What are the treatment options for atraumatic rib pain with a popping sensation?

Atraumatic Rib Pain with Popping Sensation

The popping sensation with atraumatic rib pain is highly suggestive of slipping rib syndrome, which should be diagnosed clinically with the hooking maneuver and confirmed with dynamic ultrasound if needed, followed by conservative management initially and surgical cartilage excision for refractory cases. 1, 2, 3

Clinical Diagnosis

Key Physical Examination Findings

• Perform the hooking maneuver: Place fingers under the lower costal margin and pull anteriorly to reproduce the pain and popping sensation—this is pathognomonic for slipping rib syndrome 4
• Palpate for focal tenderness over the affected costochondral junction or lower ribs (typically ribs 8-12) 1, 2
• Check for a mobile or popping rib with direct palpation 2, 3
• Assess for chest wall asymmetry, which is present in many cases 2
• Pain that is reproducible with palpation, breathing, turning, twisting, or bending strongly argues against cardiac angina 1

Diagnostic Imaging Approach

• Start with chest radiography to rule out fracture, infection, neoplasm, or pneumothorax, though standard films may miss up to 50% of rib fractures 5, 1
• Dynamic ultrasound is the diagnostic test of choice for slipping rib syndrome, with 89% sensitivity and 100% specificity for detecting the slipping motion 5, 1
• Place radio-opaque skin markers on the site of pain before imaging to help localize abnormalities 5, 1
• Rib series radiographs add minimal value unless there is high suspicion for fracture, as they rarely change management 5

Specific Diagnosis: Slipping Rib Syndrome

This condition results from hypermobility of the floating ribs (8-12), which are not connected to the sternum but attached to each other with ligaments 4. The popping or clicking sensation with activity associated with pain is reported in the majority of cases 2, 3.

Timeline Considerations

• Patients typically experience a median of 2 years from symptom onset to definitive diagnosis, representing significant diagnostic delay 2
• Early recognition avoids unnecessary testing, radiographic exposure, and years of debilitating pain 4

Treatment Algorithm

First-Line Conservative Management

• Reassurance and activity modification: Avoid postures and movements that worsen pain 4
• Regular acetaminophen as first-line analgesic 1
• NSAIDs as second-line for severe pain, considering potential adverse events 1
• Immobilization, cold compresses, or dressings in conjunction with pharmacological therapy 1

Alternative Conservative Approaches

• Osteopathic manipulation techniques (OMT) with rib manipulation and instrument-assisted soft tissue mobilization (IASTM) can achieve complete resolution in some cases of atypical costochondritis 6
• Low-dose ketamine (0.3 mg/kg over 15 minutes) as an alternative to opioids for severe pain 1

Surgical Intervention for Refractory Cases

• Costal cartilage excision is the definitive treatment for slipping rib syndrome when conservative measures fail 2, 3
• Surgery should be considered early (rather than waiting years) to avoid unnecessary diagnostic tests and prolonged disability 2
• All excised cartilages in surgical series were grossly abnormal on pathology 2
• Surgical outcomes are excellent: Most patients experience total resolution of symptoms following localized excision of the offending cartilage 3
• One study showed only 2 of 7 patients had any residual symptoms post-operatively, with one having recurrence in a different location 2

Important Caveats

Differential Diagnosis Considerations

• Always rule out serious cardiac causes first, especially in patients >35 years or with cardiac risk factors—obtain an ECG 7
• Consider cough-induced rib fractures, which occur in 82.4% of patients with post-tussive chest pain, most commonly affecting the 10th rib 1
• Costochondritis is a diagnosis of exclusion and typically self-resolves within weeks; persistent symptoms beyond this suggest atypical costochondritis or alternative diagnosis 6

Pitfalls to Avoid

• Do not rely solely on chest radiographs, as they miss up to 50% of rib fractures and are insensitive to costochondral abnormalities 1
• Do not delay surgical referral in confirmed slipping rib syndrome with refractory symptoms—median time to surgery of 2 years represents unnecessary suffering 2
• The diagnosis is primarily clinical; normal imaging does not exclude slipping rib syndrome 4