Ribs
Most people are only vaguely aware of ‘ribs’ aside from the very nice ‘main course’ at some of the local pubs, that is until they become dysfunctional and invariably painful.
Ribs are the long-curved bones that form the thoracic cage and are made up of twelve pairs, so 24 in total (some people have extra ones, it gets complicated!). They protect the internal organs of the chest and to an extent abdomen and facilitate breathing through lung expansion and contraction. They vary in shape and size from the 1st rib at the base of the neck which is short, very curved and steeply angled downward from the back to the front attaching to the sternum. At the other end we have rib 12 which is mid length, slightly curved and not attached at the front. Rib 1 to 7 are ‘true’ ribs running from the vertebra at the back to the sternum (via a cartilage or ‘chondral’ section) in the front. Rib 8 to 12 are called the ‘false’ ribs because they originate at the spine but 8, 9 and10 only attach broadly to the cartilage frame at the front; while rib 11 and 12 ‘float’ in other words they are unattached at the front.
Breathing is mildly important to most people, so to help explain the process, start by imagining the thorax is like a barrel. The top is the neck and head, bottom is a large musculotendinous sheet called the diaphragm, the walls are the ribs and intercostal muscles. When the diaphragm contracts and flattens the volume inside the thoracic cage decreases and air is drawn in and visa-versa. At the same time there is also some contraction of the intercostal muscles (between the ribs) and in heavy inspiration other muscles of the neck and shoulder region as well as spinal movement which helps facilitate the process.
Most of the time ribs happily sit there doing their thing, barely noticeable and covered in the thoracic muscle and in my case a lot of adipose tissue. I do see patients with ribs problems fairly regularly, normally restrictions where the ribs articulate with the spine. These small joints are synovial, the same kind seen in the fingers and the most common type of joint in the body. The ribs that play up most commonly are the upper 5, this in my opinion largely due to posture and environment. We sit at desks, drive cars, carry tension in upper back and shoulders, cough, sneeze, sleep on inappropriate pillows, become rounded with age and all of this and much more beside causes restrictions in the ribs and pain regularly affecting the muscle and joints of the neck and shoulders.
There are many pathologies affecting the ribs here are a few:
Pleurisy is inflammation of the serous (highly lubricated) membrane that lines the inside of the thoracic cage and covers the lungs. In this condition an area can dry out due to local infection resulting in the two structures rubbing against one another and causing pain in the chest wall on breathing.
Costochondritis like all ‘itis’ it is ‘inflammation’ in this case of the joints in the front of the chest between the end of the bony rib and its junction with the cartilage that then attaches onto the sternum itself. There are lots of causes such as direct local trauma, arthritis, chest infection etc but basically these joints become inflamed, swollen and very uncomfortable.
Lung cancer, well we know about this. There are many types and unfortunately a lot are not picked up until quite late, because unfortunately they can look like other conditions such as chest infections and can similarly cause coughs, chest pain, hoarse voice, weakness, fatigue, loss of appetite. You are all aware of the predisposing factors asbestos and smoking and this disease can also be found secondary to other cancers as it potentially spreads through the body.
Osteoporosis, yes it can affect ribs and can be a source of great anxiety for osteopaths affecting what treatment can be safely carried out to the suspected osteoporotic patient’s ribs and thorax. A fracture presenting as a ribs restriction is always a possibility, so we look at the ‘mechanism of injury’, did the onset described by the patient be enough to cause a fracture in a patient with normal bone density or otherwise, does that patient have a family history of osteoporosis, did they have an early menopause etc?