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: Thorax and Ribcage

Comprehensive OMT reference hub, interactive cheat sheets, and board review notes for COMLEX Level 1, 2-CE, and 3.

22 Review Modules Master OMT Practical Guide OMM Diagnostic Solver Autonomic & Chapman Map
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Key Takeaway

Master the thoracic Rule of Threes for spinous process palpation. Distinguish pump-handle (ribs 1–5), bucket-handle (ribs 6–10), and caliper (ribs 11–12) mechanics. For exhalation rib dysfunctions, treat the KEY TOP RIB (B-E-T); for inhalation rib dysfunctions, treat the KEY BOTTOM RIB (I-B).

Thoracic respiratory excursion: pump-handle cephalad anterior lift (ribs 1–5, sagittal plane) and bucket-handle lateral flare (ribs 6–10, coronal plane).
Rib Kinematics (Ribs 1–10)

1. Thoracic Spine Anatomy & Rule of Threes

The thoracic spine consists of twelve vertebrae (T1–T12) articulating with twelve pairs of ribs. The facet orientation of the thoracic spine is BUL (Back, Up, Lateral), which favors sidebending while limiting extension.

Thoracic LevelSpinous Process Alignment Relative to Vertebral BodyPalpation Rule
T1 – T3Spinous process is at the SAME level as its own vertebral body.T2 transverse process is at the level of T2 spinous process.
T4 – T6Spinous process is 1/2 segment BELOW its vertebral body.Tip of T5 spinous process lies between T5 and T6 transverse processes.
T7 – T9Spinous process is 1 FULL segment BELOW its vertebral body.Tip of T8 spinous process lies at the level of T9 transverse process.
T10Spinous process is 1 FULL segment BELOW its vertebral body.Behaves like T7–T9.
T11Spinous process is 1/2 segment BELOW its vertebral body.Behaves like T4–T6.
T12Spinous process is at the SAME level as its vertebral body.Behaves like T1–T3.

High-Yield Palpation Landmark: The inferior angle of the scapula corresponds to the T7 spinous process (level of T8 vertebral body), while the spine of the scapula aligns with T3.

2. Rib Classification & Motion Mechanics

Ribs are classified anatomically (True, False, Floating) and structurally (Typical vs. Atypical). Motion occurs around three primary axes.

Rib GroupAnatomical ClassificationKey Structural Characteristics
Ribs 1 – 2True / AtypicalRib 1: Broadest, shortest, articulates with T1 only, no angle/tubercle, subclavian vessel grooves. Rib 2: Tuberosity for serratus anterior.
Ribs 3 – 9True (3–7) & False (8–9) / TypicalHave head, neck, tubercle, angle, and shaft with costal groove for intercostal neurovascular bundle.
Ribs 10 – 12False (10) & Floating (11–12) / AtypicalRib 10: Single articular facet on head. Ribs 11–12: Single facet, no neck, no tubercle, float free anteriorly.

Rib Motion Triad

Motion TypeRib LevelsPrimary Axis & PlanePalpation Location & Motion
Pump-HandleRibs 1 – 5Costovertebral-costotransverse axis (Transverse axis in Sagittal plane).Anterior mid-clavicular line: Anterior end moves superiorly/anteriorly on inhalation.
Bucket-HandleRibs 6 – 10Costovertebral-costosternal axis (Anteroposterior axis in Coronal plane).Lateral mid-axillary line: Lateral rib shaft expands superiorly/laterally on inhalation.
CaliperRibs 11 – 12Vertical axis (Transverse plane).Posterior mid-scapular line over rib tips: Ribs open laterally/posteriorly on inhalation.

3. Somatic Dysfunctions & Key Rib Treatment Rules

Rib dysfunctions are classified as either Exhalation Dysfunctions (stuck in exhalation, won't inhale) or Inhalation Dysfunctions (stuck in inhalation, won't exhale). Successful treatment requires identifying the Key Rib.

GOLDEN RULES OF KEY RIBS: - Exhalation Dysfunction (Group stuck down): The KEY RIB IS THE TOP RIB of the group! Mnemonic: B-E-T (Bottom Exhalation Top). - Inhalation Dysfunction (Group stuck up): The KEY RIB IS THE BOTTOM RIB of the group! Mnemonic: I-B (Inhalation Bottom).

Exhalation Rib Motor Drivers for MET

Key Exhalation RibPrimary Muscle Access (Motor Driver)Patient Treatment Action / Positioning
Rib 1Anterior & Middle ScalenesHead lifted straight forward into flexion against resistance.
Rib 2Posterior ScaleneHead turned 45° away; lifted forward against resistance.
Ribs 3 – 5Pectoralis MinorIpsilateral elbow pulled down toward opposite ASIS against resistance.
Ribs 6 – 9Serratus AnteriorIpsilateral arm pushed straight forward against resistance.
Ribs 10 – 11Latissimus DorsiIpsilateral arm abducted/adducted against resistance.
Rib 12Quadratus LumborumIpsilateral pelvic pull against resistance in prone position.

4. COMLEX Practice Knowledge Check

Practice Drill
Q1: Upon deep respiration, ribs 3 through 6 stop moving during inhalation, but move freely during exhalation. Which rib is the key rib to target with muscle energy?
Practice Drill
Q2: Palpation of T6 reveals the spinous process is displaced left, and tenderness is noted at the right transverse process. T6 rotates right more easily in extension. What is the somatic dysfunction?

Source

Based on the publicly available table of contents and topic organization of OMM Review: A Comprehensive Review of Osteopathic Medicine. All notes are original; no copyrighted text, figures, or full source material is included.