Slipping rib syndrome

Symptoms

Presentation varies by individual and may occur on one or both sides of the rib cage, with symptoms appearing primarily in the abdomen and back. Pain is typically episodic and ranges from minor to severely impacting quality of life, lasting from minutes to hours. A common reported sensation is a popping or clicking of the lower ribs due to subluxation of the cartilaginous joints. Individuals often report an intense, sharp pain that can radiate from the chest to the back and may be reproducible by pressing on the affected rib.

A dull, aching sensation has also been reported. Certain postures or movements such as stretching, reaching, coughing, sneezing, lifting, bending, sitting, sports activities, and respiration may exacerbate symptoms. Vomiting and nausea have also been associated with the condition.

Diagnosis

Diagnosis of slipping rib syndrome relies mainly on a physical exam of the affected rib. A common test is the hooking maneuver, where the examiner curls their fingers under the lower rib edge and pulls outward and upward; the test is positive if this reproduces the pain or causes a sensation of movement. Standard imaging like X-rays, CT scans, MRI, and regular ultrasound cannot show the problematic cartilage, but they help rule out other conditions.

Dynamic ultrasound can sometimes assess how loose or displaced the cartilage is, but it is often no better than a skilled doctor’s hands-on exam, since the result depends heavily on the technician’s familiarity with the condition. A positive dynamic ultrasound requires seeing the cartilage slip out of place, which may be triggered by actions like bearing down or doing a crunch. Nerve block injections are another diagnostic tool: if pain disappears after numbing the intercostal nerves of the affected ribs, the diagnosis is supported.

Slipping rib syndrome is frequently mistaken for costochondritis or Tietze syndrome. Costochondritis, a common cause of chest pain accounting for up to 30% of emergency room visits for that symptom, usually affects the upper chest where the ribs meet the breastbone, unlike slipping rib syndrome which involves the lower ribs. Tietze syndrome involves swelling and inflammation at the rib joints, typically of the second and third ribs, and stems from infection, rheumatologic disease, or cancer.

Treatment

Treatment ranges from conservative measures to surgical procedures. Conservative measures are often first-line for minor symptoms and include reassurance, activity limitation, ice, and pain medication such as nonsteroidal anti-inflammatory drugs. Non-invasive methods such as osteopathic manipulation treatment, physical therapy, chiropractic treatment, and acupuncture aim for relief or symptom management. Topical medications like Diclofenac gel and lidocaine transdermal patches may provide temporary relief.

For moderate cases, minimally invasive procedures include nerve blocking injections with steroidal or local anesthetic agents, which are considered temporary and require repeated injections to prevent symptom resurgence. Surgical intervention is performed when other treatments fail. Four types of surgical procedures are noted: costal cartilage removal, rib resection, laparoscopic costal cartilage removal, and rib stabilization with plating. Costal cartilage removal, first attempted in 1922 by Davies-Colley, involves removing the affected cartilage from the sternum to the boned portion of the rib, with or without preserving the perichondrium.

Rib resection removes a small bone portion of the affected rib. Laparoscopic costal cartilage removal is a minimally invasive intra-abdominal approach excising cartilage from the sternocostal junction to the costochondral junction. Some individuals may experience recurrence of symptoms after these procedures.

Epidemiology

Slipping rib syndrome is often missed or misdiagnosed. In a 1980 study, it made up 1% of new diagnoses in a general medicine clinic and 5% in a gastroenterology clinic, with rates climbing among patients sent there after other tests found nothing.

Another study from 1993 reported it accounted for 3% of new referrals to a combined general medicine and gastroenterology clinic. Whether it affects women more than men is uncertain; some research shows equal rates, while others find more cases in women. A theory linking female hormones to looser ligaments during pregnancy has been proposed but remains unconfirmed.

Did You Know?

• The hooking maneuver was noted in 1977 by Heinz & Zavala as an accurate diagnostic method.
• Slipping rib syndrome may result from a birth defect such as an unstable bifid rib.
• Generalized hypermobility has been suggested as a possible risk factor.