Week 3 The Thorax Asymmetrical Ribcage CONOR HARRIS

Week 3: The Thorax & Asymmetrical Ribcage CONOR HARRIS – CSCS, XPS, CES, CPT

Learning Objectives Appreciate the anatomy & biomechanics of the thorax Understand how proximal structures (ribcage) influence distal joint position (shoulder) Understand the role of Scapulohumeral Rhythm Explain how our asymmetrical body biases us in a certain trunk position

ANATOMY

Overview of the Shoulder Girdle Made for mobility Quarter on a golf ball Needs joint centration within glenoid fossa

Anatomy of the Scapula Concave structure that needs to sit on convex ribcage Normal human spinal curve flexes at upper back Triceps = hamstrings of upper body

Normal Respiratory Mechanics: Inhalation (b) Upper cervical extension Lower cervical flexion Thoracic kyphosis decreases overall Counter-nutation of sacrum Lumbar lordosis decreases Scapula goes inward External rotation Abduction Downward rotation Posterior tipping

Normal Respiratory Mechanics: Exhalation (a) Upper cervical flexion Lower cervical extension Thoracic kyphosis increases overall Nutation of sacrum Lumbar lordosis increases Scapula goes outward Internal Rotation Adduction Upward rotation Anterior tipping

Scapular Mechanics Downward Rotation Levator Scapulae (C 3 -Superior Medial Border of scapula) Rhomboids (T 2 -5) Pec Minor (Anterior T 3 -5) Long Head of Triceps (lateral border of scapula)

Scapular Mechanics. Posterior Tipping & Depression Low Traps (T 6 -12) Lats (inferior angle of scapula) Pec Minor (Anterior T 3 -5) Subclavius (Anteroinferior surface of middle third of clavicle)

Scapular Mechanics External Rotators Mid Traps (T 1 -5) Rhomboids (T 2 -5) Serratus Anterior (T 1 -8)

Scapular Mechanics Upward Rotators Upper Traps (C 7 -Clavicle) Low Traps (T 6 -12) Serratus Anterior (T 1 -8)

Scapular Mechanics – Internal Rotators Deltoids (posterior & middle fibers) Pec Minor (Anterior T 3 -5)

Scapular Mechanics – Anterior Tipping & Elevation Upper Traps (C 7 -Clavicle) Levator Scapulae (C 3 -Superior Medial Border of scapula) Rhomboids (T 2 -5)

Humeral External Rotators Infraspinatus Teres (T 6 -8) Minor (T 6 -8) Posterior scapula) Deltoid (spine of

Humeral Internal Rotators Subscapularis (T 2 -8) Lats (inferior angle of scapula) Teres Major (inferior angle of scapula) Anterior Deltoid

BIOMECHANICS

Ribcage Biomechanics

Wide ISAs Posterior thorax compression pushes scapula back into: External rotation Adduction Downward rotation Posteriorly tipped Humerus compensates into IR limiting ER measures (at first) Important: Most wides will be limited in IR

Narrow ISAs Anterior thorax compression leads to scapula being pulled forward into: Internal rotation Abduction Upward rotation Anteriorly tipped Humerus compensates into ER limiting IR measures (at first)

Posterior Ribcage Chambers “Upper” = T 2 -4 Mid/Upper Traps Rhomboids Upper Parts of Serratus Anterior “Lower” = T 5 -T 7 Infraspinatus (Rotator Cuff) Teres Minor (Rotator Cuff) Lower Parts of Serratus Anterior Low Traps UPPER LOWER BELOW SCAPS Below the Scaps = T 8 & Below Source: Alex Effer: https: //resilientedu. com/

Anterior Ribcage Chambers “Upper” = T 2 -4 Pec Minor Pec Major (Superior Fibers) UPPER “Lower” = T 5 -7 Pec Major (Inferior Fibers) Below Sternum = Infrasternal Angle LOWER BELOW SCAPS/ STERNUM Source: Alex Effer: https: //resilientedu. com/

Humeral Flexion: 060 Degrees Scapula IR, Humeral ER Scapular ER muscles eccentrically oriented Low & Mid Traps, Serratus Anterior (lateral ribcage) Has greater posterior expansion from T 8 -12

Humeral Flexion: 60120 Degrees Scapula ER, Humeral IR Serratus & Scapular ER's become concentrically oriented Will be harder to get as much air laterally & posteriorly Air is maximized into eccentric areas in front of thorax (T 5 -7)

Humeral Flexion: 120180 Degrees Scapula (relative) IR, Humeral ER Progressive upward rotation causes need to keep scapula on ribcage Scapula reorients into scapular plane via posterior tipping Pecs, lats become more eccentrically oriented Upper parts of sternum get more air as flexion increases (T 2 -4)

The Cervical Spine Shoulder flexion beyond ~120 degrees requires slight cervical rotation to ipsilateral side Facets will turn in other direction Cervical rotation causes vertebral rotation all the way down to (potentially) T 4

Manubrium & Sternum One can be in flexion & other in extension Upper ribcage expansion: T 2 -T 4 Parallel to manubrium Lower ribcage expansion: T 5 -7 Parallel to body of sternum Source: Alex Effer: https: //resilientedu. com/

Determining Restriction Loss of Humeral Adduction = Loss of expansion in Upper Ribcage (Anterior & Posterior) (T 2 -4) Loss of Humeral Abduction = Loss of expansion in Anterior & Posterior Lower Ribcage (T 5 -7) Loss of Humeral ER = Loss of expansion in Posterior Inferior Ribcage (T 5 -7) Loss of Humeral IR = Loss of expansion into Anterior Inferior Ribcage (5 -7) UPPER LOWER BELOW SCAPS

Reaches for Expansion 0 -60 Degree Reaches 1. Posterior Lower (T 5 -7 & T 8+) 2. Anterior & Posterior Upper (T 2 -4) 120+ Degree Reaches 60 -120 Degree Reaches Anterior Lower (T 5 -7) 1. Anterior & Posterior Upper (T 2 -4) 2. Posterior Below Scaps (T 8+)

Pronation The Influence of Pronation & Supination • IR of Humerus • ER of Scapula • ↑ Anterior Expansion Supination • ER of Humerus • IR of Scapula • ↑ Posterior Expansion

PRACTICAL WALKTHROUGH

The Influence of Trunk Rotation Example: Left Trunk Rotation Left scapula goes into: Adduction External Rotation Downward Rotation Posterior tilt Right scapula goes into: Internal rotation Abduction Upward rotation Anterior tilt

Influence of Trunk Rotation Coupled with Humeral Flexion Example: Right Reach w/ Left Trunk Rotation Scapula goes into relatively more external rotation & upward rotation above 60 degrees Spinous processes will turn to right Concentric musculature on right posterior thorax (↑ Posterior expansion on left) Eccentric left pump handle (↑ Anterior expansion on right)

ASYMMETRY

The Diaphragm Due to right ribs staying down & open left chest wall, air from right diaphragm goes to left lung Left diaphragm is overly descended due to loss of leverage (open chest wall), causing it to function as more of a postural stabilizer

The Right Brachial Chain (R BC) Chain of muscles in trunk Anterior-Lateral Intercostals, Deltoid-Pectoral Muscles, Sibson's Fascia, Triangularis Sterni, Sternocleidomastoid, Scalenes, Diaphragm When overly concentrically-oriented, these muscles: Enhance chest wall concavity Reduce lympatic drainage Restricts anterior lobe expansion Limits trunk rotation to ipsilateral direction or lower half to contralateral direction Figure used with permission. Copyright © Postural Restoration Institute® 2019. www. posturalrestoration. com

Right BC Outcomes Right shoulder sits lower than left due to default trunk position Right Anterior: Compression Right Posterior: Expansion Left Anterior: Expansion Left Posterior: Compression

Right Scapular Orientation Left trunk rotation causes: Internal rotation Abduction Upward rotation Anteriorly tipped Primary Needs: Low trap (scapular ER, downward rotation) Triceps (downward rotation) Serratus Anterior (scapular ER) Internal Oblique Figure used with permission. Copyright © Postural Restoration Institute® 2019. www. posturalrestoration. com

Left Scapular Orientation Left trunk rotation causes: Adduction External Rotation Downward Rotation Posteriorly Tipped Primary Needs: Posterior expansion External oblique Figure used with permission. Copyright © Postural Restoration Institute® 2019. www. posturalrestoration. com

Expected Limitations Expected ribcage limitations: ↓ Right Anterior Thorax Expansion (T 2 -7) ↑ Right Posterior Thorax Expansion (T 2 -7) ↓ Left Posterior Thorax Expansion (T 2 -7) ↑ Left Anterior Thorax Expansion (T 2 -7) Expected *relative* testing outcomes: ↓ Right Humeral IR ↓ Right Humeral Adduction ↓ Left Humeral ER ↓ Left Horizontal Abduction Photo credit: Neal Hallinan

Proper Breathing Guidelines • Put hands on lower ribs, relax belly. "Jelly belly" Hands • Exhale all the air out through your mouth (but don't lose height in your skeleton) until you feel obliques turn on. RELAX Exhale • Pause for five full seconds with your tongue on the roof of your mouth Pause Inhale

Wall Supported Downward Reach ANTERIOR & POSTERIOR LOW/UPPER RIBCAGE EXPANSION ONLY LOW BACK AGAINST WALL TO OPEN POSTERIOR RIBCAGE (OPTIONAL) BALL BETWEEN KNEES FOR ADDUCTION & IR Technique used with permission. Copyright © Postural Restoration Institute® 2019. www. posturalrestoration. com

Rockback Lat Stretch OPENS T 2 -4 ECCENTRIC IPSILATERAL CERVICAL SPINE INHIBITS CONCENTRIC LATS

Senior Portrait Pose OPPOSES L AIC/R BC PATTERN: OPENS RIGHT ANTERIOR RIBCAGE COMPRESSES LEFT ANTERIOR RIBCAGE LEFT ADDUCTOR + LEFT HIP EXTENSION RIGHT PELVIC EXTERNAL ROTATION Technique used with permission. Copyright © Postural Restoration Institute® 2019. www. posturalrestoration. com

PRACTICAL WALKTHROUGH

Sources Postural Restoration Institute: https: //www. posturalrestoration. com/ Bill Hartman: https: //billhartmanpt. com/ Zac Cupples: https: //zaccupples. com/ Alex Effer: https: //www. resilientrehab. ca/

ARTICLES: Suggested Reading Abe T, Kusuhara N, et al. Differential respiratory activity of four abdominal muscles in humans. J Appl. Physiol. 80(4): 1379 -1389, 1996. PRI Left AIC/R BC Example Beginner Program Chaitow L. Breathing pattern disorders, motor control and low back pain. J Osteopathic Medicine, 2004; 7(1): 34 -41.

WEEK 3 STUDY GUIDE LINK HERE – MAKE A COPY, READ QUESTIONS, DO THE READING, THEN COME BACK TO THEM!