What are the key differences in anatomy, clinical presentation, physical‑exam findings, and management between painful rib (costochondral) syndrome and slipping rib syndrome?

Painful Rib (Costochondral) Syndrome vs Slipping Rib Syndrome

Painful rib syndrome (costochondritis/Tietze syndrome) involves inflammation of the costochondral junctions with tenderness on palpation but no rib hypermobility, while slipping rib syndrome is a distinct mechanical disorder caused by subluxation of ribs 8-10 with nerve impingement, diagnosed by the hooking maneuver and dynamic ultrasound showing 89% sensitivity. 1, 2

Anatomic Differences

Costochondritis/Tietze Syndrome:

• Affects the costochondral junctions, typically ribs 3-7, most commonly left-sided or retrosternal 1
• Involves inflammation of the cartilage and joint without structural displacement 1
• No anatomic subluxation or hypermobility present 3

Slipping Rib Syndrome:

• Specifically involves the false ribs (ribs 8-10) where costal cartilage is defective 2, 4
• Results from actual subluxation of the rib from its normal joint position 2
• The displaced rib slips underneath the adjacent superior rib, causing mechanical impingement of intercostal nerves 4, 5
• Structural hypermobility of the anterior costal cartilages is the defining anatomic feature 6

Clinical Presentation Differences

Costochondritis/Tietze Syndrome:

• Pain described as stinging (53%) or pressing (35.1%) 1
• Sharp, stabbing pain that worsens with inspiration or palpation 1
• Symptoms occur more than once daily (62.9%), with chronic course >6 months common (55.4%) 1
• Pain is typically retrosternal (52%) or left-sided (69.2%) 1

Slipping Rib Syndrome:

• Sudden onset of severe intermittent pain triggered by jerking motions, upper-extremity activities, coughing, laughing, or leaning over 4, 6
• Pain can be localized, radiating, or diffuse visceral in nature 4
• Characteristic popping or clicking sensation with activity (reported in 5/7 patients in one series) 7
• Pain often alleviated by positions that offload the impinged nerve 4
• Lower anterior chest wall and upper abdominal pain distribution 5, 6

Physical Examination Findings

Costochondritis/Tietze Syndrome:

• Reproducible tenderness on palpation of affected costochondral joints is the hallmark finding 1, 3
• No rib mobility or clicking on examination 3
• No chest wall asymmetry 1
• Pain reproduction with direct palpation confirms musculoskeletal origin 3

Slipping Rib Syndrome:

• Positive hooking maneuver is pathognomonic: place fingers under the lower costal margin and pull anteriorly to reproduce pain and clicking 5, 6
• Mobile or popping rib palpable on examination (present in 4/7 patients in surgical series) 7
• Chest wall asymmetry may be visible (present in 4/7 patients) 7
• Reproducible pain with palpation over affected cartilage 7
• Possible ipsilateral rectus abdominis muscle thinning on ultrasound (emerging sign) 8

Diagnostic Approach

Costochondritis/Tietze Syndrome:

• Diagnosis is primarily clinical based on physical examination 3
• ECG within 10 minutes to exclude acute coronary syndrome in patients >35 years or with cardiac risk factors 1
• Imaging studies reserved for atypical presentations or ruling out alternative diagnoses 3
• Laboratory studies not useful for diagnosis, though inflammatory markers may be elevated 3

Slipping Rib Syndrome:

• Clinical diagnosis confirmed by hooking maneuver 5, 6
• Dynamic ultrasound is the most useful imaging modality, detecting slipping rib syndrome in 89% of cases and ruling it out in 100% of negative cases 9, 2
• Ultrasound can identify rib and cartilage anatomic abnormalities plus soft tissue swelling 6
• Definitive diagnosis confirmed by pain relief with intercostal nerve block 4
• Surgical visualization of altered anatomy provides ultimate confirmation 4

Management Differences

Costochondritis/Tietze Syndrome:

• First-line: 1-2 week course of NSAIDs 1
• Second-line: Add low-dose colchicine if symptoms persist despite NSAIDs 1
• Acetaminophen alternative if NSAIDs contraindicated 1
• Topical lidocaine patches for localized relief with minimal systemic effects 1
• Ice pack application as adjunctive therapy 1
• Reassessment required if pain persists to rule out other causes 1

Slipping Rib Syndrome:

• Initial conservative therapy: Rest, ice, and NSAIDs 4, 6
• Physical therapy and osteopathic manipulative treatment 6
• Intercostal nerve blocks with local anesthetics and steroids provide both diagnostic confirmation and symptomatic relief 4, 6
• Botulinum toxin injections attempted for refractory cases 6
• Emerging role for prolotherapy 6
• Surgical costal cartilage excision is the definitive treatment for refractory pain 4, 6, 7
• Surgery should be considered early (median 2 years from symptom onset in one series) to avoid unnecessary diagnostic delays 7
• Surgical excision shows excellent pain relief results 4, 7

Critical Pitfalls to Avoid

• Do not use nitroglycerin response as a diagnostic criterion, as relief does not distinguish cardiac from non-cardiac chest pain 1
• Do not delay cardiac evaluation in high-risk patients, as coronary artery disease can coexist with musculoskeletal findings 1
• Do not miss slipping rib syndrome by failing to perform the hooking maneuver in patients with lower chest wall pain and clicking sensations 5, 6
• Do not subject slipping rib syndrome patients to prolonged conservative therapy when surgical excision provides definitive cure 7
• Recognize that slipping rib syndrome is often underdiagnosed and requires high clinical suspicion 4, 5