Master Ribs: Exhalation Dysfunction Treatment with Picmonic for Medicine

A common way to remember the various treatment positions for muscle energy is the combined mneumonic ‘at 1AM I got up to pee, because from 3-5PM I had 6-8 sodas and from 9-10 to lay down and from 11-12 I was quiet’. This combines the treatment of the ribs to remind you which muscles are engaged to treat each group of ribs.

Anterior and middle scalene muscles both have attachments to rib one, making them the target for muscle energy. The patient should be positioned supine and raise the forearm of the affected side to their forehead with the palm facing toward the ceiling. The patient should take a deep breath while the provider engages the angle of the affected rib inferiorly. The patient will then raise their head toward the ceiling against resistance for 3-5 seconds. Repeat muscle energy to the anterior and middle scalene 3-5 times before rechecking for improvement of motion. The muscles engaged can be remembered with ‘at 1 A.M’ for rib 1 and anterior/middle scalenes.

The posterior scalene has a direct attachment to rib 2. The patient should, again, lay supine and place the forearm against the forehead with the palm facing toward the ceiling. They then turn their head to the affected side 30 degrees before raising their head toward the ceiling against resistance. Repeat this 3-5 times before rechecking for improvement of motion. The muscle engaged can be remembered by ‘I got up TO PEE,' indicating rib 2 is affected by the posterior scalene.

Pectoralis minor is associated with ribs 3-5. While lying supine, the patient will place their forearm to their forehead with their palm toward the ceiling on the affected side. The patient will then attempt to bring the elbow toward the opposite anterior superior iliac spine against resistance for 3-5 seconds before relaxing. Repeat this 3-5 times, then recheck for improvement of motion. The muscle engaged can be remembered by ‘from 3-5 PM’ for posterior scalene treating ribs 3-5.

Serratus anterior is associated with ribs 6-8. To treat this dysfunction, have the patient lie supine with their forearm placed to their forehead and palm facing toward the ceiling. The patient will push the arm anteriorly against resistance for 3-5 seconds before relaxing and placing it into the new feather edge. Repeat this 3-5 times, then recheck for improvement of motion. The muscle engaged can be remembered by ‘had 6-8 Sodas’ to remind you the serratus anterior treats ribs 6-8.

The Latissimus Dorsi is targeted for the treatment of ribs 9 and 10. The patient will lay supine with their forearm brought to their forehead, palm facing superiorly. Then instruct them to adduct the arm against resistance for 3-5 seconds. Repeat this 3-5 times before checking for improvement of motion. The muscle engaged can be remembered by ‘from 9-10 to lay down’, indicating Latissimus Dorsi treats ribs 9 and 10.

Quadratus Lumborum is associated with ribs 11-12. The patient should, again, lay in a supine position. The provider grasps the leg of the affected side and has the patient attempt to raise the ipsilateral ASIS toward the ipsilateral shoulder for 3-5 seconds. Repeat this 3-5 times before checking for improvement of motion. The muscle engaged can be remembered by ‘from 11-12 I was quiet’ indicating that quadratus lumborum treats ribs 11 and 12.

Acute muscle spasm is an absolute contraindication for muscle energy. Instead, wait until the spasm has resolved before attempting muscle energy to the area.

Fracture is another absolute contraindication for muscle energy to the ribs. If a fracture is suspected or confirmed, muscle energy should not be attempted until fully healed.