.

Whitney Lowe:

Don't poke the bear.

Til Luchau:

Sing the bear a lullaby, don't poke it.

Whitney Lowe:

That's right.

Til Luchau:

Slipping rib syndrome, that's same thing. It's an inflamed either cartilage or juncture with the bone and cartilage, but that is more around the costal arch you could say, or the costochondral junctures there were those imposter ribs, the false ribs come around and meet the cartilage.

Whitney Lowe:

And a couple of them, I think it was in that same paper, and we'll put a link to this paper in the show notes as well. It was this paper by, Arroyo, costovertebral joint dysfunction, another misdiagnosed cause of atypical chest pain. And one of the things that they were talking about in this paper is the frequency with which these conditions get misdiagnosed. Thinking somebody's having a heart attack when they've got rib juncture pain, or there's some other type of internal organ system problem in there, because that's what you look for first when you're in that type of medical practice. You don't often think in terms of musculoskeletal disorders of the rib cage. So good thing to remember that a lot of those things may be misdiagnosed as other type of problems.

Til Luchau:

And it's a great reminder for us as musculoskeletal people to think, well, maybe it is a cardiac issue too, or maybe it is pleurisy, or pneumonia, or flu, or COVID, or one of those things that can make the ribs feel painful too. Maybe it's not just their ligaments or something.

Whitney Lowe:

For sure, you're going both ways. Well, we had that on our list also of looking for all those possible things, and you were going to speak a little on-

Til Luchau:

Osteoporosis, bone density concerns, osteopenia. It's worth mentioning here as we start to think about working with ribs. They are not, by the way, some of the most vulnerable bones to this condition. They're not the most commonly injured, or most commonly in trouble. But if you're, it's good for all of us to know about the possibility of bone density issues from working with people. And osteoporosis, just a couple of facts about it. It affects about 3% of people in the U.S., both male and female. It's not just a female thing. The problem with it from my point of view is that, it often doesn't have any signs until a bone breaks, until someone actually experiences the pain they go in and say, we got a broken bone. They don't even know they have a bone density issue.

Til Luchau:

So the general rule of thumb is to get screened if you have three out of five of these different signs I'm going to list, and I'll put these in the show notes too, three out of five of these signs. First sign, age over 65, second sign, Caucasian or Asian, third sign, being female, fourth sign, low body weight, fifth sign, family history of osteoporosis. If you have three out of five of those, then it's good to get screened, to go find out through different tests if you are vulnerable to a bone density issue, or if you have some already. And it's basically a continuum with osteopenia being some bone density effects, and osteoporosis being greater bone density effects. And by the way, my first fact, I started out with about 3% of people, I think in certain populations, as we get older, both men and women, but especially women, it's a lot more than that.

Til Luchau:

It is so common to have a bone density diagnosis or label that is almost not something to get too freaked out about. I'm not saying don't take it seriously, because you should, but it's so common at some points in life that it seems to be part of aging as well. But, that means as hands on therapists, we don't want to be just wailing away on everybody or pushing too hard, not just because of bone density, because that's not always necessary or not a great thing anyway.

Til Luchau:

But even if someone comes to you and they say, I've got osteopenia or osteoporosis, you can still work with them. You're just not going to think, you're not going to try to compress those ribs like that springy C shape idea I mentioned. You're going to be really gentle with that. We had in the videoing for that class, I was lucky enough to have a model who had pretty advanced osteoporosis as my model for that class.

Whitney Lowe:

Oh, great.

Til Luchau:

It was really great to have her there. She was really kind to volunteer for that, but I got to show how to work with that situation with her too.

Whitney Lowe:

Excellent. So while we're on that topic of working with things, tell us a little bit about what's in the handout, and maybe some other ideas you were going to share with us in those strategies.

Til Luchau:

Absolutely. We're going to put this outline of our discussion here in the handout. And then I'll also just put some of the interesting excerpts from the course manual for that course that's coming up. Some standalone techniques that you can just take and go that work with those different motions of the ribs, really. Because, if there's one thing that I would give people it's really that idea that their ribs move in three dimensions. And if you can help someone feel that with their breathing, use your hands, or your guided instructions to help someone feel movement, like say, feel the bucket handle, or feel the front going up and down, or to feel the twisting of the ribs, that's going to do so much for people.

Til Luchau:

And then from the other side, you can use those motions to essentially strategize what places, structures, or certainly which movements might be involved in an issue someone presents you with, and almost reverse engineer from there too. I'll put some different techniques that do that into the handout. And then, he had a reference, this had a pretty interesting, I'll put that in there as well.

Whitney Lowe:

As a matter of fact, I had a couple in there I was going to... There was that paper that I mentioned that had the information about all those costovertebral ligaments and everything like that. It was a pretty interesting anatomic study in there, so we'll put both of those in there as well.

Til Luchau:

That reminds me of that study I sent you about lizard ribs.

Whitney Lowe:

Tell me about that.

Til Luchau:

It was so fun, just to read something that's so quirky, and geeky, and that way down the rabbit hole of a study of lizard rib motion, and the authors' theory that their observations were suggesting that ribs evolved as a movement structure rather than a respiratory structure. That as extensions of the spinus, sorry, the transverse processes of the vertebrae, which is what ribs are immunologically. It started as the same projection of cells that eventually differentiate out into either ribs or transverse processes, that as an extension of the vertebrae, that especially in a quadruped, if you can imagine a lizard side bending as it moves, the ribs were part of that ambulatory story or the walking story for ribs more than a breathing story.

Whitney Lowe:

Interesting.

Til Luchau:

There's lots of animals like fish that also have ribs, but that don't use the ribs in the same way to breathe obviously. Fish don't breathe in that same way.

Whitney Lowe:

That's interesting though.

Til Luchau:

And then birds, hey, birds have a weird one way lung.

Whitney Lowe:

Whole air sacs system and everything that's...

Til Luchau:

I didn't know about that until I read this study. So rather than a tidal lung where you're taking air in and out, birds apparently, you tell us, have a circulatory system that's one way through their lungs.

Whitney Lowe:

I don't quite have a good, complete, thorough understanding of how that works, but we dealt with that a lot, especially with the smoke from fires, because they can't get it out of their lungs very easily because of that whole process. But they don't have lungs the same way that we do, they have air sacks that act differently for them.

Til Luchau:

And so, their respiration movements are way different, and their ribs are way different. But they got ribs anyway, and so do fish, so go figure the ribs about movement.

Whitney Lowe:

I think. So be sure to check out that handout, look at all the other good stuff on there. Anything else you want to say about that around those?

Til Luchau:

Oh yeah, I meant to give Larry, my co-teacher, Larry Coley, a shout out. Because, he and I worked really closely together to develop that material that's going to be in the handout. And then in the rib chorus, that's coming up, the principals class, we're calling it, it's part of the principal series where I give myself permission to do a deep dive into the theory and principles behind the work on those Zoom lectures. And then you get access to all the recordings of the demonstrations that again, Larry and I put together, and then my son, Entil, filmed in a really great way. And then we get together in small groups, and discuss, and analyze and apply those as well. It's been a really rich cycle, the principal series that we've been doing since COVID began. And we're about to launch that here at the end of January, 2022 at the beginning of February. You can jump in at any point in there and be part of that with us. We'd love to have you.

Whitney Lowe:

Great. That sounds exciting. So well, all right then, so we'll wrap the ribs for the day here, and thank you all for delving into that with us. And thank you again, sir, for your in depth explorations there, that was some fascinating stuff to look into.

Til Luchau:

Likewise.

Whitney Lowe:

So we would also like to say thank you to our sponsors and in particular, Books of Discovery, who's been a part of massage therapy education for over 20 years. Thousands of schools around the world teach with their textbooks, eTextbooks and digital resources. And in these trying times, this beloved publisher is dedicated to helping educators with online friendly digital resources that make instruction easier and more effective in the classroom, or virtually.

Til Luchau:

Books of Discovery likes to say learning adventures start here. They see that same spirit here on The Thinking Practitioner Podcast, and they're proud to support our work, knowing we share the mission to bring the massage and body work community in livening content that advances our profession. Check out their collection of eTextbooks and digital learning resources for pathology, kinesiology, anatomy, and physiology @booksofdiscovery.com, where The Thinking Practitioner listeners can save 15% by entering thinking at checkout.

Whitney Lowe:

And we would now like to say thank you to all of our sponsors and to all of our listeners. To you in particular, thanks for hanging out with us, and I hope you got some goodies from the show here. You can stop by our sites for the handout Til mentioned to you earlier. Show notes, transcripts, and any other extras, you can get links to that from my site @academyofclinicalmassage.com, and Til, where can people find that from your site?

Til Luchau:

That's advanced-trainings.com. If there are questions or things you'd like to hear us talk about, just email us at info@thethinkingpractitioner.com or look for us each on social media, just our names. My name is Til Luchau, and yours?

Whitney Lowe:

Today, my name is Whitney Lowe, and you can find me over there that way as well. Don't forget if you will take a quick moment out to rate us on Apple Podcasts, as it does help other people find the show. And you can also of course, hear us on Spotify, Stitcher, Google Podcast, or wherever else you happen to listen. Please do share the word and tell a friend. And then remember also, if you're unable to find us in any of those locations, you can head over to your local forest, and if a tree falls and no one is around to hear it, you can still hear us in the background.

Til Luchau:

Wow, deep.

Whitney Lowe:

Yes, indeed. I was listening, I was reading this interesting thing in this book that I had read years ago and picked it up again, great book that I would recommend if anybody's interested in anything about acoustics. The book's called, This Is Your Brain on Music. Really recommend this. Anyway, he was talking about that statement in there. If a tree falls in the forest and no one is around to hear it, will it make any noise? Because, that's the pondering philosophical-

Til Luchau:

That's a big one. Here's one, that very aphorism or question came up with me this morning when someone was talking about working on a client who didn't remember the improvement she had. It made me think, so if we worked on a client, and they got better, and no one remembered, would it still make a difference?

Whitney Lowe:

Well there is an answer to that question actually.

Til Luchau:

Tell me, what is it?

Whitney Lowe:

About the tree falling in the forest.

Til Luchau:

About the tree? Okay.

Whitney Lowe:

It does not make a sound, because in order for sound to occur, there has to be a recipient of the movement of the airwaves. And so, with no recipient of that sound around there, there isn't a sound.

Til Luchau:

Sound is the receiver's experience, not just the vibrating error.

Whitney Lowe:

That's right.

Til Luchau:

Nice. Thanks for vibrating some air with me today, Whitney.

Whitney Lowe:

Enjoyed it thoroughly. You get various different frequencies here, so yes, indeed. So we'll do it again here in a couple weeks. Thank you all for hanging out with us again, and we'll see you soon.

Til Luchau:

Bye for now.