What is slipping rib syndrome?

Slipping Rib Syndrome

Slipping rib syndrome is a musculoskeletal condition characterized by chest pain caused by one or more ribs (typically ribs 8-10) subluxing from their normal joint position, resulting in hypermobility and impingement of intercostal nerves. 1

Pathophysiology

• The syndrome occurs when the costal cartilage of the false ribs (ribs 8-10) becomes abnormally mobile due to defects or laxity in the cartilaginous attachments 2, 3
• These ribs are not directly connected to the sternum but are attached to each other via ligaments, making them more susceptible to displacement 4
• The increased mobility causes the affected rib to slip beneath the adjacent superior rib, pinning and irritating the intercostal nerve 2
• This mechanical irritation of the intercostal nerves is the primary source of pain 2

Clinical Presentation

• Patients present with sudden onset of sharp pain in the lower chest or subcostal region, often triggered by jerking motions, upper-extremity activities, coughing, laughing, or leaning over 2, 5, 3
• Pain can be localized to the affected area, radiating, or present as diffuse visceral discomfort 2
• Pain is typically exacerbated by specific physical movements and may be alleviated by positions that offload the impinged nerve 2, 4
• The condition is intermittent and can be severe, often leading to years of debilitating symptoms if undiagnosed 4

Epidemiology and Risk Factors

• Slipping rib syndrome is rare and spans all genders and ages, though most epidemiologic evidence remains conflicting and anecdotal 2
• Risk factors include trauma and high-intensity athletic activity 2
• The condition frequently remains undiagnosed for many years due to low clinical awareness 5, 4

Diagnosis

Diagnosis is primarily clinical and can be confirmed using the "Hooking Maneuver" during physical examination. 5, 4, 3

Clinical Examination

• The Hooking Maneuver involves placing fingers under the lower costal margin and pulling anteriorly to reproduce the patient's pain and potentially elicit an audible click 5, 4
• A positive hooking maneuver is highly suggestive of slipping rib syndrome 4

Imaging Studies

• Dynamic ultrasound has emerged as the most useful diagnostic imaging modality, detecting slipping rib syndrome in 89% of cases and ruling it out in 100% of negative cases 1
• Dynamic ultrasound can identify abnormalities in rib and cartilage anatomy, visualize the slipping motion of ribs, and detect associated soft tissue swelling 3, 6
• Standard radiographic tests (chest X-rays, CT, MRI) are rarely helpful and typically fail to identify any underlying abnormality 4

Confirmatory Tests

• Definitive diagnosis can be achieved through pain relief following intercostal nerve block 2
• Surgical visualization of altered anatomy and subsequent relief after surgical correction provide definitive confirmation 2

Treatment Algorithm

Initial Conservative Management

• Begin with rest, ice application, and NSAIDs for symptomatic relief 2
• Reassure the patient and advise avoiding postures and movements that worsen pain 4
• Screen for comorbid conditions that may complicate management 2
• Consider physical therapy and osteopathic manipulative treatment 3

Second-Line Interventions

• For patients with persistent symptoms despite conservative measures, intercostal nerve blocks with local anesthetics and corticosteroids provide both diagnostic confirmation and therapeutic relief 2, 3
• Botulinum toxin injections have been attempted in refractory cases, though evidence is limited 3
• Prolotherapy may have a role in treatment, though further study is needed 3

Surgical Management

• Surgical correction remains the definitive treatment for refractory cases that fail conservative and injection therapies 2, 3, 6
• Traditional cartilage rib excision (CRE) has been the most common technique but carries a high recurrence rate and associated risks 6
• More recent minimally invasive techniques, including rib fixation and costal cartilage excision with vertical rib plating, have shown superior outcomes with lower recurrence rates in both adult and pediatric populations 6
• Surgical techniques continue to evolve to address the high recurrence rates seen with traditional approaches 3, 6

Clinical Pitfalls

• The condition is frequently misdiagnosed or undiagnosed for years, leading to unnecessary testing, radiographic exposure, and prolonged suffering 4
• Relying solely on imaging studies without performing the hooking maneuver will miss the diagnosis, as standard imaging is typically unremarkable 4
• Physicians must maintain high clinical suspicion in patients with chronic lower chest or upper abdominal pain that is movement-related and not explained by other etiologies 5
• Early recognition requires awareness of the characteristic symptomatology and the importance of the clinical examination over imaging 5, 4