What is the treatment for a slipped rib?

Treatment for Slipped Rib Syndrome

The treatment for slipped rib syndrome should begin with conservative management including reassurance, activity modification, and pain control, with surgical intervention reserved for refractory cases that fail to respond to non-operative measures. 1, 2, 3

Understanding Slipped Rib Syndrome

Slipped rib syndrome (SRS) is a rare and frequently underdiagnosed condition characterized by hypermobility of the lower "floating" ribs (8th-10th ribs) that are not directly connected to the sternum but attached to each other with ligaments. This hypermobility causes pain in the lower chest or upper abdomen when the affected ribs slip and rub against each other 1, 3.

Diagnosis

• Clinical diagnosis is primarily based on history and physical examination
• Hooking maneuver: A simple clinical test where the clinician hooks fingers under the lower ribs and pulls anteriorly to reproduce the patient's pain 1, 4
• Dynamic ultrasound: Can visualize the slipping of the lowest rib over the next lowest rib, confirming diagnosis 1, 3
• Standard imaging (X-rays, CT, MRI) typically shows no abnormalities 1

Treatment Algorithm

First-Line Treatment

1. Reassurance and education about the benign nature of the condition 1, 2
2. Activity modification:
   • Avoid postures and movements that worsen pain
   • Modify exercise routines to prevent exacerbation 1, 5
3. Pain management:
   • Acetaminophen: Regular administration (1 gram every 6 hours) 6
   • NSAIDs: Consider adding with caution, especially in elderly patients 6
   • Ice/heat therapy: Application of ice or hot packs to the affected area 5

Second-Line Treatment

If pain persists despite conservative measures:

1. Regional anesthesia:

   • Intercostal nerve block: Can provide lasting relief in many patients 2
   • Consider other techniques such as serratus anterior plane blocks or erector spinae plane blocks for pain control 6

2. Physical therapy:

   • Focused on strengthening the core and intercostal muscles
   • Improving posture and body mechanics 5

Third-Line Treatment (Refractory Cases)

For patients with persistent, debilitating symptoms despite conservative management:

1. Surgical intervention:
   • Cartilage rib excision (CRE): Traditional approach but has shown high recurrence rates 3
   • Minimally invasive rib fixation: Newer technique with promising results 3
   • Costal cartilage excision with vertical rib plating: Alternative surgical approach 3

Important Considerations

• Delayed diagnosis: SRS is frequently misdiagnosed, leading to years of unnecessary testing, radiographic exposure, and chronic pain 1, 4
• Psychiatric misdiagnosis: Approximately one-third of patients with SRS have been incorrectly considered psychoneurotic due to persistent pain without obvious imaging findings 2
• Duration of treatment: Conservative treatment should be attempted for several months before considering surgical options 5
• Post-treatment monitoring: Follow-up within 2-3 weeks after initiating treatment to evaluate pain control and functional status 6

Pitfalls to Avoid

• Misdiagnosis: Don't mistake SRS for intercostal strain, oblique strain, fractured rib, or pleuritic chest pain 5
• Unnecessary imaging: Extensive radiographic testing is rarely helpful and exposes patients to unnecessary radiation 1
• Delayed referral: Consider surgical consultation after 4-6 months of failed conservative treatment rather than allowing years of chronic pain 5, 3
• Overlooking psychological impact: Chronic pain from SRS can lead to significant psychological distress that should be addressed alongside physical symptoms 2

By following this structured approach to diagnosis and treatment, clinicians can effectively manage slipped rib syndrome and prevent the prolonged suffering often associated with this elusive condition.