Osteopathic Manipulative Treatment: HVLA Procedure - Exhaled Ribs

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Continuing Education Activity

High-Velocity Low-Amplitude (HVLA) incorporates rapid thrust techniques over a short distance through a pathologic barrier. HVLA techniques require a physician to locate immobile or asymmetrical joints using his or her hands. The physician controls the pathologic barrier by setting it in motion and applying rapid but short thrusts until usually a pop sound is heard, confirming the restoration of motion in the affected joint. This activity reviews the evaluation and treatment of exhalation dysfunctions and highlights the role of the HVLA techniques in evaluating and treating this condition.


  • Summarize the common HVLA treatment considerations for patients with exhaled ribs.
  • Describe the classic exhalation physiology.
  • Review the screening indications for exhaled ribs.
  • Explain the importance of collaboration and communication amongst the MDs and DOs to enhance treatment considerations for patients affected by exhalation dysfunction.


High-velocity low-amplitude (HVLA) incorporates rapid thrust techniques over a short distance through a pathologic barrier.[1] HVLA techniques require a physician to locate immobile or asymmetrical joints using his or her hands. The physician controls the pathologic barrier by setting it in motion and applying rapid but short thrusts until usually hearing an audible release, confirming the restoration of motion in the affected joint. HVLA techniques have been widely reported across medical literature and have been proven effective in subsiding neck and shoulder pain after their utilization in the cervicothoracic region.[2]

Exhalation dysfunction, formerly known as inhalation restriction, refers to the caudad movement of a dysfunctional rib during exhalation with an absent cephalad rib movement during inhalation. The physician notices one (in some cases) but, generally, a class of ribs stuck in exhalation. OMT (Osteopathic Manipulative Therapy) tends to heal compromises within a joint’s normal range of motion via allocating the joint through the compromised pathologic barrier, generally not beyond the usual physiologic range of motion, which may justify the low incidence of harmful effects off OMT procedures. This review implores the usage of OMT in treating exhaled ribs under inhalation restriction.[3][4]

Anatomy and Physiology

The rib cage consists of typical and atypical ribs. A typical rib will have the following landmarks:

  • Angle
  • Shaft
  • Neck
  • A head that joins with the superior and corresponding vertebra
  • A tubercle that connects to the corresponding transverse process

Ribs 1, 2, 11, and 12 (sometimes 10) are atypical, while 3 through 10 are typical. Rib 1 is atypical as it connects only with T1 with no angle. Rib 2 is atypical due to its large tuberosity on the serratus anterior shaft. Rib 11 and 12 both articulate only with the corresponding vertebra but have no tubercles. Rib 10 is sometimes considered atypical as it only connects to T10. The ribs further classify as true, false, and floating ribs. Ribs 1 through 7 are true ribs as they connect to the sternum by costal cartilages. Ribs 8 to 12 are called false ribs as they do not directly connect to the sternum; ribs 11 to 12 are called floating ribs because they remain unarticulated anteriorly.

There are three categories of rib movement:

  1. Pump-handle motion
  2. Bucket-handle motion
  3. Caliper motion

Depending on their location amidst the ribcage, all ribs may have a mix of the above movements; however, they generally tend to follow the patterns below:

  • The upper ribs (1-5) generally move in a pump-handle motion.
  • The middle ribs (6-10) generally move in a bucket-handle motion.
  • The lower ribs (11 and 12) generally move in a caliper motion.

Muscles of inspiration refer to those muscles that uplift the chest cage. Muscles of expiration refer to those muscles that push the chest cage downward. External intercostals are the most crucial muscles of inspiration, but other noteworthy muscles are:

  1. Sternocleidomastoid muscles that elevate the sternum
  2. Anterior serrati that uplift many ribs
  3. Scaleni which lifts ribs 1 and 2

The muscles that push the chest cage downward are primarily the: 

  1. Abdominal recti, which is capable of pulling the lower ribs down when they and other abdominal muscles compact the abdominal contents up contra the diaphragm
  2. Internal intercostals

The lungs can expand and contract in two ways:

  1. Downward and upward diaphragmatic motion to expand or shorten the thoracic cavity, and 
  2. Elevation and depression of the ribs to lengthen and reduce the anteroposterior diameter.

Normal quiet breathing almost exclusively involves the first method. Diaphragmatic contraction pulls the lower lung surfaces downward during inspiration; the diaphragm relaxes during expiration while the chest wall, elastic lung recoils, and abdominal structures press the lungs and expel the air. During rapid breathing, however, the contraction of abdominal muscles becomes necessary as the elastic forces are not strong enough to produce the vital rapid expiration. The second method mentioned earlier elevates the rib cage. At rest, the ribs incline downward to let the sternum fall backward to the vertebral column. When the rib cage uplifts, the ribs protrude directly forward, allowing the sternum to move forward and away from the spine, thickening the chest about 20 percent greater at utmost inspiration than during expiration anteroposteriorly.[5][6][7]


In general, any form of somatic dysfunction that leads to motion loss can be an indication. Specifically, rib (11 or 12) inhalation restriction is related to but is not restricted to the following:

  • Sacral pain
  • Chest wall pain
  • Back pain
  • Pelvic pain
  • Abdominal pain

In exhalation dysfunction, the physician usually depresses pump-handle ribs anteriorly. The anterior portions of the rib mobilize caudad during expiration and are restricted on inspiration. The physician may also notice the narrowing of the anterior intercostal space beneath the compromised rib. The inferior edge of the posterior rib angle is usually protuberant in these cases. Tenderness may be felt in the:

  • Chondrosternal junction
  • Costochondral junction
  • Posterior rib angles

Meanwhile, bucket-handle ribs are usually depressed laterally in exhalation dysfunction. The rib shafts slightly shift downward during expiration and are limited during inspiration. The physician may also notice constricting of the lateral side of the intercostal space beneath the compromised rib. Tenderness may be felt in the:

  • Posterior rib angles
  • Intercostal muscles at the mid-axillary line


Though brief, HVLA techniques on compromised ribs do require powerful forces. It is the responsibility of the physician to reconsider treatment if the patient has the following:

  • Acute rib fracture
  • Pelvic fracture 
  • Rib or vertebral cancer
  • Severe low back pain

In most cases, the clinician should reconsider HVLA if the patient has the following conditions:

  • Osteomyelitis
  • Osteoporosis
  • Fractures in the HVLA area
  • Bone metastasis
  • Down syndrome
  • Rheumatoid arthritis (severe cases)
  • Pregnancy
  • Acute whiplash
  • Herniated nucleus pulposus
  • Postoperative conditions
  • Vertebral artery ischemia
  • History of hemophilia or ongoing anticoagulation therapy


  • An OMT table
  • An exam table
  • A massage table
  • An alternative place which comforts the patient in laying or sitting and allows the physician to perform the technique comfortably
    • Although not necessary, physicians use a pillow for patient comfort, unless it tempers with the technique.


  • A patient who has given consent
  • A physician who has had formal training in OMT during medical school or postgraduate medical training


  • Ensure that the patient is well-informed about the procedure.
    • Inform the patient about the benefits, risks, and alternative treatment options.
  • Ensure that the patient has given their consent for the procedure.
  • Warm both hands before performing the procedure by creating friction against the surfaces


This procedure uses the most cephalad rib as the main rib. The physician uses respiratory attempts and supplementary inhalation muscles to aid with treatment. In supine position:

  1. Stand on the opposite side of the compromised rib and plant your thenar eminence on top of the most medial aspect of that rib aiming the costotransverse articulation; 
  2. Clutch the ASIS on the compromised rib’s side with your other hand; 
  3. Push the costotransverse articulation anterolaterally by inclining onto it while pulling the ASIS posteriorly; 
  4. Request the patient to take a deep breath and exhale afterward. At maximum exhalation, apply a brief and quick thrust on the rib in an anterolateral direction; 
  5. Reexamine rib mobility.


In a 1925 to 1993 retrospective study conducted by a group of physicians, only 185 reports of injury caused by OMT appears in literature. HVLA techniques have not statistically caused significant adverse effects on patients; there are generally no side effects of OMT except for probable soreness for a day or two after the procedure; in fact, most manual procedures may cause transient adverse effects on patients. The degree of this potential soreness will depend on the approach taken by the physician.

HVLA procedures are considered the riskiest in that band, as it produces rapid impulses. The literature records one harmful effect per 50,000 HVLA thrust procedures; however, there is currently no compelling evidence to prescribe that HVLA thrust techniques administered by well-trained providers should be terminated because of risk. In addition to experience and adequate training in these techniques, the way to a safe OMT session is taking a thorough patient history and performing a thorough physical examination before the administration of any procedure.[8]

Clinical Significance

HVLA manipulation techniques intend to restore mobility to a compromised joint. These techniques have been used for a variety of conditions, but they are mostly used to treat low back and neck pain. Evidence suggests that HVLA spinal manipulation is as fruitful for those two conditions as other types of treatment.[9]

Enhancing Healthcare Team Outcomes

While contemporary Western surgical and medicinal knowledge is part of every practicing osteopathic physician (DO) in the United States, the current MD programs in the country refuse to incorporate the additional tool of OMT within their curriculum. With the 2020 merge of postgraduate medical education for both MDs and DOs, it is clear to us that the only difference between their overall education lies within the acceptance and refusal of OMT.

As discussed in our review, OMT works as a less risky form of treatment that may be supplemented to the traditional medicine and surgery practiced by all physicians (both MDs and DOs); therefore, it is the responsibility of osteopaths to work towards achieving osteopathic recognition for ACGME-accredited residencies of all specialties across the country. This approach will allow for the MDs to learn some of the basic OMT procedures that the DOs have traditionally learned in their OMT classes during medical school, allowing both kinds of physicians to practice traditional medicine with a helpful tool by their side.[10][11]

Article Details

Article Author

Ahmed Nahian

Article Editor:

Shane R. Sergent


8/1/2022 7:45:33 PM



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