Getting A Handle On Our Ribs

We have recently wrote about the respiratory system: from the upper respiratory airway down to the primary respiratory muscle, the diaphragm.  But what about the protective rib cage? Our ribs play a critical role in not only respiration, but in movement, too.

Let's get a better handle on our ribs.

Rib facts:

1. There are 7 sets of true ribs, ribs 1-7
2. There are 5 sets of false ribs, ribs 8-12
3. Rib sets 11-12 are considered floating ribs
4. Ribs move when we breath
5. The true ribs are dominated by a pump handle action
6. The false ribs are dominated by a bucket handle action

Understanding Fact #1

The first 7 sets of ribs directly attach to the sternum anteriorly and to the thoracic spine posteriorly.  This forms a singular unit that is stable and rigid. While this helps to protect the heart and lungs, its' position and motion will dictate the function and orientation of the scapula as well as influence apical lung expansion.

Understanding Fact #2

Rib sets 8-10 are considered false ribs.  These ribs have a posterior attachment to the thoracic spine, but anteriorly they only connect to the sternum through costal cartilage.  This makes them more mobile than the true ribs and allows them to be influenced by our abdominals. Our abdominals help the ribs facilitate the respiratory function of the diaphragm.  This is reflected in the infrasternal angle (ISA). A normal ISA is about 90 degrees, if wider, greater than 100 degrees, it indicates poor abdominal opposition and a diaphragm posturally orientated.  If less than 90 degrees, there is likely an abdominal imbalance driving a similar diaphragm orientation.

Understanding Fact #3

Rib sets 11-12 are also false ribs, but classified as our floating ribs.  These ribs attach posteriorly to the thoracic spine, but do not have an anterior attachment.  These ribs do not serve a significant role in the respiratory process, but are critical for protection of vital organs like the kidneys and the adrenal glands.

Understanding Fact #4-6

Facts 4-6 are all about normal rib mechanics during respiration.  As we breathe the ribs have to move in such a way to optimize thorax expansion.  All ribs upon inhalation will externally rotate and elevate, anteriorly, and internally rotate and depress, posteriorly.  The opposite occurs during exhalation. However this is only part of the story for optimal thorax expansion. The rest of the story is found at the thoracic spine.

The orientation of the costovertebral joints are different for the upper and lower ribs.  As a result the defining motions within these ribs also differs. The movement of true ribs can be best seen from a lateral view and resembles the motion of a pump handle.  Whereas the false ribs have more of a bucket handle motion and can be seen posteriorly. These normal mechanics both work to best increase the thorax dimensions during inhalation and decrease it with exhalation. This in turn creates a pressurized system that will drive bidirectional airflow.

But how does this influence our movement?

Our movement is dependent upon how we manage this pressure system.  You see, as the arms and legs move, they will change the shape of the thorax and alter the airflow as well as the pressure within it.  As the thorax shape changes so does the orientation of our pelvic innominates and scapulae. So if we have poor rib mechanics or don't manage our thorax pressure well we will begin to compensate and restrict our movement patterns.  Thus it becomes increasingly important to be good pressure managers to avoid these compensatory movement strategies.

The ribs have become vastly under appreciated in our movement health.  They can and do influence multiple body parts as well as systems making them an ideal starting point for almost every injury type.  Hopefully you can appreciate this and now have a better handle on why our ribs matter in the restoration of our movement health.

Stay Well, Stay Strong

Keaton

---

References:

1. Hartman, Bill, ALL GAIN, NO PAIN: The Over-40 Man's Comeback Guide to Rebuild Your Body After Pain, Injury, or Physical Therapy.  William Hartman. 2017.
2. Lee DG. Biomechanics of the thorax - research evidence and clinical expertise. J Man Manip Ther. 2015;23(3):128-38.
3. Neumann DA. Kinesiology of the Musculoskeletal System, Foundations for Rehabilitation. Mosby; 2010.

Understanding The NeuroImmune System

The nervous system is truly the most incredible and adaptable biological system ever created.  The nervous system is an intelligent design composed for bidirectional biological communication to ensure survival.  I was fortunate enough to attend a course, Mobilization of the Neuroimmune System, this weekend to enhance my understanding of how to best recognize and approach a comprised nervous system.

Weekend Takeaways:

1. The immune system heavily influences the nervous system
2. Neurodynamic tests assess the physical capacity of the nervous system
3. Active treatment is more than just moving it also includes breathing and learning.
4. The type of biological container implicated matters for treatment approach
5. "Rehab exercises" are not as much about strength as they are about homuncular clarity

In this post I want to explore the first take away to help illustrate briefly how the nervous system and immune system are related.  

The Immune System Heavily Influences The Nervous System:

We got the weekend started by diving deep into the neurobiology of the nervous system and its relationship with the immune system.  Traditionally these two systems have been viewed as separate entities, but that view is now stale, especially when pain enters the picture.  It would now be appropriate to view the nervous system as a neuroimmune organ. Have you ever wondered why you get a whole body ache when you are sick?  Or why your musculoskeletal pain worsens when sick? What about why your pain increases with a weather change? Each of these are due to an elevated neuroimmune system response based on past experiences.  The immune system is a system that knows who you are and will intervene whenever you are not yourself. The immune system is very efficient as there are nearly ten times the amount of immune cells than there are neurons (nerve cells). This is a beautiful and efficient design for protection.

Unfortunately the initial response of the nervous system tends to be inflammation and a painful experience because they are most effective at altering behavior and reducing an imposed threat.  But why does this occur with something as simple as a weather change or going on a walk? Well, the human brain never forgets. It has an amazing capacity to remember and store memories within the hippocampus.  When memories are stored so are the emotions and the environmental context of the time. So when an event or environment is encountered the body will recall memories, the associated emotions, as well as the environmental context to predict an appropriate outcome.  If there was a harmful experience in the past you may trigger an immune response. How? Interestingly enough, your emotions are derived from the amygdala and memories, the hippocampus, both of which are immune system mediators. This means that your past experiences can trigger immune responses and dictate how the nervous system responds.

How the nervous system responds is dependent upon the pathobiological mechanism, or how the brain processes the incoming information.  There are two types of mechanisms: pain and tissue. The pain mechanism tends to be related to central processing and viewed as a top-down process.  When this occurs there has become alterations in the central nervous system causing the brain to become too protective with its’ predications. There has become a belief there is more danger than there is in reality.  Danger will evoke F.E.A.R (false evidence appearing real). Remember your emotions can trigger an immune response even if unnecessary. This in turn begins to make your nerves more sensitive and more irritable for the future.  

Tip:

Often you can determine if there is a central processing issue by placing a hot pack on a painful region.  If you think about it from a physiological perspective this should increase inflammation and make you feel WORSE!  So if heat feels good be thankful because the tissue you think is damaged is likely not as bad as you think!

The tissue mechanism is related to peripheral processing, or a bottom-up process.  This is the typical process during an acute injury and follows the predictable stages of healing.  When a tissue is injured inflammation is sent locally to start the healing process. This inflammation triggers the neuron to fire a signal to the brain. If pain is the output, inflammation will be sustained to allow the tissue to heal.  Remember inflammation is a protector. So when inflammation persists it will reduce the firing threshold of the neurons, making it easier for them to be triggered. This prevents you from further tissue damage, but makes you more likely to experience pain with normally non-painful activities.  Interestingly though this is not just an acute scenario. Once you have healed completely, your body will leave some resident immune cells in the previously injured area just in case. This is why your body can remember your pain so well and allow a “relapse” to occur. Remember the brain never forgets and always predicts.

Tip:

We do not have pain receptors!  We have nociceptors that send a signal to the brain where it is decided whether or not pain is the appropriate response.  This is why tissue damage and pain rarely correlate!

That being said, deciphering if it is a pain or tissue mechanism is not as simple as placing a hot pack and seeing what happens.  Central and peripheral processes occur simultaneously, but which is the dominant player is the critical aspect. In part 2 of this series I will review how the use of Neurodynamic testing can help to illuminate the physical capacity of the nervous system and guide this clinical reasoning process.

Stay Well, Stay Strong

Keaton

What’s Driving Your Foot Pain?

Heel pain or foot pain can be one of the most debilitating conditions for an individual.  We are designed to operate in a bipedal state. Whether we are standing, walking, running, or jumping, we are meant to be on our feet. But what happens when we experience heel or foot pain and we can’t tolerate these activities?  

Often blamed is the plantar fascia, the broad triangular connective tissue, anchored at the medial aspect of the calcaneus (heel) that spans down to the toes.  Its role is to act as our first shock absorber that dissipates ground reaction forces as we move throughout our environment.  It secures the infrastructure of the foot by supporting the medial longitudinal arch, making it an essential feature for optimal foot health.  But I am here to tell you, plantar fasciitis, is not just a foot issue.  Actually, it rarely is.  Only about five percent of cases don’t resolve conservatively and require surgical intervention.

The plantar fascia plays a big role in our gait efficiency, but so does our pelvis and thorax.  Do these structures function independently of each other?  No, but they do influence one another.  Our proximal dysfunction can actually drive our foot symptoms.  We tend to hurt at our weakest point and not at the point of dysfunction.  This is where most treatments are lost.  It hurts at “X” so let me rub and massage “X.”  Treatment becomes myopically focused on tissue/structure and “damage” rather than addressing the underlying mechanism.  

We need to understand pain isn’t bad and it doesn’t necessarily equate to the degree of tissue damage.  Pain is a perceptual response to a threat.  It protects our bodies by telling us something isn’t right and we need to change a behavior to reduce said threat. 

Now this doesn’t mean we ignore the foot or negate manual therapy application.  It means there has to be an appreciation for the interconnected nature of our body to guide intervention.  

This is why it is important we take a step back from the typical local perspective and appreciate the global perspective that yields a lot more as we recognize both intrinsic and extrinsic risk factors for plantar fasciitis.

It starts at a societal level. Today is all about being able to do more, when in reality we don’t have the capacity to do so.  We, as a people don’t know how to handle more because we don’t have effective stress management strategies. The literature is reporting the highest levels of chronic stress, fatigue, and anxiety and with this comes more chronic flight/fight, or sympathetic nervous system activity.  This is the same part of the nervous system that becomes active when we experience pain.  Coincidence? I don't think so.  Our bodies can't distinguish between stressors. They simply interpret and react to ensure survival.  First order of importance when stressed, shift metabolic resources and assume a survival posture.  It is this stress response though that influences the intrinsic risk factors associated with plantar fasciitis:  big toe mobility, ankle dorsiflexion, calf muscle “tightness”, and hip motor control.  

As our posture changes to a more extended form, we will see backs that are over extended, rib cages elevated, pelvic girdles dropped forward, and calves with an increase in tone.  All of this will inherently limit our movement variability and subsequently overload our feet each step we take.  This survival posture, thus increases the metabolic demand of the plantar fascia.  It alters the function of the big toe and ultimately the windlass mechanism, which is crucial in preventing our arch from collapsing during the mid-stance of gait.  As we achieve a mid-stance position, our plantar fascia tightens thereby pulling the big toe into extension and enhancing ankle dorsiflexion.  When efficient, it will prevent excessive foot pronation (arch collapse), which is present in 81-86% of plantar fasciitis cases.  It truly is a chain effect.   

The chain continues as we move up to the hip.  Our motor control of the mid-stance position is a reflection of foot and hip integration.  However control becomes increasingly difficult the longer we remain overly extended.  This posture poorly positions hip musculature and unfortunately sets the stage for compensation at the first opportunity, the foot.  Our foot is not only the first intimate interaction with the environment, it is our first chance to respond to it.  However, if we don’t have the proximal orientation of the hip and pelvis, we can’t expect our foot to respond efficiently.  Don’t believe the hip has an influence?  Try this. Stand-up without shoes and watch what happens when we squeeze/tighten our butt.  THE ARCHES LIFT!  Every bad foot can be controlled by a good hip.  Our hips and pelvis have a powerful influence over our feet and must not be neglected in the rehabilitation process.

So here is the relevance of this matter.  

Currently 10% of the general population will develop plantar fasciitis in their lifetime and it will most often occur during occupational years.  Given that these years have proven to be the most stressful, we will be more prone to living our lives in a survival posture and thereby overloading our feet.  If left unchecked, we could miss work, lose out on wages, or experience a reduction in work productivity.  Outside of our work field, it could generate fear-avoidance behaviors to avoid the pain experience.  In turn, we reinforce bad behavioral choices and potentially elevate our stress.  Now we are in a pain-cycle searching for a way out.  

The way out of this cycle is not only addressing the aforementioned intrinsic risk factors through position, but also by addressing our extrinsic risk factors.  

As mentioned earlier, pain is an indication we need to have a behavioral change, most notably our extrinsic factors:  poor footwear, prolonged occupational weight bearing, and large increases in activity level.

All extrinsic factors are easily modifiable, but usually hard to adhere too, especially when it comes to our footwear.  Poor unsupported footwear such as; heels, sandals, flats, and some work boots don’t provide enough sensory input and end up reinforcing poor intrinsic factor development.  Despite knowing the benefits of footwear, people still struggle for various reasons:  work, financial, etc.  This is why orthotics are often sought after by the public.  Belief is that an orthotic can be the fix for poor footwear.  This may or may not be the case, but regardless it shouldn’t be the first line.  Establishment of an effective home exercise program has been shown to be just as effective when addressing the underlying mechanisms.  This should be our first line.  

The physical stress of being on our feet also cannot be overlooked, which is why prolonged occupational weight bearing is a risk factor that needs to be considered.  If we are on our feet 40+ hours week for 20 or 30 years straight, we are accumulating a lot foot stress.  Research shows walking just one mile a foot can endure nearly 60 tons of stress.  We need to have efficient foot posture and mechanics to withstand this amount of stress over the long haul.

Relating to tissue overload, large increases in our activity level can also increase our susceptibility to plantar fasciitis.  Although our bodies are adaptable they are more concerned with survival.  So if we make too large of a jump in our exercise regimen, intensity or duration, our body will let us know.  Thus, a strategic application of physical activity to control the purposeful stress of exercise is needed to allow the body to best adapt without any repercussions.  

So to recap, plantar fasciitis is not just a foot issue.  It is a multifactorial issue that demands respect of the body’s natural design.  Proximal dysfunction is most likely the offender and the foot the victim.  The success of treatment hangs on the ability to identify and address all intrinsic and extrinsic factors that are working against our feet.  And the good news?  Most of these risk factors are modifiable.  We are in control.     

Stay Well,
Keaton

References:

1. Ratey JJ. Spark, The Revolutionary New Science of Exercise and the Brain. Little, Brown; 2013.

2. Rathleff MS, Mølgaard CM, Fredberg U, et al. High-load strength training improves outcome in patients with plantar fasciitis: A randomized controlled trial with 12-month follow-up. Scand J Med Sci Sports. 2015;25(3):e292-300.

3. Sapolsky RM. Why Zebras Don't Get Ulcers, An Updated Guide to Stress, Stress-related Diseases, and Coping. 2004.

4. Tahririan MA, Motififard M, Tahmasebi MN, Siavashi B. Plantar fasciitis. J Res Med Sci. 2012;17(8):799-804.

5. Thompson JV, Saini SS, Reb CW, Daniel JN. Diagnosis and management of plantar fasciitis. J Am Osteopath Assoc. 2014;114(12):900-6.