In a 12‑year‑old with bilateral rib‑area pain below the scapula that worsens when lying flat or with respiration, what are the likely causes and recommended management?

Bilateral Rib Pain Below Shoulder Blade in a 12-Year-Old

This presentation most likely represents slipping rib syndrome (SRS), a frequently missed diagnosis in children that causes debilitating pain from hypermobility of the lower costal cartilages (ribs 8-10), and should be confirmed with the "hooking maneuver" physical exam test before considering imaging or surgical referral. 1, 2

Understanding the Clinical Picture

Why Slipping Rib Syndrome Fits This Presentation

• Bilateral involvement occurs in approximately 30% of pediatric SRS cases, making this a characteristic rather than unusual pattern 1
• Pain worsening with lying down is classic because supine positioning allows the false ribs (8th-10th) to slip anteriorly and impinge on the intercostal nerves running along the undersurface of the adjacent rib 2, 3
• Pain with breathing occurs because respiratory excursion causes the hypermobile costal cartilage tips to sublux and "click" under the rib above, triggering sharp pain 2
• Age 12 years falls within the typical presentation window (median onset 12.5 years), with 77% of cases occurring in girls 1
• Location below the scapula corresponds to the 8th-10th ribs posteriorly, where the costal cartilages attach anteriorly and become hypermobile in SRS 2, 3

Athletic History Matters

• Eight of 13 children (62%) in one surgical series were competitive athletes at symptom onset, suggesting repetitive trunk motion or trauma may precipitate cartilage disruption 1
• However, only 2 of 9 patients in another pediatric series had trauma history, indicating SRS can develop spontaneously from developmental rib abnormalities in children (unlike adults where trauma predominates) 4

Diagnostic Approach

The Hooking Maneuver (Pathognomonic Test)

• Technique: Hook your fingers under the lower costal margin and pull anteriorly while the patient is supine 2, 3
• Positive test: Reproduces the patient's pain and may produce an audible or palpable "click" as the rib slips 2
• This is a clinical diagnosis—the hooking maneuver alone is sufficient to confirm SRS in most cases 2

When to Consider Imaging

Dynamic ultrasound is the only imaging modality that can confirm SRS by visualizing real-time cartilage subluxation during the hooking maneuver, but it is reserved for diagnostically difficult cases 2

Critical Red Flags Requiring Different Workup

Before settling on SRS, you must exclude serious pathology:

Rib Osteomyelitis 5

• Fever (present in 80% of cases) plus rib pain should trigger immediate consideration 5
• Localized chest wall swelling develops in 60-80% of cases, often after initial presentation 5
• Elevated inflammatory markers (leukocytosis, ESR, CRP) are present in 80% 5
• Costochondral junction involvement occurs in 90% of pediatric rib osteomyelitis 5
• Imaging pitfall: Chest X-ray shows lytic changes in only 10% of cases; MRI is required and shows bone marrow signal abnormalities in 100% of cases 5
• Staphylococcus aureus is cultured in 80% of cases 5

Respiratory Distress Requiring Urgent Intervention 6

• Grunting, nasal flaring, head nodding, tracheal tugging, intercostal retractions, or respiratory rate ≥60 breaths/min indicate impending respiratory failure 7, 6
• SpO₂ <90% is a strong mortality predictor and mandates immediate hospitalization 6, 8
• These signs would suggest bilateral pneumonia, pleural infection, or airway obstruction rather than musculoskeletal pain 9, 8

Physical Abuse 9

• Posterior rib fractures are highly specific for non-accidental trauma in children 9
• Bilateral rib fractures detected by CT (which is 40% more sensitive than X-ray) raise concern for abuse 9
• Consider skeletal survey if there are unexplained bruises, neurologic changes, or inconsistent history 9

Management Algorithm

Step 1: Confirm Diagnosis

• Perform hooking maneuver bilaterally 2, 3
• Document absence of fever, chest wall swelling, and elevated inflammatory markers to exclude osteomyelitis 5
• Measure oxygen saturation and respiratory rate to exclude respiratory pathology 6

Step 2: Initial Conservative Management

• Activity modification: Avoid movements that reproduce pain 1
• NSAIDs: For pain control during the observation period 2
• Reassurance: Explain the benign nature and that symptoms may resolve spontaneously in some cases 2

Step 3: Surgical Referral Criteria

Refer to pediatric surgery if pain persists beyond 3-6 months despite conservative management 1, 4, 2

• Surgical procedure: Open resection of the affected costal cartilages (ribs 8-10) 1, 4
• Outcomes: 73% return to full activity by 3.5 months post-operatively, with durable pain relief 1
• Bilateral disease: Requires bilateral cartilage resection, which was performed in 4 of 13 patients in one series 1
• Emerging option: Rib stabilization for recurrent symptoms after initial resection 2

Common Diagnostic Pitfalls

Excessive Testing Before Diagnosis

• Patients see a median of 3 providers and undergo a median of 4 non-diagnostic imaging studies before SRS is recognized 1
• Chest X-ray, CT, and ultrasound are typically normal in SRS because the pathology is dynamic cartilage hypermobility, not structural bone abnormality 1, 2
• This diagnostic delay causes months to years of unnecessary activity restriction and testing 1, 2

Misattribution to Other Causes

• SRS pain can radiate to the abdomen, leading to unnecessary gastrointestinal workup 2, 3
• The bilateral nature may prompt concern for systemic disease when the actual problem is localized cartilage instability 1

Failure to Recognize Positional Worsening

• Pain worsening when lying flat is a key distinguishing feature—most musculoskeletal pain improves with rest, but SRS worsens supine because gravity allows anterior rib subluxation 2