Costosternal Anatomy

Diagrams of the chest and costosternal anatomy.

The costo-sternal anatomy makes up the thoracic wall. It encases the lungs, the heart and the great vessels.

This area is unique in the body, and quite different to the other bones and joints. This is because of its important function of protecting the vital organs, whilst still enabling breathing. The ribs make up an essential part of the thoracic wall.

The rib-cage is formed by three sets of bones:

  1. The sternum, or breastbone, in front.
  2. It connects via twelve pairs of ribs to
  3. twelve thoracic vertebrae posteriorly.

The joints between the breastbone and the ribs are made up of special so-called costal cartilage which may sometimes become subject to a very painful condition called Tietze's syndrome; see more later.

Note the costal cartilages arrowed in blue below.

They can also be injured by trauma, for example, falling on your fist whilst skating, or hitting the steering wheel during a head-on collision. Always use a safety belt.

This page was last updated by Dr Barrie Lewis on 7th July, 2019.

Costosternal Anatomy


From the chiropractic perspective, costosternal anatomy is concerned with bones, muscles, joints and nerves. Of course there are also arteries ...

The spaces between the ribs are filled by the INTERCOSTAL MUSCLES. These muscles extends from the sternum to the angle of the rib, posteriorly. They are very important in breathing.

The PECTORALIS MAJOR muscle is can be seen on the anterior thoracic wall. It has two origins, one of which is the sternocostal cartilages and the other the sternum bone.

The PECTORALIS MINOR muscle is located at a deeper level than the pectoralis major muscle. It originates from the third, fourth and fifth ribs and is inserted in the coracoid process of the scapula.

The SERRATUS ANTERIOR muscle covers most of the lateral thoracic wall and originates from the first nine ribs. Its fibers converge posteriorly to be inserted into the medial margin of the scapula, thus contributing towards forming the medial wall of the axilla.

The diminutive SUBCLAVIUS muscle originates from the first rib, close to the chondrocostal junction, to be inserted in the collarbone. Its function is to stabilize the clavicle in movements of the shoulder.

The muscles involved in chest pain.

The SERRATUS ANTERIOR muscle covers most of the lateral thoracic wall and originates from the first nine ribs. Its fibers converge posteriorly to be inserted into the medial margin of the scapula, thus contributing towards forming the medial wall of the axilla.

The diminutive SUBCLAVIUS muscle originates from the first rib, close to the chondrocostal junction, to be inserted in the collarbone. Its function is to stabilize the clavicle in movements of the shoulder.

Tietze's syndrome

Breastbone pain can be very severe.

Costo sternal joints: Breastbone Pain

These costosternal anatomy joints, when subluxated, are a common cause of chest pain.

Chiropractic treatment involves stretching the doctor's hands right around the ribcage, from the sternum to the spine, an providing gentle thrusts to release the fixations.

The rib forms three synovial facet articulations with the spine.

  • One with the TP, the costo-transverse joint, and
  • Two with the spinal bodies above and below the rib, the costo-vertebral joints.

This arrangement restrains the motion of the ribs allowing them to work in a parallel fashion during breathing.

If a rib had only one joint posteriorly, the resultant swivel action would allow it to move out of synchronization with respect to its neighbours, making for a very inefficient respiratory mechanism.

These joints may be sprained, often after a violent sneeze, causing severe sharp pain with every breath. The condition responds extremely well to a gentle chiropractic adjustment.

Treatment for costochondritis is just standard, but modified chiropractic help.

Understanding rib pain causes is important.

A big picture of the costosternal cartilage.

Bats in my Belfry

Bats in my Belfry is a chiropractic book with several stories concerning the costosternal anatomy.

If you love to read, you will probably enjoy batty chiropractor Bernard Preston's latest book, Bats in my Belfry.

Says chiropractor Emma Maria Nygren:

"I am looking forward to your third book, Dr Preston. I really enjoyed reading Frog and Bats! They make you think, laugh and relax just like a good book should!"

For more information, click here … BATS IN MY BELFRY

Rib pain treatment

The joints involved in rib pain treatment.

Notice the three arrowed facets where the rib head can be subluxated causing severe pain.

FROM THE COAL FACE : Iatrogenic Illness

The thoracic spine is usually not the source of serious problems. Irritating, and occasionally acute pain, but because of the stabilising ribs, it generally gives much less serious trouble than the neck and lower back. Consequently, it also less xrayed. Chiropractors generally, myself included will often adjust the thoracic spine without first having given it the attention that one might give the lumbar spine.

Mrs S is a woman of about thirty who had significant Low Back Pain since shortly after the birth of her first child, about three years ago.

Opinion has it that much low back pain starts during the last trimester, but in my experience it often starts soon AFTER the birth of the child. All the lifting, but sometimes within a month of falling pregnant.

The lower back pain didn't improve with various other medical ministrations, and six months the pain started radiating down her leg.

She has responded very well, and after a month her low back and leg pain is almost gone.

But I adjusted a subluxation between her shoulder blades, where she had no pain, and she is now really suffering. It's a little better, but she's not a happy lady. She came with one pain, and left with another.

That's what we call Iatrogenic Illness, or doctor caused disease.


UPDATE: Fortunately with the correct management of her rib the pain soon passed. My point? Rib pain can be caused by an overly zealous manipulation in the mid back.

For information about chiropractic treatment of rib pain, click here; RIB PAIN TREATMENT

Costosternal Anatomy - The Breast

The breast obviously lies just adjacent to the costo-sternal joints, and covers some of the muscles.

A breast condition may mimic the costo-sternal syndrome, and occasionally a breast examination by your chiropractor may be indicated. Alternatively, you could ask that your GP do the examination. Talk frankly about it.

During the treatment of the costo-chondral syndrome, the doctor's hands will approximate the breast tissue as s/he firmly adjusts the rib during the in or out phase of breathing. He should release his grip, and slightly remove his hands during the inactive phase of breathing, to ensure that there is no embarrassment.

Should you feel awkward then it may be necessary to ask a friend or family member to accompany you for breastbone pain treatment, or ask if the secretary may be present. It is best to talk frankly about it.

Rib pain treatment involving the costosternal anatomy ventures close to the breast.

Nerves - costo sternal anatomy

The nerves involved in the costosternal anatomy.

The NERVE bundles from the spine, are threaded between the muscle layers, and are responsible for the innervation of the intercostal muscles.

The pain often radiates along the length of the rib causing flank pain (under the armpit), chest pain mimicking a heart attack if it's on the left side and, if it involves the lower ribs on the right, gallbladder or liver conditions.

As can be seen the costosternal anatomy is unusual in both function and structure, making it vulnerable to various pain syndromes. Other conditions may mimic a rib problem. For example, should you also be experiencing indigestion, a hiatus hernia.

First thought though with indigestion should always be to drink first, and eat afterwards, especially at night, and avoid bread and rolls.

Second thought should be to start making your own kefir; it's an ancient Bulgarian drink, not unlike a very strong yoghurt. It is known as a probiotic and should you have a heliobacter infection, or other, the huge mass of friendly bacteria will help to overwhelm them.

On a personal note these kefir benefits cured a grumbling ulcer and small hiatus hernia that gave me great indigestion at night, in just one week; I still take it regularly.

Copy and paste 'kefir benefits' into the Site Search function in the navigation bar on your left.

Kefir benefits fixed my severe indigestion. Make it in your own kitchen.
  1. Chiropractic Help
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  3. Costosternal Anatomy

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Interesting challenges of the day

1. Mr S is a 76 year old man with neck pain of some 9 months duration. Luckily, most of the discomfort is upper cervical which is only rarely arthritic; his lower cervical spine is a degenerative mess that I have left alone. After seven treatments his pain and stiffness is 50 percent better, and he is happy in the circumstances. He can sleep through the night now and that makes a huge difference.

2. Mr P is 32 year old man with very severe lower back pain radiating to the big toe which is 30 percent numb. He had an episode three weeks ago, took anti-inflammatories and was soon better as is typical of the medial disc herniation. But before it healed, after a trivia it came roaring back, much worse. The characteristic crossed sign was evident; sitting in a chair, straightening the right leg provoked severe left back pain and tingling in the leg. He is doing well.

3. Severe lower back pain is scary; just ask Mrs P. Just watching her get out of the car I she was in trouble; she had a slipped disc at L4 making her lean towards the opposite side; luckily she had no pain in the leg. Despite family pressure that this was far too severe for a chiropractor, she persevered. Within five days she was standing upright, and after two weeks almost pain-free. 

Despite a hectic job, she wisely took my advice and stayed home for what I call exercising bed rest.

4. Mr S has had lower back, groin and back of thigh and calf pain for fourth months.

He has a pincer deformity in the hip causing the stabs in the groin, and a degenerative facet causing the sciatica. Both are responding well to chiropractic and he is well pleased; sixty-five percent better after three treatments.

5. Mr T is a wise man; he has taken a warning TIA seriously and has lost 15 pounds, and has at least as much again to lose. A change to a low starch diet and half hour daily stroll has made the difference; but the walking is making his foot and back miserable. The expensive orthotic is hopeless; luckily his hips and back are fine, but he needs a simple heel lift; he has a short leg.

6. I too have had serious lower back issues, luckily fixed by my own chiropractor; so I too have to do my exercises, take care when lifting supers full of honey, gardening and using the chainsaw. Regaining the function of your spine is just as important as the pain.

7. My own granddaughter, only 7 is hypermobile giving her pelvic, knee and ankle issues. X-rays show a mildly dysplastic hip. Years ago we would have called it growing pains. She too regularly needs chiropractic care and luckily responds well. Increased range of motion is more difficult than too stiff in my opinion. Our care is for kids too.

8. This 65-year old lady is a serious gardener; every day she is bending, lifting and digging for 2 to 3 hours a day. It regularly catches her in the sacroiliac joint, so she has a treatment once a month that sorts it out. She does her lower back exercises faithfully.

9. This 88-year old lady is an inspiration; every day she is busy in the community. With a nasty scoliosis she manages very well with a chiropractic adjustment every six weeks and exercises faithfully done. 

10. Mr X is a 71-year old retired man who wants to continue with maintenance care every six to eight weeks; he had suffered from two years of lower back pain when he first came a few months ago. He has no discomfort now after 8 chiropractic treatments, but is aware that danger lurks.

11. Mrs C has been having severe headaches, and taking a lot of analgesics. It is a non-complicated upper cervical facet syndrome, and she is doing well.

12. Mr D is a 38-year old year man with chronic shoulder pain after a rotator cuff tear playing cricket. It responded well to treatment, but he knows he must do his exercises every day; for two years he could not sleep on that shoulder.

13. Mr D, a 71-year old man, has a severe ache in the shoulder and midback since working above his head. Trapped nerve tests are negative but he has advanced degenerative joints of Luschka; after just two treatments he is 50 percent better. Can we reach 90?

And so the day goes; chiropractors should not be treating the elderly most medical sites state but that is so much bunkum.

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Knowing that up to 70 percent of the time the correct diagnosis is made with no examination, no special tests, no xrays, but just from the history, there is a fair chance I can add some insight to your unresolved problem. But at least 30% of the time, I may be quite wrong. Give plenty of detail if you want a sensible reply.

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