Recently I have been bugged by a pain in my left sacroiliac joint. It had been bugging me for a few months now. The pain was fairly severe and made it hard to transition from sitting to standing. I had tried many things to get it to resolve but just had not gotten anywhere. For years I had noticed a strong relationship between low back pain and the ribs. Finally this occurred to me with my pain. I searched for and treated some very tender areas on my sides. It brought me some relief. Finally, I found a very tender rib 8 on the left. I gently moved it forward. Immediately I could feel the sacroiliac joint releasing. The release produced a “pop” in my spine and suddenly felt a freedom in my pelvis I have not felt in a long time.
There appears to be a strong connection between the rib cage, especially the lower ribs, and the pelvis and sacrum. I have consistently noticed the rib cage involved with sacroiliac joint pain, iliacus hypertonicity and tenderness, and more. This is not something that I was taught during my training, nor have I seen much emphasis of this relationship in articles and books. Here I want to describe the connections between the rib cage and pelvis, especially the ones that are often not mentioned or neglected that can produce low back pain. If you are an osteopath and you get patients with low back pain, it will serve you to address rib dysfunctions. Below is an evaluation and treatment guide to help you.
Linea Alba and Rectus Abdominis
The linea alba attaches from the xyphoid process to the pubic symphysis of the pelvis. It continues inferiorly into the suspensor ligament of the penis or clitoris. Tension in the linea alba is produced by the pyramidalis muscles. They are influenced by the rectus abdominis and the obliques. They are anchored to the public symphysis on one end and attach to the inferior portion of the linea alba. An anterior or posterior rotation can make the linea alba taut or slack depending on how the pubis is shifted. Furthermore, a pelvic or pubic shear can strongly affect the tension up to the xyphoid process. In this case, one side of the xyphoid process will be more tender.
Similarly, there is the rectus abdominis that connects the rib cage to the pelvis. The rectus abdominis attaches from the anterior surface of the cartilage of ribs 5-7 to the pubic bones. The rectus abdominis can influence the pelvis with anterior lower rib dysfunctions. Simultaneously a pelvic rotation affecting the position of the pubic bones can produce dysfunction at the lower ribs. The rectus abdominis and linea alba can also be affected by the viscera deep to it.
The Obliques and Transversus Abdominis
The obliques are, in my opinion, some of the most overlooked muscles with low back pain. The external and internal obliques along with the transversus abdominis attach from the lower ribs to the pubic bones, iliac crest, linea alba, thoracolumbar fascia, and inguinal ligaments. Dysfunctions in the lower ribs can produce facilitation of the iliacus muscle via the obliques.
The external obliques attach on the outer surface of ribs 5-12 down to the outer lip of the iliac crest and the anterior layer of the rectus sheath and linea alba.
The internal obliques attach to the deep layer of the thoracolumbar fascia, intermediate portion of the iliac crest, ASIS, and lateral half of the inguinal ligament. On the other end, they attach to the lower borders of ribs 10-12, the anterior and posterior layers of the rectus sheath, and linea alba.
The transversus abdominis attaches to the deep surface of the continuos cartilaginous margin of ribs 7-12, deep layer of the thoracolumbar fascia, iliac crest, ASIS, and lateral portion of the inguinal ligament. From there, transversus abdominis attaches to the posterior layer of the rectus sheath and linea alba.
Hypertonicity at the obliques can result in lumbar compression and maintain a superior pelvic shear. The obliques cover the torso anteriorly, laterally, and posteriorly. Based on the hypertonic fibers, they can guide you to where along the ribs the dysfunction is. The obliques are highly influenced by or strongly influence the diaphragm because they attach to many of the same ribs. Because of attachments to the thoracolumbar fascia, it may be important to release the latissimus dorsi and shoulder for a complete effect.
The intercostal muscles can also influence or be influenced by the diaphragm and obliques. Releasing the obliques posteriorly can produce a release of the sacroiliac joint. This means any rib dysfunctions along their course from posterior to anterior All the muscles crossing the abdominal cavity can be influenced by visceral dysfunctions or problems.
Quadratus lumborum and Psoas Major
These form the most common areas of blame for low back pain that connect the rib cage to the pelvis. The quadratus lumborum attaches to rib 12 and transverse processes of the lumbar spine down to the iliac crests and iliolumbar ligaments. Psoas major attaches from the transverse processes of the lumbar spine, crosses the sacroiliac joint and acetabulum on its way to the lesser trochanter of the femur. Superiorly the quadratus lumborum and psoas major are traversed by the lateral and medial arcuate ligaments of the diaphragm respectively. This creates a strong influence between the diaphragm and the quadratus lumborum and psoas major muscles.
The superficial cervical fascia continues inferiorly and becomes the fascia of the trunk. Anteriorly the fascia anchors onto the midline at the sternum. Posteriorly it anchors at the spinous processes. From there, there are many splits and divisions. The fascia of the trunk is tough and divides into multiple layers to invest many of the muscles.
The fascia of the trunk invest the sacrolumbar mass of the sacrospinal muscles and the pectoral, latissiumus dorsi, and trapezius muscles. Portions split off and form the aponeuroses of the deep muscles, including the quadratus lumborum and external intercostals. Aponeuroses in the abdomen are those of internal and external obliques, transversus abdominis, and rectus abdominis. The aponeuroses lateral to the rectus abdominis form the linea semilunaris.
Posteriorly there is the thoracolumbar fascia where also become the lumbar fascia as it inserts into the spinous processes from L2 down to S2 and throws off strong ligaments including the sacrospinous and sacrotuberal ligaments. This may be a reason for the improved motion at the sacroiliac joints with a release of the lower ribs.
Anteriorly, the upper portion is derived from the aponeuroses between the subclavius and pectoralis major and minor muscles. Laterally it is indirectly continuous with the aponeurosis of the latissimus dorsi muscle. It continues in the lower medial and lateral regions with the aponeuroses of the oblique and transverse muscles and the sheath investing rectus abdominis. All aponeuroses meet at the midline, forming linea alba.
The aponeuroses of the abdominal muscles join with the lower part of the abdomen extending from one ASIS to the other. Several groups of fibers come together to form the inguinal ligament, including fascia lata. The inguinal ligament is a point of continuity or the fascia systems between the abdomen and lower extremities.
Eventually the many layers of the fascia of the trunk joins with the transversalis fascia. The deepest layer continues as the iliac fascia. The iliac fascia invests psoas major and eventually the lumbar plexus as well. The fascia of the trunk continues as the superficial and perineal fascia. Anteriorly the fascia of the trunk connects to the deep perineal fascia and fascia associated with pelvic organs via the umbilical ligament. The fascia of the trunk continues inferiorly as the fascia of the lower extremities.
- With patient supine, spring on the ASIS’s anterior to posterior. Also check the motion by moving the ASIS medial and lateral to inflare and outflare motion.
- Slide your hands medial from the ASIS to palpate the iliacus as much as possible on the medial portion of the innominate. Palpate medial to lateral moving your hands side to side.
- Next move your hands under and spring the sacrum near the SI joint posterior to anterior on both sides to evaluate the motion of the sacrum at the SI.
- Spring at the L5-S1 joint posterior to anterior to evaluate motion there.
- Spring and glide fingers superior to inferior on the rib angles posteriorly from ribs 5-12.
- Then palpate laterally and anteriorly with a superior to inferior motion along the ribs.
- Check the xyphoid process and evaluate for tenderness along lateral borders.
- Treat the thoracic spine vertebrae in whatever manner you prefer.
- If tenderness and motion along rib angles has not improved, release tension by gliding ribs medial or lateral, anterior, superior or inferior.
- Look for areas where the ribs lack space between them and spread apart to create space.
- Work to release the ribs laterally anywhere where there is tenderness and dysfunction. Create space where ribs lack space between them to release the intercostals, diaphragm, and obliques. Be sure to go all the way to the inferior border. If the tip of rib 11 is tender, gently glide it posteriorly until it releases. Be as complete as possible.
- Now release the ribs and cartilage anteriorly in the same fashion you have been focusing on the dysfunctional areas that have lingered.
- Now recheck the pelvis and ribs to see how the areas previously checked have changed.
- If the xyphoid process is still tender, you may need to treat the pubic bones, innominate rotations, and pelvic and sacral shears. The idea is to normalize the pubic bone attachments of the linea alba and rectus abdominis that may be affecting the attachments at the xyphoid process and anterior ribs.
- Lastly, you may need to consider visceral influences and other structures (latissimus dorsi, trapezius, paravertebral muscles, serratus posterior inferior and superior, etc.) if areas of tenderness remain.
- Monitor your initial parameters to evaluate for changes as you go along.
I am aware this is not a complete list and there are plenty more structures to consider. This is just to give you some guidance treating some areas you may not have considered or spent enough time on. Evaluating and treating dysfunctions of the rib cage in depth can produce strong results in releasing the innominate bones and get the sacrum moving more efficiently between the ilia. The above examples are ways for you to evaluate these areas and appreciate how the ribs and pelvic structures influence each other.
Hebbard PD, Barrington MJ, Vasey C. Ultrasound-guided continuous oblique subcostal transversus abdominis plane blockade: description of anatomy and clinical technique. Reg Anesth Pain Med. 2010 Sep-Oct;35(5):436-41.
Paoletti, Serge. The Fasciae: Anatomy, Dysfunction and Treatment. 1st Edition. Eastland Press. August 1, 2006. Pages 28-34.