What to do for a patient with a popping noise in the left lower rib?

Clinical Approach to Popping Noise in Left Lower Rib

Begin with systematic palpation of the left costal margin to reproduce the popping sensation and assess for tenderness, as this patient likely has slipping rib syndrome (SRS), a clinical diagnosis that requires no imaging in uncomplicated cases. 1, 2

Initial Clinical Assessment

Perform the Hooking Maneuver

• Hook your fingers under the lower costal margin and pull anteriorly while the patient is supine 2, 3
• A positive test reproduces the pain and/or popping sensation, confirming SRS 2, 4
• The syndrome involves hypermobility of ribs 8-12 (the floating ribs not connected to the sternum), which slip over adjacent ribs 2, 4

Key Physical Examination Findings

• Identify a tender spot on the costal margin - this is one of the three cardinal features of painful rib syndrome 1
• Assess whether pressing the tender spot reproduces the patient's symptoms 1
• Note if pain is movement and posture-dependent 5
• The left lower ribs (particularly ribs 8-10) are the most common location 2, 4

Diagnostic Strategy

When Imaging is NOT Needed

If the hooking maneuver is positive with a tender costal margin and no trauma history, this is a safe clinical diagnosis requiring no investigation 1, 5

• Standard radiographs, CT, and MRI are typically normal in SRS 2, 3
• Extensive imaging workup is unnecessary and exposes patients to radiation without diagnostic benefit 1, 2

When to Consider Imaging

Only pursue imaging if:

• History of trauma is present - then obtain a chest X-ray as the initial test to exclude rib fracture 6
• Red flag symptoms exist: respiratory distress, hemodynamic instability, or concern for intra-thoracic injury 6
• Physical examination suggests complications: pneumothorax, hemothorax, or flail chest 6

Optional Advanced Imaging

• Dynamic high-frequency ultrasound can visualize rib slipping during the hooking maneuver if diagnosis remains uncertain 2, 3
• This demonstrates the eighth rib slipping over the seventh rib (or similar patterns) with associated clicking 3
• Ultrasound is radiation-free and can guide subsequent nerve blocks if needed 3

Management Approach

First-Line Conservative Treatment

• Provide reassurance and explain the benign nature of the condition 1, 5
• Advise avoiding postures and movements that worsen pain 2, 5
• Most patients learn to live with residual symptoms without intervention 1

Refractory Cases

If conservative measures fail after adequate trial:

• Intercostal nerve block under ultrasound guidance 2, 3
• Surgical options (cartilage rib excision or rib fixation) reserved for persistent, debilitating cases 4
• Note that cartilage rib excision has high recurrence rates; newer techniques like vertical rib plating show promise 4

Critical Pitfalls to Avoid

This condition accounts for 3% of general medical referrals but remains significantly underdiagnosed 1

• 43% of patients undergo extensive unnecessary investigations before diagnosis 1
• Some patients even undergo non-curative cholecystectomy due to misdiagnosis 1
• 33% are re-referred to specialists despite firm diagnosis, leading to repeated negative workups 1

The key error is failing to perform systematic palpation of the costal margin in patients with lower chest or upper abdominal pain 1, 5