Osteopathy Practical Technique Bridging Course

Session 9: Sternum and Rib Cage

Part A:

Surface Anatomy and Palpation of the Sternum and Rib

Cage

References:
Moore KL, Dalley AF, Agur AMR. Clinically Oriented Anatomy. 6th Ed. Philadelphia:Wolters
Kluwer/Lippincott Williams & Wilkins. 2010. Ch 1, p 71
Lumley JSP. Surface Anatomy. The anatomical basis of clinical examination. 4th Ed.
Edinburgh:Churchill Livingstone. 2008. Ch 4
Chila AG. Editor. Foundations of Osteopathic Medicine. 3rd Ed. Philadelphia:Lippincott
Williams & Wilkins. 2011. Ch 39
Greenman PE. Principles of Manual Medicine. 2nd Ed. Philadelphia:Lippincott Williams &
Wilkins. 1996. Ch 15
Standing S. Ed. Grays Anatomy. The Anatomical Basis of Clinical Practice. 40th Ed.
London:Churchill Livingstone Elsevier. 2008. p 917-924

Structures of the Sternum and Rib Cage that need to be known

The following list contains the structures to be covered in this lecture and associated
practical class. You will need to use the above references, or other suitable texts, to outline
the details required. For muscles and ligaments you will need to know their origin*, insertion*
and action.
*Note the origin and insertion may be known as proximal, distal, superior or inferior
attachment in some texts.
Bones:
Landmarks:

Muscles:

Ribs, sternum (manubrium, body, xiphoid process)

Ribs: rib angles, body or shaft of rib, atypical ribs
Sternum: jugular or sternal notch, manubriosternal angle, xiphoid process,
costal margin, costal arch, infrasternal angle,
Mid clavicular line, mid axillary line, anterior and posterior axillary line
Axillary folds, axilla
Anterior: pectoralis major, pectoralis minor, intercostal muscles, external
oblique
Lateral: serratus anterior
Posterior: erector spinae, latissimus dorsi, trapezius, rhomboids

Palpation of the Sterunum

A. Jugular notch (sternal notch or suprasternal notch)
Patient position: supine
Practitioner position: standing at the side of the table, level with the patients thorax and
facing toward the patients head
Applicator:
pad of the index finger
Procedure:
a. locate the medial aspect of the clavicles and distal attachment of the
sternocleidomastoid muscle
b. with the pad of the index finger locate the superior border of the sternum;
this is the superior part of the manubrium bone
c. in the mid-line, your index finger should find an indentation or hollow. This
is the jugular notch
B. Manubriosternal angle or joint (sternal angle or angle of Louis)
Patient position: supine
Practitioner position: standing at the side of the table, level with the patients thorax and
facing toward the patients head
Applicator:
pad of the index finger
Procedure:
a. place the pad of the index finger on the jugular notch
b. bring the pad of the index finger over the anterior surface of the
manubrium
c. approximately 4 cm from the superior border of the manubrium you will
find a raised, horizontal bony ridge or line
d. this is the manubriosternal angle or joint
e. the manubristernal angle can also be found at the level of where the
second costal cartilage joins the sternum
C. Xiphoid process
Patient position: supine
Practitioner position: standing at the side of the table, level with the patients thorax and
facing toward the patients head
Applicator:
pad or flat of the index finger
Procedure:
a. find the sternum and place the pad or flat of the index finger on the
sternum
b. move the finger in a caudad direction along the body of the sternum
c. at the inferior aspect of the sternum, the finger will find that it sinks down
slightly in a dip.
d. let the pad of the index finger rest in this dip and increase the pressure
slightly until you feel resistance
e. the resistance is caused by the presence of the xiphoid process
Alternative procedure:
a. place the pads of your fingers on the costal margin of the rib cage
b. follow the rib cage in a medial and superior direction, ie toward the midline
c. this point should be at the inferior border of the sternum
d. at the mid line place the pad of the index finger (with finger pointing
toward the head) and let it sink down slightly until a resistance is felt
e. this resistance is the xiphoid process

Ribs and Lateral Border of the Sternum

A. First Rib medial aspect
Patient position: supine
Practitioner position: standing at the side of the table, level with the patients thorax and
facing toward the patients head
Applicator:
pad of the index finger
Procedure:
a. locate the medial end of the clavicle and follow it laterally 1 cm
b. with the pad of the index finger locate the inferior border of the clavicle
c. move the pad of the index finger off the inferior border so that it rests next
to the clavicle
d. let the pad of the index finger sink through the layers until it contacts the
flat surface of the first rib.
Note this is quite a deep structure. Rather than pressing hard, allow the pad of the finger to
sink through the tissue layers. You will gain more information from your palpation and it will
be more comfortable for your patient.
If your finger goes too inferior it will contact the second rib. To ensure you are on the first rib
note the level of the manubrium medial to your finger. If you are at the level of the
manubriosternal angle you have placed your finger too inferiorly.

B. First Rib superior aspect

Patient position: supine
Practitioner position: standing at the side of the table, level with the patients thorax and
facing toward the patients head
Applicator:
pad of the index finger and or middle finger
Procedure:
a. locate the middle of the clavicle with the pad of the finger
b. find the superior border and let your fingers move into the supraclavicular
fossa
c. the superior and lateral borders of the first rib may be felt by allowing the
pad of the finger to sink through the tissues
Note: This aspect of the rib is deep and covered by muscles and tissues that are often
hypertonic or in an irritated state. Therefore, pressure that is too hard or applied too quickly
will cause discomfort for the patient and make it harder to palpate the structure.
It is possible that you will be able to achieve a reflection or sense of the rib rather than
direct contact if the tissues covering it are too tense to allow palpation through them.

C. Second Rib and Costal Cartilage

Patient position: supine
Practitioner position: standing at the side of the table, level with the patients thorax and
facing toward the patients torso
Applicator:
pad or flat of the index finger or middle finger
Procedure:
a. locate the manubriosternal angle with the pads of the finger

b. move the finger pad laterally until the you feel the line indicating the join of
the bone with the costal cartilage
c. continue to move the finger laterally, approximately 3 cm from the lateral
border of the sternum, until you feel the line of the join between the costal
cartilage and the rib
Alternative Procedure:
a. place all the finger pads of one hand close to the lateral border of the
sternum
b. bring the pads laterally until some encounter the costal cartilage and
others encounter the intercostal space between the costal cartilages
c. once the costal cartilage is located follow steps b-c in above.
D.

Ribs 3 6 and their costal cartilages

Patient position: supine

Practitioner position: standing at the side of the table, level with the patients thorax and
facing toward the patients head
Applicator:
pad of the fingers
Procedure:
a. locate the second rib
b. move the finger in a caudad direction until you palpate the rib inferior to rib
two
c. you can then palpate along the rib from the sternum to the rib, palpating
the costochondral junction
d. for ribs 4-6 repeat steps, ie move caudad until you encounter the rib
below. The costochondral joint is located at slightly wider intervals as you
palpate each rib, ie the costochondral joint for rib 2 is approximately 3 cm
from the sternum, it will be slightly wider for rib 3, wider again for rib 4 and so
on, ie, they lie more laterally in relation to the sternum.
E. Rib 7 and the costal cartilage
Patient position: supine
Practitioner position: standing at the side of the table, level with the patients thorax and
facing toward the patients head
Applicator:
pad of the index finger and or middle finger
Procedure:
a. locate the xiphoid process and the costal margin
b. the costal cartilage of rib 7 articulates with the sternum at the xiphisternal
junction
c. place the pad of the finger on the anterior surface of the costal margin and
follow it laterally until you feel the seventh rib. This may be as far as 12 cm.
F. Ribs 8-10 and costal cartilage
Patient position: supine
Practitioner position: standing at the side of the table, level with the patients thorax and
facing toward the patients head or torso
Applicator:
pad of the finger
Procedure:
a. Find the 7th rib
b. Move the pad of the finger inferiorly until you encounter the next rib
c. Repeat b to locate ribs 9 and 10.
d. The costal cartilage for the 10th rib is approximately 18 cm long, measured
from the xiphoid process to the rib
Note: The costal cartilages of ribs 8 10 form the anterior part of the costal margin of the
thoracic cage. The costal margin runs inferolaterally from the xiphoid process until it joins

with the 10th rib. At the level of the 9th costal cartilage, an angle forms known as the costal
angle. This lies at the level of the spinous process of L1 and the tip of the 12th rib.
G. Ribs 11 and 12
Patient position: prone
Practitioner position: standing at the side of the table, level with the patients thorax and
facing toward the patient
Applicator:
pad of the finger
Procedure:
a. locate the 12th vertebras spinous process
b. move the finger pad laterally until the edge of the erector spinae muscle is
found
c. lateral to this muscle the finger pad should encounter a bony tissue that is
more superficial than the lamina of the vertebra.
d. follow the bony tissue of the 12th rib inferolaterally until the tip of the rib is
encountered
Alternative procedure:
a. locate the iliac crest
b. move the palpating finger(s) superiorly until bony tissue is contacted
c. this should be the 12th rib, unless the palpating fingers are closer to the
mid axillary line, in which case it is more likely to be the 11th rib.
d. follow the rib superomedially until a spinous process is felt
e. determine the vertebral level of the spinous process using any of the
methods described elsewhere.
To find the 11th rib, find the 12th and move the palpating finger superiorly until the next rib is
encountered.
H. Intercostal space, muscles and lateral border of the sternum
Patient position: supine
Practitioner position: standing at the side of the table, level with the patients thorax and
facing toward the patients head
Applicator:
pad of the finger(s)
Procedure:
a. locate the midline of the sternum
b. place the pads of the fingers of the palpating hand on the sternum and
move them laterally until they locate the costal cartilage or the space between
the costal cartilage
c. this represents the border of the sternum and the fingers can palpate up
and down this border. Note the manubrium is wider than the sternum
d. locate the space between two costal cartilages. This is the intercostal
space and the muscle that can be felt beneath the fingers is the intercostal
muscle.

I.

Infrasternal Angle

Patient position: supine

Practitioner position: standing at the side of the table, level with the patients thorax and
facing toward the patients head
Applicator:
pad of the index finger and or middle finger
Procedure:
a. locate the xiphoid process

b. locate the costal margin

c. follow the costal margin to midline.
d. the infrasternal angle is that which is formed where the two costal margins
meet at the xiphoid process
J. Rib shaft (or body) and rib angle
Patient position: Prone.
Practitioner position: standing at the side of the table, level with the patients thorax and
facing toward the patients head
Applicator:
pad of the finger(s)
Procedure:
a. locate the spinous processes of the thoracic vertebrae
b. move the finger laterally and locate the lateral border of the erector spinae
muscles
c. locate the rib(s) and follow it laterally. You will note that the finger moves
slightly higher (or more posterior) until it reaches the angle of the rib (the most
posterior aspect of the rib).
d. the angle of the rib is located close to the line along the medial border of
the scapular (this precise location will vary depending on the position of the
scapular)
e. follow the rib over the angle laterally and palpate the shaft or body of the
rib as far laterally as possible in the prone position

Part B:

Range of Motion

Passive Range of Motion of the Sternum

Patient:
supine
Practitioner: standing beside the patient, at a level with the patients upper torso.
Applicator:
palm of hand or pads of fingers (the medial or ulnar side of the hand may be
used for female patients)
Procedure:
a. place the palm of your hand on the patients sternum, so that the fingers
are pointing in a cephalad direction and the heel of the hand is at the inferior
end of the body of the sternum
b. NOTE: for female patients you may ask them to place their own hands
on their breasts and move them laterally to provide clear access to the
sternum. Alternatively, contact the sternum with the medial or ulnar side of
your hand, rather than using the palm of your hand, while the patient has their
hands over their breasts.
Anteriorc. to test the motion of the sternum press gently with the pads of your
posterior
fingers against the manubrium in a posterior direction to encourage posterior
movement of the manubrium. You should be able to feel the inferior aspect of
the sternum move anteriorly against the heel of your hand
d. release your pressure
e. gently press the heel of your hand against the inferior aspect of the
sternum in a posterior direction. You should feel the manubrium moving
anteriorly against your finger pads
f. release the pressure
g. repeat steps c f a few times to determine the quality and quantity of
the sternal motion

four
corners

h. to assess the oblique motion of the sternum, start by gently pressing with
the pads of your fingers in a posterior direction on the left lateral aspect of the
manubrium. Gently release
i. gently press on the right lateral aspect of the manubrium with the pads of
your fingers in a posterior direction. Gently release
j. gently press on the right lateral aspect of the inferior sternum with the heel
of your hand. Gently release
k. gently press on the left lateral aspect of the inferior sternum with the heel
of your hand. Gently release.

Note: This motion is like a springing motion. The goal is to initiate the motion and then let
go. Avoid holding the pressure for any length of time once you have reached the end range
of motion. This motion is a rocking or see-saw motion.
The amount of pressure should only be enough to create motion. Start gently and slowly and
increase the pressure as needed. The sternum can be quite tender and may bruise easily,
so this is one reason why care needs to be taken. The other reason is too much pressure
may cause a strain at the costochondral junctions and this can cause significant pain for
your patient.
If you are using the side of your hand, use the distal end of the fingers to move the
manubrium and the pisiform, or adjacent part of the hand, to move the sternum.

Apply pressure here for

anteroposterior movement

Apply pressure for oblique movement

Source: Wikipedia: Sternum. Available: http://en.wikipedia.org/wiki/Human_sternum

Passive Range of Motion of the Ribs supine

Patient:
supine
Practitioner: standing beside the patient, at a level with the patients upper torso, or at the
head of the table and to the side you are assessing.
Applicator:
palm of hand or pads of fingers
Procedure:
a. for the upper ribs, place the patients upper extremity (on the side you are
assessing) and place it in to flexion and internal rotation. This position locks
the glenohumeral joint and allows movement to be isolated to the ribs being
assessed. Use your hand that is cephalad, if standing at the side of the table
or the hand more lateral to the patient.
b. place the heel of your other hand on the patients on the anterior aspect of
the patients second or third rib (it may not be possible to contact the second
rib in some people). Put just enough pressure to ensure that the rib will not
move when the arm is taken into flexion. You are assessing the motion of the
superior rib
c. bring the patients upper extremity into greater flexion to assess the
movement of the rib
d. bring the patients upper extremity back through extension until the
tension is released on the rib you are contacting
e. repeat steps b to d for ribs 4 or 5 in women and to approximately rib 8
or 9 in males
f. repeat on the other side.
Alternative
a. stand at the patients side and place patients arm into abduction
b. place your hand over the lateral aspect of the rib 10 or 9 and hold so that
it does not move
c. bring the patients arm into further abduction (you may wish to have the
patients arm against your hip and move your hip in a cephalad direction and
move the patients arm with your hip motion)
d. bring the patients arm back with in adduction direction
e. repeat steps b to d for each rib. The patients physique will determine
how many ribs you can assess. For example the lateral aspect of a females
breast tissue may prevent you from contacting the more cephalad ribs
This is a long lever technique. You are using the flexion/extension of the upper extremity to
create motion through the ribs.
Passive Range of Motion of the Ribs sidelying
Patient:
Practitioner:
Applicator:
Procedure:

sidelying
standing in front of the patient, at a level with the patients upper torso
palm of hand or pads of fingers
a. abduct the patients arm to shoulder height; have the patients elbow
flexed
b. thread your cephalad hand through the patients elbow so that the hand
can rest on the lateral ribs, or posterior axillary fold
c. place your caudad hand on the lowest rib, lateral aspect. Hold the rib
firmly so that it does not move when the patients arm is moved
d. with the rib secure, bring the patients arm toward their head with your
cephalad hand and assess the motion of the rib. Return the arm to shoulder
height.
e. repeat steps c to d for each rib as high as you can go