What is the likely cause of a clicking or popping sensation over a rib and what is the appropriate evaluation and management?

Clicking Sound Over Rib: Diagnosis and Management

Most Likely Diagnosis

A clicking or popping sensation over a rib is most likely slipping rib syndrome (SRS), a condition caused by hypermobility of the false ribs (8-10) where defective costal cartilage allows the rib to subluxate and slip under the adjacent rib, impinging the intercostal nerve. 1, 2

Key Distinguishing Features

Slipping Rib Syndrome

• Location: Affects ribs 8-10 (the false ribs not connected to sternum), typically in the lower chest or subcostal region 1, 3
• Characteristic symptom: Clicking, popping, or slipping sensation with movement or palpation 4, 3, 2
• Pain pattern: Sharp pain exacerbated by activity, specific movements, or deep breathing 4, 3
• Physical exam: Mobile or popping rib with palpation, reproducible pain at the affected cartilage, possible chest wall asymmetry 4, 5

Costochondritis (Alternative Diagnosis)

• Location: Affects ribs 3-7 at costochondral junctions, typically retrosternal (52%) or left-sided (69%) 1
• No clicking: Pain is reproducible with palpation but without rib mobility, clicking, or asymmetry 1
• Pain quality: Stinging (53%) or pressing (35%), sharp and stabbing 1

Diagnostic Approach

Clinical Diagnosis

The diagnosis of SRS is primarily clinical based on history and physical examination findings. 2

Perform the "hooking maneuver": Hook your fingers under the lower costal margin and pull anteriorly—this reproduces the pain and clicking sensation in SRS 3, 6

Imaging Strategy

Dynamic ultrasound is the imaging modality of choice for confirming SRS, with 89% sensitivity and 100% negative predictive value. 7, 1

• First-line imaging: Chest radiography to exclude fracture, infection, or neoplasm if clinically indicated 7, 8
• Confirmatory test: Dynamic (real-time) ultrasound showing the rib slipping over the adjacent rib during the examination 7, 1
• Avoid: MRI is not appropriate for isolated chest wall pain and has no supporting evidence for this indication 9
• CT chest: Reserved only for suspected malignancy or other pulmonary pathology 8, 9

Critical Pitfall

Standard chest radiographs and rib series will be normal in SRS because the pathology involves cartilage hypermobility, not bony fracture. 7 Patients often undergo months to years of unnecessary testing before diagnosis 4, 3, 2

Management Algorithm

Conservative Management (First-Line)

• NSAIDs: 1-2 week course as first-line therapy 1, 8
• Acetaminophen: Regular dosing, especially if NSAIDs contraindicated 8
• Activity modification: Avoid postures and movements that trigger the clicking and pain 3
• Reassurance: Explain the benign nature of the condition 3

Interventional Options (Refractory Cases)

• Intercostal nerve block: For persistent pain despite conservative measures 3, 2
• Surgical excision: Resection of the affected costal cartilage(s) is the definitive treatment with good pain relief outcomes 4, 2, 5
  • Median time from symptom onset to surgery in one series was 2 years, highlighting the importance of early diagnosis 4
  • All excised cartilages show gross abnormalities at surgery 4
  • Complications are rare, and most patients achieve complete symptom resolution 4, 5

When to Consider Surgery Early

Surgical excision should be considered early in patients with debilitating pain to avoid unnecessary diagnostic tests and years of suffering. 4, 2

Important Caveats

• Sternocostal variant: A rare form affects the sternocostal junction (ribs 1-7) with similar clicking at the sternal attachment—treated similarly with localized cartilage excision 5
• Cardiac evaluation: In patients >35 years or with cardiac risk factors presenting with chest pain, obtain an ECG within 10 minutes to exclude acute coronary syndrome before attributing symptoms to musculoskeletal causes 1
• Coexisting pathology: Cardiac disease can coexist with musculoskeletal findings—do not delay cardiac workup in high-risk patients 1
• Nitroglycerin response: Relief with nitroglycerin does NOT differentiate cardiac from non-cardiac chest pain and should not be used diagnostically 1