The thorax

The skeleton of the thorax includes the sternum, ribs and costal cartilages, and thoracic vertebrae and intervertebral discs.


The sternum, or breast bone, is a flat bone that consists of manubrium, body, and xiphoid process.


There are usually 12 ribs on each side of the body. They are elongated yet flattened bones that curve inferior and anterior from the thoracic vertebrae. The ribs, as well as the costal cartilages, increase in length from the first to the seventh, and their obliquity increases from the first to the ninth. Generally, ribs 1 to 7 are connected to the sternum' by their costal cartilages and are called true ribs, whereas ribs 8 to 12 are termed false ribs. Usually, ribs 8 to 10, by means of their costal cartilages, join the costal cartilage immediately above, whereas ribs 11 and 12, which are free, are known as floating ribs. A supernumerary rib may be found in either the cervical or lumbar region. In thoracic surgery, a portion of a rib can be excised, leaving its periosteum, which later allows regeneration of the bone.

Thoracic vertebrae

The superior costal facet of a typical thoracic vertebra, together with the intervertebral disc and the inferior costal facet of the vertebra immediately superior, forms a socket for the head of the corresponding rib.

Any problems in whole body posture may limit thoracic cage elasticity and compliance, and hence have an effect on other functions of the thoracic cage, such as respiration.

Osteopathic models of rib cage mechanics

Rib movements are classically described as being like those of a bucket handle and pump handle, relating to the orientation of the rib movement against the spinal column. Classically, the ribs move upwards in inspiration and downwards in expiration.

Such rib movements gave rise to the idea that, when restricted, the ribs could become fixed, either in inspiration or expiration (the anterior ends of the ribs being held superiorly or inferiorly, respectively, and the posterior section of the ribs - the angles - being held inferiorly in inspiration and superiorly in expiration). There are many

manipulative techniques that are designed to correct these malalignments, using thrust techniques or muscle energy techniques, for example.

Any problems in whole body posture may limit thoracic cage elasticity and compliance, and hence have an effect on other functions of the thoracic cage, such as respiration. The integrity of the thoracolumbar fascia, and hence its ability to act as a load transfer system, depends in part upon the activity of the abdominal muscles. The abdominal muscles

help to tense the thoracolumbar fascia (and also the rectus sheath), and this tension helps the fascia to dissipate force. The tension in the thoracolumbar fascia induced through abdominal muscle action also enables the thoracolumbar fascia to provide a stable insertion point for many muscles involved with locomotion and the control of posture (e.g. erector spinae, the glutei and latissimus dorsi).

The rectus sheath and abdominal muscles that tense the thoracolumbar fascia are shown in Figure 8.2. Through this link, poor abdominal muscle activity and tone may lead to inefficient action of the thoracolumbar fascia, and hence contribute to mechanical disturbance in the upper and lower limbs and the spine.

The tension in the thoracolumbar fascia acts through the glutei muscles to the iliotibial tract, which engages the fibula. This then provides tension in the intraosseous membrane between the fibula and the tibia, forming an absorptive mechanism allowing the tibiotalar joint a degree of 'non-muscular' flexibility. These inferior connections (through the fibular and intraosseous membrane and associated muscles) blend with the plantar fascia. In this way they help to absorb weight-bearing forces and sway-motion forces during static and dynamic posture.

The thoracolumbar fascia also helps transfer the weight-bearing forces through the pelvis, where it helps to engage the ligamentous arrangement of the sacroiliac joints (especially the sacrotuberous ligaments and the fascial/ligamentous annular ring, which travels from the sacrotuberous ligaments to the ischial tuberosities and along the inferior pubic rami to the symphysis pubis). This provides an effective system for absorbing forces that would tend to nutate the sacrum.

This enables the thoracolumbar fascia to support the spine posteriorly up to the lower thoracic area, where the posterior convexity of the thoracic spine helps to maintain static posture with minimal effort. The tension in the rectus sheath (which offsets pelvic torsion) is transmitted through the anterior rib cage via the sternum, and is in itself offset by the action of the scalene muscles on the upper ribs (which help to support the sternum).

If trunk and pelvic posture is correctly maintained, with the head ultimately in line with the anterior talus, the shoulder girdle becomes oriented so that the weight of the arms hangs slightly posterior to the head position. This enables the arm weight to act through the clavicle and to spread the anterior thorax, also offsetting the inferior pull by the rectus sheath.

Blood vessels, lymphatic drainage and nerves of the thorax

Pulmonary circulation

The pulmonary trunk and arteries carry deoxygenated blood, but they are arteries in the sense that they transmit blood away from the heart at a relatively high pressure (20 to 30 mm of mercury) and in a pulsatile manner and in the sense that they have elastic walls like the aorta.

The pulmonary trunk extends from the conus arteriosus of the right ventricle to the concavity of the arch of the aorta, to the left of the ascending aorta, where it divides into the right and left pulmonary arteries. The point of division is approximately at the left side of the sternal angle. The pulmonary arteries and their branches are largely responsible for the normal shadows seen radiographically in the roots and hili of the lungs.

The right pulmonary artery, longer and wider than the left, passes inferior to the arch of the aorta and enters the hilus of the lung. The left pulmonary artery is connected to the arch of the aorta by the ligamentum arteriosum, which is the fibrous remains of a prenatal vessel, the ductus arteriosus.

A pulmonary vein arises in each lobe of the lung. The right upper and middle veins usually unite, so that four veins, upper and lower on each side, enter the left atrium.

Systemic circulation

The aorta.

The systemic supply of the thorax is derived mainly from branches of the aorta, the chief systemic artery of the body. The aorta is divided into the ascending aorta, arch of the aorta, and descending aorta. The part of the descending aorta in the thorax is called the thoracic aorta. The aorta is an elastic artery that withstands the systolic blood pressure and provides elastic recoil. The walls of the ascending aorta and arch contain pressure receptors, which are reflexly connected to aortic depressor fibers in the vagi (slowing the hear in response to increased blood pressure).

The ascending aorta begins at the root of the aorta, where the three aortic sinuses are located. Its branches are the right and left coronary arteries. It ascends to the level of the sternal angle.

The arch of the aorta runs posterior on the left side of the trachea and esophagus and superior to the left main bronchus. The arch of the aorta, in proceeding backward, lies in an almost sagittal plane in the superior mediastinum, behind the lower part of the manubrium sterni. The arch is related on its inferior side to the bifurcation of the pulmonary trunk and is connected to the left pulmonary artery by the ligamentum arteriosum. The left recurrent laryngeal nerve hooks inferior to the arch. There are three main branches of the arch (situated posterior to the left brachiocephalic vein): the brachiocephalic trunk, left common carotid artery, and left subclavian artery. Immediately distal to the last-named branch, the aorta is slightly constricted (isthmus). A severe constriction (coarctation of the aorta) may occur here during development, in which case the adequacy of the collateral circulation depends on the relationship of the constriction to the opening of the ductus arteriosus (which connects the pulmonary trunk and aorta).

The brachiocephalic trunk.

The brachiocephalic trunk divides behind the right sternoclavicular joint into the right subclavian and right common carotid arteries. The left common carotid and left subclavian arteries enter the neck behind the left sternoclavicular joint. Variations in the branches of the arch of the aorta may be encountered, e.g., a common origin of the brachiocephalic trunk and left common carotid artery. Sometimes an aortic ring may encircle the trachea and esophagus and press on them. The right subclavian artery may arise from the thoracic aorta and be retro-esophageal, which is frequently stated to cause dysphagia (difficulty in swallowing).

The thoracic aorta descends in the posterior mediastinum and traverses the diaphragm to become the abdominal aorta. It begins to the left of the vertebral column, gradually moves arteriorly and to the right (where it lies behind the esophagus), and enters the abdomen in the median plane. The branches of the thoracic aorta are parietal and visceral. The parietal include several posterior intercostal arteries and the subcostal and some phrenic arteries. The visceral branches are the bronchial, esophageal, pericardial, and mediastinal.

Brachiocephalic veins.

Each brachiocephalic vein is formed by the confluence of the subclavian and internal jugular veins behind the corresponding sternoclavicular joint. The right vein descends vertically, whereas the left crosses in an oblique orientation anterior to the branches of the arch of the aorta. Near the level of the sternal angle, the two brachiocephalic veins unite to form the superior vena cava. The superior vena cava descends on the right side of the ascending aorta, receives the azygos vein, and ends in the right atrium. Rarely, a left superior vena cava may persist: it comprises parts of the left brachiocephalic vein, left superior intercostal vein, oblique vein of the left atrium, and coronary sinus.

The azygos system.

The azygos system consists of veins on each side of the vertebral column, which drain the back as well as the walls of the thorax and abdomen. These veins are highly variable, but they end in the azygos, hemiazygos, and accessory hemiazygos veins. The azygos vein (Gk, a zygon, "unpaired") is formed by small vessels (such as the right subcostal and right ascending lumbar veins), and it ascends through the posterior and superior mediastinum. It arches anteriorward over the root of the right lung and ends in the superior vena cava. It receives the hemiazygos, accessory hemiazygos, and a number of posterior intercostal veins. The hemiazygos and accessory hemiazygos veins form a very variable arrangement on the left side. The hemiazygos vein arises in a manner comparable to that of the azygos. The accessory hemiazygos vein corresponds to the upper portion of the azygos vein.

The vertebral venous system.

The vertebral venous system consists of plexuses that drain the back, vertebrae, and structures in the vertebral canal. They communicate above with the intracranial veins and below with the portal system, and they empty into the vertebral, posterior interosseous, lumbar, and sacral veins. The veins in the vertebral plexus are valveless: blood may flow in either direction, and pressure in them is reflected in the cerebrospinal fluid. Reversed blood flow permits tumor cells to be transported from the breast, thorax, abdomen, or pelvis to the vertebrae, spinal cord, or brain. Veins of the thoracic wall (such as the thoraco-epigastric veins, which are superficially placed) connect the superior and inferior venae cavae and can provide a collateral circulation in obstruction of one of the venae cavae.

Extensive anastomoses among the caval, azygos, and vertebral systems provide multiple routes for the return of blood to the heart. In effect, the azygos and vertebral systems bypass the caval system and these veins dilate in caval obstruction.

Lymphatic drainage

Lymph nodes

The parietal nodes of the thorax are the parasternal, phrenic, and intercostal. The visceral nodes drain the lungs, pleurae, and mediastinum. The nodes in the roots and hili of the lungs are arranged in several groups: pulmonary along the larger bronchi, bronchopulmonary mainly at the hilus, and tracheobronchial near the bifurcation of the trachea. Lymph nodes in the roots of the lungs tend to be involved secondarily in infections, such as tuberculosis, and in tumors of the lungs and mediastinum. Their density may increase so that they become visible radiographically, especially if they become calcified. The tracheobronchial nodes drain into the tracheal (or paratracheal) nodes. Mediastinal nodes are scattered in the superior mediastinum, and they receive vessels from the thymus, pericardium, and heart. The efferents of the tracheal and mediastinal nodes form a bronchomediastinal trunk on each side of the trachea. There are also posterior mediastinal nodes, most of which drain directly to the thoracic duct.

Lymphatic vessels

All of the lymphatic drainage of the thorax is directed toward the bronchomediastinal trunks, thoracic duct, and descending intercostal lymphatic trunks, but the actual lymphatic trunks themselves are highly variable.

The thoracic duct extends from the abdomen to the neck, where it ends in one of the large veins. It begins as either a plexus or a dilatation called the cisterna chyli, passes through or near the aortic opening of the diaphragm, and ascends in the posterior mediastinum between the aorta and the azygos vein. Next it crosses obliquely to the left, posterior to and then along the left side of the esophagus. Finally it passes posteiror to the left subclavian artery, enters the neck (where it forms an arch above the level of the clavicle), and commonly ends in the left internal jugular vein (fig. 24-3). Variations are common. The thoracic duct receives the left subclavian and jugular trunks and often the left bronchomediastinal trunk.

Most of the lymph in the body reaches the venous system by way of the thoracic duct, but anastomoses are so extensive that no serious effects result if the thoracic duct is ligated.

On the right side, the bronchomediastinal trunk forms various combinations with the subclavian and jugular trunks. Rarely, all three unite to form a right lymphatic duct, which then empties directly into the junction of the internal jugular and subclavian veins.


The thymus is partly in the neck and partly in the thorax. It comprises one to three lobes, each of which consists of numerous lobules containing lymphocytes, which are important in the development and maintenance of the immune system. The cervical part of the thymus lies on the anterior and lateral sides of the trachea, whereas the thoracic part lies posterior to the superior portion of the sternum. The organ has a profuse blood supply and lymphatic drainage. The thymus reaches its greatest size at puberty and then begins to regress. Much of its substance is replaced by fat and fibrous tissue, but thymic tissue never disappears completely.


The phrenic nerves.

The phrenic nerves supply the diaphragm. These nerves usually arise from cervical nerves 3-5. (The contribution of the C5 nerve root to the phrenic nerve often arises from the nerve to the subclavius, and it may enter the thorax separately as an accessory phrenic nerve.) After descending on the anterior surface of the anterior scalene muscle in the neck, the phrenic nerves enter the thorax and pass anterior to the roots of the lungs. Each givesrise to sensory branches to the pericardium and pleura and then divides into several branches, which pierce the diaphragm and supply that muscle, as well as part of the peritoneum, from below. The phrenic nerves contain (1) motor fibers to the diaphragm, (2) pain fibers from the pericardium, pleura, and peritoneum, and (3) sympathetic vasomotor fibers. Pain is usually referred to the skin over the trapezius muscle that is normally innervated by cervical nerves 3 and 4. Pain sometimes refers to the region of the ear innervated by C2 and 3.

The vagi.

The vagi descend through the neck and enter the thorax, where they contribute to the pulmonary plexuses and then form the esophageal plexus. They then continue as anterior and posterior vagal trunks, which pass through the esophageal opening of the diaphragm. Each vagus has a recurrent laryngeal branch and a variable number of cardiac branches in the neck and thorax.

The right recurrent laryngeal nerve arises as the vagus crosses anterior to the subclavian artery, hooks around that vessel, and ascends between the trachea and esophagus. The left recurrent laryngeal nerve arises as the vagus crosses the left side of the arch of the aorta, hooks around the inferior side of the arch (to the left of the ligamentum arteriosum), and then ascends on the right side of the arch between the trachea and esophagus. The left recurrent laryngeal nerve is liable to damage from disorders of the aorta (e.g., aneurysms) or of the mediastinum (e.g., tumors), resulting in hoarseness. It is believed that both recurrent laryngeal nerves owe their adult relationships to their embryonic arrangement caudal to the sixth aortic arches.

The vagi contain (1) parasympathetic fibers (e.g., to the heart), (2) sensory fibers (many of which are concerned with cardiovascular and pulmonary reflexes; others, in the mucosa of the bronchial tree, cause coughing), and (3) motor fibers to the pharynx and larynx, in the head and neck.

The sympathetic trunks.

The sympathetic trunks descend through the neck and enter the thorax, where they lie anterior to the necks of the ribs. The thoracic part of each trunk has about a dozen ganglia, the first of which is often fused with the inferior cervical ganglion to form the stellate ganglion. The sympathetic trunks enter the abdomen by piercing the crura of the diaphragm or by passing posterior to the medial arcuate ligaments. The trunks and ganglia are connected with the thoracic ventral rami by rami communicantes, which convey preganglionic and postganglionic fibers. Preganglionic fibers from segments T1 to 6 of the spinal cord supply the heart, coronary vessels, and bronchial tree. Apart from cardiac and pulmonary branches, the main visceral branches are the three splanchnic nerves. The greater, lesser and least splanchnic nerves (from superior to inferior) traverse the lower thoracic ganglia, pierce the crura of the diaphragm, and end in ganglia and plexuses (celiac and renal) in the abdomen. The sympathetic trunks and their branches contain pain fibers from the thoracic and abdominal viscera and from blood vessels. These sensory fibers traverse the sympathetic trunks and rami communicantes to reach the spinal nerves, dorsal roots, and spinal cord.

Many branches of the vagi and sympathetic trunks form plexuses in the thorax, e.g., the cardiac, pulmonary, esophageal, and aortic plexuses.

How can Osteopathy help?

I normally focus on the individual symptoms that affect each person, taking their condition into consideration. Normally, the osteopathic treatments I offer consist of soft tissue and muscle energy techniques. I often concentrate on the thoracic spine, rib cage and diaphragm. A wide range of non-invasive manual techniques, such as deep tissue massage, joint articulation, trigger point therapy, myofascial release and where appropriate medical acupuncture, can be used.


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