Slipping Rib Syndrome: Difference between revisions

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The subluxating rib can irritate several structures. This can result in the clinical presentation of the slipping rib syndrome. This structures can be:<ref name=":10">Malghem J. et al.; Costal Cartilage Fractures as Revealed on CT and Sonography; American Journal of Roentgenology, 2001 (LoE 2B) </ref><ref name=":11">Cranfield K.A.W. et al.; The twelfth rib syndrome;Journal of Pain and Symptom Management, 1997. (LoE 3B)</ref><ref name=":9">Kumar R. et al.; The painful rib syndrome; Indian Journal of Anaesthesia, 2013 (LoE 4)</ref><br>• Intercostal muscles: External and internal intercostal muscles and innermost intercostal muscle<br>• Lower costal cartilage <br>• V. intercostal anterior and posterior<br>• A. intercostal anterior and posterior<br>• Intercostal nerves
The subluxating rib can irritate several structures. This can result in the clinical presentation of the slipping rib syndrome. This structures can be:<ref name=":10">Malghem J. et al.; Costal Cartilage Fractures as Revealed on CT and Sonography; American Journal of Roentgenology, 2001 (LoE 2B) </ref><ref name=":11">Cranfield K.A.W. et al.; The twelfth rib syndrome;Journal of Pain and Symptom Management, 1997. (LoE 3B)</ref><ref name=":9">Kumar R. et al.; The painful rib syndrome; Indian Journal of Anaesthesia, 2013 (LoE 4)</ref><br>• Intercostal muscles: External and internal intercostal muscles and innermost intercostal muscle<br>• Lower costal cartilage <br>• V. intercostal anterior and posterior<br>• A. intercostal anterior and posterior<br>• Intercostal nerves


Further, local inflammation and/or muscle spasms of the multifidi, rotatores and levator costalis can occur <ref name=":12">Bahram J. et al.; Ribs don’t sublux, ribs don’t “go out” … so what’s going on?; Advanced Physical Therapy Education Institute, 2015 (LoE: 4)</ref>. <br>
Further, local inflammation and/or muscle spasms of the multifidi, rotatores and levator costalis can occur <ref name=":12">Bahram J. et al.; Ribs don’t sublux, ribs don’t “go out” … so what’s going on?; Advanced Physical Therapy Education Institute, 2015 (LoE: 4)</ref>.  


== Epidemiology/Etiology  ==
== Epidemiology/Etiology  ==
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The intense pain is usually described by patients as a intermittent sharp stabbing pain followed by a constant monotonous pain that may last from several hours to many weeks <ref name=":11" /><ref name=":18">Mooney D.P. et al.; Slipping rib syndrome in childhood; J. Pediatr. Surg., 32 (7) (1997), pp. 1081–1082 (LoE 3B) </ref><ref name=":5" /><ref name=":19">Arroyo JF, Vine R, Reynaud C, Michel JP. Slipping rib syndrome: don’t be fooled. Geriatrics. 1995;50:46–49. (LoE 3A)</ref><ref name=":20">Copeland GP, Machin DG, Shennan JM. Surgical treatment of the ‘‘slipping rib syndrome.’’ Br J Surg. 1984;71:522–523. (LoE 1A)</ref>.The range of severity of pain varies from being a minor nuisance, moderately severe to interfering with activities of daily living <ref name=":5" /><ref name=":8" /><ref name=":1" />.The pain may also be reported to radiate from the costochondral area to the chest or to the same level in the back <ref name=":5" />.
Pain
* Usually described by patients as a intermittent sharp stabbing pain followed by a constant monotonous pain that may last from several hours to many weeks <ref name=":11" /><ref name=":18">Mooney D.P. et al.; Slipping rib syndrome in childhood; J. Pediatr. Surg., 32 (7) (1997), pp. 1081–1082 (LoE 3B) </ref><ref name=":5" /><ref name=":19">Arroyo JF, Vine R, Reynaud C, Michel JP. Slipping rib syndrome: don’t be fooled. Geriatrics. 1995;50:46–49. (LoE 3A)</ref><ref name=":20">Copeland GP, Machin DG, Shennan JM. Surgical treatment of the ‘‘slipping rib syndrome.’’ Br J Surg. 1984;71:522–523. (LoE 1A)</ref>.
* Range of severity of pain varies from being a minor nuisance, moderately severe to interfering with activities of daily living <ref name=":5" /><ref name=":8" /><ref name=":1" />.
* May also be reported to radiate from the costochondral area to the chest or to the same level in the back <ref name=":5" />.
* Exacerbated by certain postures and movements: lying or turning in bed, rising from a chair, driving, stretching, reaching, lifting, bending, twisting the trunk, coughing, walking, or bearing loads <ref name=":5" /><ref name=":6" /><ref>Machin D.G. et al.; Twelfth rib syndrome: a differential diagnosis of loin pain; British Medical Journal, 1983 (LoE 4) </ref><ref name=":15" /><ref name=":3" /><ref name=":14" /><ref name=":19" /><ref name=":20" />. 
* May affect sporting activities involving trunk movements and deep breathing, but in particular running, horseback riding <ref name=":18" />, arm abduction, or swimming <ref name=":1" />. Pain may be severe enough to make patients stop playing sports.
* Visceral innervation converges at the same spinal cord levels as slipping ribs and intercostal nerves and this close association of the intercostal nerves and the sympathetic system may also cause a variety of somatic and visceral complaints, such as biliary or renal colic <ref name=":21">Bass J. et al.; Slipping Rib Syndrome; Journal of the National Medical Association, 1979;71(9):863-865. (LoE 4) </ref><ref name=":11" /><ref name=":18" /><ref name=":1" />.


The pain is also exacerbated by certain postures and movements: lying or turning in bed, rising from a chair, driving, stretching, reaching, lifting, bending, twisting the trunk, coughing, walking, or bearing loads <ref name=":5" /><ref name=":6" /><ref>Machin D.G. et al.; Twelfth rib syndrome: a differential diagnosis of loin pain; British Medical Journal, 1983 (LoE 4) </ref><ref name=":15" /><ref name=":3" /><ref name=":14" /><ref name=":19" /><ref name=":20" />. Thus, this condition may affect sporting activities involving trunk movements and deep breathing, but in particular running, horseback riding <ref name=":18" />, arm abduction, or swimming <ref name=":1" />. Pain may be severe enough to make patients stop playing sports.
== Differential Diagnosis ==
The slippage or movement of the rib can lead to an irritation of the intercostal nerve, strain of the intercostal muscles, sprain of the lower costal cartilage or general inflammation in the affected area <ref name=":5" /> . This causes severe pain and patients may describe a slipping movement or a ‘popping’, ‘clicking’ or ‘giving way’ sensation <ref name=":2" /><ref name=":3" /><ref name=":1" />.


Visceral innervation converges at the same spinal cord levels as slipping ribs and intercostal nerves. Because of this close association of the intercostal nerves and the sympathetic system, slipping rib syndrome may also cause a variety of somatic and visceral complaints, such as biliary or renal colic <ref name=":21">Bass J. et al.; Slipping Rib Syndrome; Journal of the National Medical Association, 1979;71(9):863-865. (LoE 4) </ref><ref name=":11" /><ref name=":18" /><ref name=":1" />.
The differential diagnosis of slipping rib syndrome includes a variety of conditions
* cholecystitis
* esophagitis
* gastric ulcers
* stress fractures
* muscle tears
* pleuritic chest pain
* bronchitis
* asthma
* costochondritis, or Tietze syndrome
* appendicitis
* heart conditions
* bone metastases<ref name=":7">Healthline [https://www.healthline.com/health/slipping-rib-syndrome#symptoms Slipping Rib Syndrome] Available from:https://www.healthline.com/health/slipping-rib-syndrome#symptoms (last accessed 6.5.2020)</ref>


<br>
== Diagnostic Procedures  ==


= Differential Diagnosis  =
Slipping rib syndrome is difficult to diagnose because the symptoms resemble other conditions. First take a medical history and ask about symptoms, including when they started and if anything makes them worse.


The differential diagnosis of slipping rib syndrome includes a variety of conditions, such as (1) cholecystitis, (2) esophagitis, (3) gastric ulcer, (4) hepato-splenic abnormalities, (5) rib fracture, (6) inflammation of the chondral cartilage, and (7) pleuritic chest pain <ref name=":7">Taubman B. et al.; Slipping rib syndrome as a cause of chest pain in children; Clin. Pediatr., 35 (1996), pp. 403–405 (LoE 2B)</ref>.  
The hooking maneuver that helps diagnose slipping rib syndrome. To perform this test hooks your fingers under the rib margins and then move them upward and back - If this test is positive and causes the same discomfort, usually no need to do any additional tests such as an X-ray or MRI scan<ref name=":7" />.  


Other differential diagnosis of slipping rib syndrome includes <ref name=":5" /><ref name=":22">Migliore M. et al.; Flank pain caused by slipping rib syndrome; The Lancet, 2014 (LoE 4) </ref><ref name=":13" />:<br>• Stress fracture<br>• Pleuritis<br>• [http://www.physio-pedia.com/Pneumonia Pneumonia]<br>• Radiculitis<br>• [http://www.physio-pedia.com/Herpes_Zoste Herpes zoster]&nbsp;<br>• [http://www.physio-pedia.com/Abdominal_Aortic_Aneurysm Aortic aneurysm&nbsp;]<br>• [http://www.physio-pedia.com/Tietzes Tietze syndrome]&nbsp;(syndrome typically affects one joint and is associated with swelling)<br>• Costochondritis (may affect numerous costochondral joints with no swelling)<br>• Abscesses<br>• Bone metastases<br>• Muscle tears<br>• Abdominal diseases<br> 
== Outcome Measures ==
* The physiotherapist can reproduce chest pain by palpation of the ribs and chest wall <ref name=":5" />.
* Hooking manoeuvre - Reproduce the symptoms. This is a relatively simple clinical test where the clinician places his or her fingers under the lower costal margin and pulls the hand in an anterior direction. Pain or clicking indicates a positive test <ref name=":5" /><ref name=":21" /><ref name=":16" /><ref name=":17" />
* [[Patient Specific Functional Scale|Patient-specific functional scale]] ( PSFS)<ref name=":24">Richard B. Westrick et al.; EVALUATION AND TREATMENT OF MUSCULOSKELETAL CHEST WALL PAIN IN A MILITARY ATHLETE; Int J Sports Phys Ther. 2012 June; 7(3): 323–332 (LoE 4) </ref>.
* The Global rating of change (GROC) - To measure the patient’s subjective rate of improvement, the GROC has been stated to be reliable <ref>Proulx A. M. et al.; Costochondritis: Diagnosis and treatment; American Family Physician; 80(6), 617–620. doi:10.1016/S0015-1882(09)70196; 2009 (LoE 5)</ref>.


= Diagnostic Procedures  =
== Examination ==
 
The diagnosis of the slipping rib syndrome is one of exclusion, abdominal or thoracic diseases need to be ruled out <ref name=":5" /><ref name=":21" />. The slipping rib syndrome can be diagnosed by sonography and physical examination. It is often overlooked because of the lack of available paraclinical procedures and because CT scans have almost replaced a thorough clinical examination for patients with flank pain <ref name=":5" /><ref name=":13" /><ref name=":17" />.
 
• '''Sonography'''
 
Interchondral joints can be precisely depicted with sonography. Sonography with a high-frequency linear probe shows accurately the luxation of the cartilaginous rib, which can be triggered by Valsalva maneuvers <ref name=":13" />.
Sonography is also used to exclude other causes of thoracic pain such as rib fractures, Tietze syndrome, abscesses, metastases, muscle tears, pleuritis, and abdominal diseases <ref name=":13" /><ref>Paik S.H. et al.; High-Resolution Sonography of the Rib : Can fracture and Metastasis Be Differentiated?; American Journal of Roentgenology, 2005 (LoE 2B) </ref>.
 
• '''Physical examination'''
 
Palpation of the affected rib will reveal a tender spot on the costal margin and reproduce the specific pain. The hooking maneuver, first described in 1977, is a relatively simple clinical test which can be used to diagnose the syndrome. It can be combined with an intercostal nerve block , to see if the pain can be relieved. Also the Valsalva Maneuver can be used. For more information see outcome measures and examination <ref name=":5" /><ref name=":21" />.
 
• '''Radiologic investigation'''
 
Generally radiologic imaging is not useful in the diagnosis of slipping rib syndrome, but it can be used to exclude the other conditions in the differential diagnosis<ref name=":5" />.
 
Laparoscopies have been performed in attempts to unsuccessfully diagnose and treat the upper abdominal pain <ref name=":4" />.
 
<br>
 
= Outcome Measures =
* Evaluation of the patient
To look for an association between certain movements or postures and pain intensity <ref name=":5" />.
* Determine if the patient has experienced recent trauma (although not always present). 
The physiotherapist can reproduce chest pain by palpation of the ribs and chest wall <ref name=":5" />.
* Hooking maneuver
Reproduce the symptoms (see characteristics) with the hooking maneuver. This is a relatively simple clinical test where the clinician places his or her fingers under the lower costal margin and pulls the hand in an anterior direction. Pain or clicking indicates a positive test <ref name=":5" /><ref name=":21" /><ref name=":16" /><ref name=":17" />(See examination).
* [http://www.physio-pedia.com/Cervicothoracic_tests Valsalva maneuver]
The physiotherapist can look for rib restriction by observing a lack of symmetry of the posterior chest wall movements on deep breathing. During the Valsalva maneuver, it is possible to palpate the slipping of the rib as the abdominal muscles contract <ref name=":13" /><ref name=":23">Ronga A. et al.; Development and validation of a clinical prediction rule for chest wall syndrome in primary care; BiomedCentral, 2012. (LoE 2B)</ref> (See examination).
* Patient-specific functional scale ( PSFS) 
The PSFS has been stated to be a valid, reproducible, and responsive outcome measure for patients with neck pain, back pain, and upper quarter complaints <ref name=":24">Richard B. Westrick et al.; EVALUATION AND TREATMENT OF MUSCULOSKELETAL CHEST WALL PAIN IN A MILITARY ATHLETE; Int J Sports Phys Ther. 2012 June; 7(3): 323–332 (LoE 4) </ref>.
* The Global rating of change (GROC) 
To measure the patient’s subjective rate of improvement, the groc has been stated to be reliable <ref>Proulx A. M. et al.; Costochondritis: Diagnosis and treatment; American Family Physician; 80(6), 617–620. doi:10.1016/S0015-1882(09)70196; 2009 (LoE 5)</ref>.
 
<br>
 
= Examination  =


The physiotherapist looks for an association between certain movements or postures and pain intensity (signs and symptoms), determines if the patient has experienced recent trauma (not always present), constrained posture, or previous abdominal surgery and reproduces the symptoms (eg, pain, clicking) <ref name=":5" /><ref name=":13" />.<br>
The physiotherapist looks for an association between certain movements or postures and pain intensity (signs and symptoms), determines if the patient has experienced recent trauma (not always present), constrained posture, or previous abdominal surgery and reproduces the symptoms (eg, pain, clicking) <ref name=":5" /><ref name=":13" />.<br>


1. '''Signs and symptoms'''  
1. '''Signs and symptoms'''
* Classically, the pain occurs in the upper abdomen or lower chest, in the abdominal wall and above the anterior costal margin.
* At that place the involved costal cartilage moves more freely than normal and the examiner can typically feel tenderness<ref name=":16" /><ref name=":13" />. A painful click is sometimes felt over the tip of the involved costal cartilage with certain movements.
* [https://www.youtube.com/watch?v=j38Sfn_1syU <sup></sup>][https://www.youtube.com/watch?v=SC29GbWbN-M <sup></sup>]Palpation - At physical examination, the most common finding in a case of slipping rib syndrome is the tenderness above the costal margin. The physiotherapist can reproduce chest pain by palpation <ref name=":6" /><ref name=":17" /><ref name=":23">Ronga A. et al.; Development and validation of a clinical prediction rule for chest wall syndrome in primary care; BiomedCentral, 2012. (LoE 2B)</ref><ref name=":1" />.
* The Hooking manoeuvre - positive test


Classically, the pain occurs in the upper abdomen or lower chest, in the abdominal wall and above the anterior costal margin. At that place the involved costal cartilage moves more freely than normal and the examiner can typically feel tenderness<ref name=":16" /><ref name=":13" />.
== Medical Management  ==
A painful click is sometimes felt over the tip of the involved costal cartilage with certain movements. See clinical presentation for more information.
In some cases, slipping rib syndrome resolves on its own without treatment. Home treatment may include:
* resting
* avoiding strenuous activities
* applying heat or ice to the affected area
* taking a painkiller like acetaminophen (Tylenol) or a nonsteroidal anti-inflammatory drug (NSAID), such as ibuprofen (Advil, Motrin IB) or naproxen (Aleve)
* doing stretching and rotation exercises
If the pain continues despite taking a painkiller:
* a corticosteroid injection to help reduce the swelling
* an intercostal nerve block (an injection of an anesthetic in the intercostal nerve) to relieve pain
* physical therapy
If the condition persists or causes severe pain, surgery may be recommended. The procedure, known as costal cartilage excision, has been shown in clinical studies to be an effective treatment for slipping rib syndrome.<ref name=":7" />


2. '''Physical examination'''
== Physical Therapy Management  ==
Exercises to Avoid


There are two tests for investigating Slipping rib syndrome: the Hooking maneuver and Valsalva maneuver. Palpation or compression can reproduce chest pain when the patient has the slipping rib syndrome. Also the sit-up test is positive in reproducing the pain <ref name=":21" />.
Because of the inherent instability of joints, exercises that put direct pressure on your chest should be avoided. Pushups or exercises that involve pitching or throwing motions increase risk. Sports that involve a potential for contact with other athletes such as football or basketball should be avoided until the condition resolves.
* The hooking maneuver 
This test was described by Heinz and Zavala <ref>Heinz G.J. et al.; Slipping rib syndrome; JAMA1977; 237(8): 794-5 (LoE 5)</ref>. In this test the patient lies on his unaffected side, while the therapist hooks his fingers under the lower costal margin and pulls anteriorly (anterior stretching). A positive test reproduces exactly the patient’s pain and can cause a clicking sound <ref name=":5" /><ref name=":21" />. The condition is almost always unilateral, thus performing the maneuver on the contralateral side will serve as a control <ref name=":21" /><ref name=":16" /><ref name=":17" />. [https://www.youtube.com/watch?v=j38Sfn_1syU <sup></sup>https://www.youtube.com/watch?v=j38Sfn_1syU]
* Valsalva maneuver
During the Valsalva maneuver the patiënt should forceful exhale against a closed airway (closing mouth and nose) and hereby contract the rectus muscle. During this contraction there is an overlapping movement of the rib above, when the contraction increases, the ribs are slowly pushed in and simultaneously a rebound effect is perceptible at the very moment the patient feels pain. The slipping movement of the affected rib along the margin of the rib above, can be felt as a click under the fingers of the examiner <ref name=":13" /><ref name=":23" />.  


https://www.youtube.com/watch?v=SC29GbWbN-M
Early Exercise
* [https://www.youtube.com/watch?v=SC29GbWbN-M <sup></sup>]Palpation
At physical examination, the most common finding in a case of slipping rib syndrome is the tenderness above the costal margin. The physiotherapist can reproduce chest pain by palpation <ref name=":6" /><ref name=":17" /><ref name=":23" /><ref name=":1" />.


<br>
In the beginning stage of recovery, segmental breathing is used to gain more mobility in the ribs.


= Medical Management  =
Pressure is applied, usually by a therapist, to where the ribs join the sternum. Client needs to breathe in and expand lungs while the pressure is applied. The pressure is moved from one segment to another while long slow breaths are drawn in to put pressure against the therapist's hand.


The treatment of slipping rib syndrome is possible by a multidisciplinary approach. It consists of surgeons, pain clinic specialists, radiologists, psychiatrists, and physiotherapists <ref name=":22" /> (LoE 4).
Expanding Exercises
In the event of short-term pain relief, the more invasive procedures can be considered, which may be determined by the patient <ref name=":21" /> (LoE4). These could include intercostal nerve blocks, percutaneous dorsal root ganglion radiofrequency thermo-coagulation performed under local anaesthetic with X-ray screening, and rarely rib excision <ref name=":22" /><ref name=":24" /> (LoE 4).
Further medical management can include:
* Recognition of the condition and reassurance <ref name=":25">Gregory P.L. et al.; Musculoskeletal problems of the chest wall in athletes; Sports Med. 2002 (LoE 3A)</ref><ref name=":16" /><ref name=":13" /> (LoE 3A,5,4). The patient can be taught to avoid movements and positions that provoke the pain. (LoE 3A)
* Local anaesthetic (intercostal) nerve blocks and long-acting steroïd to the affected rib tip(s) <ref name=":16" /> (LoE 5). Nerve blocks involve the injection of an anesthetic, a corticosteroid and other agents onto or near a nerve, usually for pain relief or anesthesia. It usually lasts hours or days. The procedure can easily be repeated if required. The immediate relief afforded by this procedure is often sufficient to reassure the patient of the ‘musculo-skeletal’ pain diagnosis <ref>Stephen R. Keoghane et al.; TWELFTH RIB SYNDROME: A FORGOTTEN CAUSE OF FLANK PAIN; BJUI Volume 103, Issue 5 March 2009, Pages 569–570 (LoE 2C)</ref> (LoE 2C). Local anaesthetic nerve blocks were proven useful in some studies <ref name=":25" /><ref name=":17" /> (LoE 3A,5).
** ''<sub>Local anaesthetic and long-acting steroid (depomedrone 40 mg in 5 mL 0.25–0.5% bupivacaine) <ref name=":25" /><ref name=":24" /> (LoE 3A,4)</sub>''   
** ''<sub>Supplementation of corticosteroids can give varying amounts of relief <ref name=":25" /><ref name=":21" /> (LoE 3A,4).</sub>''   


* Analgesics <ref name=":16" />: NSAID might be value <ref name=":1" /> (LoE 5).      
To increase mobility around the rib joints
[[File:Picture_1-_rib_mwm.png|right|frameless|286x286px]]
Thoracic extension and flexion exercises can be used ie arching the back and allowing rib cage to expand, then bend forward and compress chest and ribs. Only perform to the limits of comfort.  


* Wiring of a ‘slipping rib’ through the costo-chondral junction has been described but is rarely required <ref name=":17" /> (LoE 5).
Seated rotation exercises can be done by sitting and turning chest and shoulders as far one side as you can ie like turning and looking over your shoulder, then turning to the other side. Use caution advice client to go slowly to avoid injury.
 
* Rib excision <ref name=":17" /><ref>N. Gonzales Tempranoet al.;  Slipping rib syndrome: An aggressive but effective treatment; Anales del Sistema sanitario de Navarra, 2014. (LoE 4)</ref> (LoE 5,4):  At failure of this general management, removal of the anterior end of the rib and costal cartilage may be performed. This has many reports of successful outcomes, reported in the literature (LoE 4). They make an incision along the costal margin (directly over the point of maximum tenderness). The eighth, ninth or tenth ribs are almost always involved. You must take care to inspect all three ribs and perform appropriate resection.
* Pulse radiofrequency treatment of dorsal root ganglion<ref name=":17" /><ref>Chan P. et al.; Assessing the effectiveness of ‘pulse radiofrequency treatment of dorsal root ganglion’ in patients with chronic lumbar radicular pain: study protocol for a randomized control trial; BiomedCentral, 2012.(LoE 1B)</ref>(LoE 5,1B).
* Percutaneous dorsal root ganglion radiofrequency thermo-coagulation performed under local anaesthetic with X-ray screening. <br><br>
 
= Physical Therapy Management  =


'''Specific for slipping rib syndrome'''  
'''Specific for slipping rib syndrome'''  
* Recognition and education of the condition <ref name=":5" /><ref name=":25" /><ref name=":16" /><ref name=":13" />. The patient can be taught to avoid movements and positions that provoke the pain without creating asymmetric overcharge in other regions of the body (LoE 3A).
* Recognition and education of the condition <ref name=":5" /><ref name=":25">Gregory P.L. et al.; Musculoskeletal problems of the chest wall in athletes; Sports Med. 2002 (LoE 3A)</ref><ref name=":16" /><ref name=":13" />. The patient can be taught to avoid movements and positions that provoke the pain without creating asymmetric overcharge in other regions of the body
* Reassurance of the benign nature of the disease combined with explanation and advice concerning postural avoidance <ref name=":25" /> (LoE 3A).
* Reassurance of the benign nature of the disease combined with explanation and advice concerning postural avoidance <ref name=":25" />
* Using heat (hot packs) or cold (ice), ultrasound and NSAID to the affected rib might be of value in relieving the pain for intermittent periods <ref name=":5" /><ref name=":17" /><ref name=":1" /> (LoE 5).
* Using heat (hot packs) or cold (ice), ultrasound and NSAID to the affected rib might be of value in relieving the pain for intermittent periods <ref name=":5" /><ref name=":17" /><ref name=":1" />.
* Manual therapy by a chiropractor or physical therapist: manipulation of the costovertebral joint and electric stimulation can help manage the pain, but probably no long term relief <ref name=":5" />.
* Manual therapy: manipulation of the costovertebral joint and electric stimulation can help manage the pain, but probably no long term relief <ref name=":5" />.
* The therapeutic attitude is far from consolidated. Most authors advise treatment depending on the intensity of pain. In moderate pain, we recommend wearing an elastic bandage around the thorax for 1 to 2 weeks, associated with pain treatment and psychological support <ref>Roche N. et al.; Syndrome de la cöte glissante ou syndrome de Cyriax; La Presse Médicale, 2010 (LoE 4)</ref> (LoE 4).
* <u>Taping</u> of ribs can possibly provide some temporary relief.[[File:30_3.jpg|right|frameless]]To decide on the location and direction of taping, apply a manual superior compression force through the postero-lateral aspect of the rib cage. Now ask the patient to take in a deep breath or rotate. If the patient notes a significant improvement in symptoms, then apply the tape at that level <ref name=":12" /><sup>.</sup>
* Wiring of a ‘slipping rib’ through the costo-chondral junction has been described but is rarely required <ref name=":16" /><ref name=":17" />.
*<u>Rib mobilization with movement (MWM)</u> as proposed by Brian Mulligan.    The range of motion and pain level are evaluated. A cranial glide is applied over the lateral aspect of the rib above the painful region. While sustaining this rib elevation (unloading), the patient is asked to rotate again while ROM and pain are once again evaluated. If there is no change, the technique is repeated on a rib above or below. If MWM on a rib at a specific level is found to reduce or eliminate the pain, it is repeated 10 times <ref name=":12" />.
*<u>A home program of self MWM</u> may be provided. Instruction: “lift the rib up with the web space of one hand and actively rotate towards the painful direction, repeat as often as necessary”. The goal is to move the irritated costovertebral joint without pain as often as possible to reduce both the protective muscle spasm and the local inflammation <ref name=":12" />  




There is a lack of articles that describe the physical treatment of slipping rib syndrome. For that reason we used some other conditions that have a connection to this disease.
'''Treatment of a Subluxated Rib'''<ref name=":12" />


'''Chest Wall Syndrome'''
A subluxating rib is a symptom of slipping rib syndrome  
 
We found an article that gives some guidance of moderate evidence (LoE 3A) of the physical treatment of Chest Wall Syndrome (Generic Term of Slipping Rib Syndrome). This article suggests as part of the treatment to give the patient a good explanation of the mechanism of the disease and proposes a logical postural avoidance. With this approach the patient is limited in his movements and may better tolerate the discomfort. Strapping the ribs has provided limited relief in a few cases <ref name=":25" />(LoE 3A).
Manipulative techniques may treat this syndrome, for example the manipulation of the costovertebral joint in combination with anaesthetic nerve blocks and/or corticosteroids injections <ref name=":25" />.
 
'''Treatment of a Subluxated Rib'''<ref name=":12" />
 
A subluxating rib is a symptom of slipping rib syndrome, that’s the reason why we can inspire us on this article with low evidence (LoE 5).
* <u>Muscle training</u> of the small local muscles, such as the Multifidi, rotatores and levator costalis in an attempt to stabilize the sprained costovertebral and costotransversal joints (LoE 5).    For example: Core stability training.  
* <u>Muscle training</u> of the small local muscles, such as the Multifidi, rotatores and levator costalis in an attempt to stabilize the sprained costovertebral and costotransversal joints (LoE 5).    For example: Core stability training.  
* <u>Rib mobilization with movement (MWM)</u> as proposed by Brian Mulligan.    The range of motion and pain level are evaluated. A cranial glide is applied over the lateral aspect of the rib above the painful region. While sustaining this rib elevation (unloading), the patient is asked to rotate again while ROM and pain are once again evaluated. If there is no change, the technique is repeated on a rib above or below. If MWM on a rib at a specific level is found to reduce or eliminate the pain, it is repeated 10 times <ref name=":12" />.   
* <u>Rib mobilization with movement (MWM)</u> as proposed by Brian Mulligan.    The range of motion and pain level are evaluated. A cranial glide is applied over the lateral aspect of the rib above the painful region. While sustaining this rib elevation (unloading), the patient is asked to rotate again while ROM and pain are once again evaluated. If there is no change, the technique is repeated on a rib above or below. If MWM on a rib at a specific level is found to reduce or eliminate the pain, it is repeated 10 times <ref name=":12" />.   
https://www.youtube.com/watch?v=cvPIKZ5IsJw  
https://www.youtube.com/watch?v=cvPIKZ5IsJw
 
[[File:Picture 1- rib mwm.png|286x286px]]<br><sup>Picture 1: rib mwm</sup> <ref name=":12" />
* <u>A home program of self MWM</u> may be provided.
Instruction: “lift the rib up with the web space of one hand and actively rotate towards the painful direction, repeat as often as necessary”. The goal is to move the irritated costovertebral joint without pain as often as possible to reduce both the protective muscle spasm and the local inflammation <ref name=":12" /> (LoE 5). <br>[[Image:30 2.jpg]]<br><sup></sup><sup>Picture 2: rib self-mwm</sup> <ref name=":12" />
* <sup></sup><u>Taping</u> of ribs can possibly provide some temporary relief. 
To decide on the location and direction of taping, apply a manual superior compression force through the postero-lateral aspect of the rib cage. Now ask the patient to take in a deep breath or rotate. If the patient notes a significant improvement in symptoms, then apply the tape at that level <ref name=":12" /><sup>.</sup>
 
[[Image:30 3.jpg]]<br><sup>Picture 3: rib taping step #1 and #2 </sup> <ref name=":12" />
 
[[Tietzes|'''Tietze Syndrome''']] <br>This condition has also as purpose restoring normal thoracic and rib joint movement. Diversified manipulation (high-velocity, low-amplitude [HVLA]) of posterior joints, and manipulation of anterior joints by means of an activator, helps restoring the normal thoracic and rib joint movement <ref>Gijsbers E. et al.; Clinical presentation and chiropractic treatment of Tietze syndrome: A 34-year-old female with left-sided chest pain; J Chiropr Med., 2011, 10(1),60-63 (LoE: 4) </ref> (LoE 4).   
 
<br>   
 
= Key Research  =
 
[[Www.ncbi.nlm.nih.gov/pubmed|Pubmed]]<br>[[Www.pedro.org|Pedro]]<br>[[Www.webofknowledge.com|Web of knowledge]]
 
Google scholar<br><br>
 
= Resources  =
 
All information used for this physiopedia subject is found on Pubmed, Physiopedia and Web Of Science. 
 
<br> 
 
= Clinical Bottom Line  =
 
The Slipping rib syndrome is an often under diagnosed disease for which sometimes comprehensive diagnostic evaluation is performed. Knowledge of the slipping rib syndrome can lead to quick and simple diagnosis and prevent months or years of chronic complaints. The impingement can cause severe constant monotonous pain and a slipping sensation provoked by several movements. It can also lead to an irritation of the intercostal nerve or problems to structures in that area. This because of the hypermobility of the anterior ends of the false rib costal cartilages often related to trauma. Therefore knowledge of the syndrome is important; it can lead to quick and simple diagnosis. Radiological imaging (sonography) and physical examination could help ruling out other conditions. Treatment of pain should be the first step; by medication or placement of a nerve block. If this is not conclusive a partial resection of the rib can be performed. About the physical management for this condition there isn’t a lot of evidence, only patient education, using heat and ultrasound, using elastic bandage for 1 to 2 weeks associated with pain treatment and psychological support. But there are some advises for other conditions, like chest wall syndrome, Tietze syndrome and subluxating rib, that we can use for the treatment of the slipping rib syndrome. 


'''Summary'''
== <sup></sup><sup></sup>Clinical Bottom Line ==
The Slipping rib syndrome is an often under diagnosed disease for which sometimes comprehensive diagnostic evaluation is performed. 


Slipping rib syndrome remains rarely recognized and frequently undiagnosed or misdiagnosed. Awareness of this condition may prevent extensive and unnecessary diagnostic evaluation and avoid chronic debilitating pain. Persistent lower chest and/or upper abdomen pain after analgesic treatment may suggest the possibility of this disorder. The diagnosis of this syndrome, is a clinical one, based on history and the hooking maneuver. A few cases have been published in the literature, giving no clear consensus about the treatment of this condition. In this overview article, clinical manifestations, diagnostic approach, and treatment modalities of this syndrome will be discussed.
Knowledge of the slipping rib syndrome can lead to quick and simple diagnosis and prevent months or years of chronic complaints.  


'''Keywords'''
The impingement can cause severe constant pain and a slipping sensation provoked by several movements. 


Rib; Slipping; Costal; Hooking
It can also lead to an irritation of the intercostal nerve or problems to structures in that area. 


<br>
Knowledge of the syndrome is important; it can lead to quick and simple diagnosis. 


= References  =
== References  ==


<references />
<references />

Revision as of 08:07, 6 May 2020

Original Editor - User:Jeroen Verwichte

Top Contributors - Tessa de Jongh, Laura Van Der Perren, Areeba Raja, Kim Jackson, Ine Wittevrongel, Gwen Wyns, Jeroen Verwichte, Lucinda hampton, Joao Costa, Claire Knott, Evan Thomas, Anouk Van den Bossche and Khloud Shreif

Introduction[edit | edit source]

Slipping rib syndrome occurs when the cartilage on a person’s lower ribs slips and moves, leading to pain in their chest or upper abdomen.

33.jpg

Slipping rib syndrome goes by many names, including clicking rib, displaced ribs, rib tip syndrome, nerve nipping, painful rib syndrome, and interchondral subluxation, among others.

The condition is slightly more common in women than men. It’s been reported in people as young as 12 years and as old as mid-80s, but it mostly affects middle-aged people.

Overall, the syndrome is considered rare.

Description[edit | edit source]

The slipping rib syndrome [1] is an infrequent cause of thoracic and upper abdominal intermittent pain and is thought to arise from hypermobility of the rib cartilage of the false and floating ribs (these are the most involved in this syndrome) [2] . This may cause a disruption and allows the costal cartilage tips to subluxate and irritate the intercostal nerves [3].

Afbeelding34.jpg
  • It’s an often mis- or underdiagnosed condition and can consequently cause months and even years of unresolved pain.
  • Patients may sometimes describe a “slipping” movement of the ribs or a “popping sensation” [4][5].
  • This condition may mimic many visceral types of discomfort, leading to ordering of many needless laboratory and radiological tests [6].
  • The syndrome can be diagnosed by a clinical test (the hooking maneuver)
  • Often related to direct or indirect trauma (which can be neglected or forgotten), constrained posture and previous abdominal surgery.[7][8][9]

Clinically Relevant Anatomy[edit | edit source]

The slipping rib syndrome is a condition affecting the false ribs.

File:Figure 2 Costovertebral joints.png

There are 3 types of ribs:
• Ribs which are attached to the sternum by costosternal joints and ligaments (true ribs - 1-7th)
• Ribs which are connected to each other through a weaker cartilaginous or fibrous band (false ribs – 8-10th)
• Ribs which aren’t attached to the sternum or to each other (floating ribs – 11-12th)

The condition arises from hypermobility of the anterior ends of the false rib costal cartilages, which often leads to slipping of the affected rib under the superior adjacent rib.This slippage or movement can lead to an irritation of the intercostal nerve, strain of the intercostal muscles, sprain of the lower costal cartilage, or general inflammation in the affected area. Because of their weak connection, there is an increased mobility and greater susceptibility to trauma [7][4].

Anterior rib hypermobility is also likely to cause problems in the posterior thoracic area, because it’s a closed system [7].

The subluxating rib can irritate several structures. This can result in the clinical presentation of the slipping rib syndrome. This structures can be:[10][11][12]
• Intercostal muscles: External and internal intercostal muscles and innermost intercostal muscle
• Lower costal cartilage
• V. intercostal anterior and posterior
• A. intercostal anterior and posterior
• Intercostal nerves

Further, local inflammation and/or muscle spasms of the multifidi, rotatores and levator costalis can occur [13].

Epidemiology/Etiology[edit | edit source]

The ‘Slipping rib syndrome’

  • Affects 20% to 40% of the general population during their lifetime [14][15][16].
  • May occur at any age, more common in middle-aged adults, and is a relatively uncommon, but recognized cause of recurrent lower chest and/or upper abdomen pain in adolescents [17][18][19].
  • Less common in young children because of the flexibility of their chests [11][20][21][12][6].

Caused by

  • Hypermobility of the rib cartilage of the false and floating ribs (mostly involved in this syndrome), this allows the costal cartilage tips to subluxate and irritate the intercostal nerves. This hypermobility is thought to be the primary cause of slipping rib syndrome, and can be the result of thoracic or abdominal trauma (which can be neglected or forgotten) but this does not have to be [7][10][11].
  • Constrained postures and previous abdominal surgery [7][8][22][23].
  • People who play sports with higher risks for chest wall impacts (e.g. rugby, hockey, football players,…) [7].
  • History of minor or significant trauma to the chest.

Characteristics/Clinical Presentation[edit | edit source]

Slipping rib syndrome is presented through the following characteristics [7][8][24][25]:

  • Intense pain in the lower chest or upper abdomen above the costal margin, mostly at the height of the 8th, 9th and 10th ribs (false ribs)
  • A tender spot on the costal margin
  • Reproduction of the pain by pressing the tender spot or by external influences
  • Signs and symptoms are usually unilateral, however there are also cases where patients reported bilateral pain[7][8][26].


Pain

  • Usually described by patients as a intermittent sharp stabbing pain followed by a constant monotonous pain that may last from several hours to many weeks [11][27][7][28][29].
  • Range of severity of pain varies from being a minor nuisance, moderately severe to interfering with activities of daily living [7][21][3].
  • May also be reported to radiate from the costochondral area to the chest or to the same level in the back [7].
  • Exacerbated by certain postures and movements: lying or turning in bed, rising from a chair, driving, stretching, reaching, lifting, bending, twisting the trunk, coughing, walking, or bearing loads [7][8][30][20][5][17][28][29].
  • May affect sporting activities involving trunk movements and deep breathing, but in particular running, horseback riding [27], arm abduction, or swimming [3]. Pain may be severe enough to make patients stop playing sports.
  • Visceral innervation converges at the same spinal cord levels as slipping ribs and intercostal nerves and this close association of the intercostal nerves and the sympathetic system may also cause a variety of somatic and visceral complaints, such as biliary or renal colic [31][11][27][3].

Differential Diagnosis[edit | edit source]

The differential diagnosis of slipping rib syndrome includes a variety of conditions

  • cholecystitis
  • esophagitis
  • gastric ulcers
  • stress fractures
  • muscle tears
  • pleuritic chest pain
  • bronchitis
  • asthma
  • costochondritis, or Tietze syndrome
  • appendicitis
  • heart conditions
  • bone metastases[32]

Diagnostic Procedures[edit | edit source]

Slipping rib syndrome is difficult to diagnose because the symptoms resemble other conditions. First take a medical history and ask about symptoms, including when they started and if anything makes them worse.

The hooking maneuver that helps diagnose slipping rib syndrome. To perform this test hooks your fingers under the rib margins and then move them upward and back - If this test is positive and causes the same discomfort, usually no need to do any additional tests such as an X-ray or MRI scan[32].

Outcome Measures[edit | edit source]

  • The physiotherapist can reproduce chest pain by palpation of the ribs and chest wall [7].
  • Hooking manoeuvre - Reproduce the symptoms. This is a relatively simple clinical test where the clinician places his or her fingers under the lower costal margin and pulls the hand in an anterior direction. Pain or clicking indicates a positive test [7][31][24][26]
  • Patient-specific functional scale ( PSFS)[33].
  • The Global rating of change (GROC) - To measure the patient’s subjective rate of improvement, the GROC has been stated to be reliable [34].

Examination[edit | edit source]

The physiotherapist looks for an association between certain movements or postures and pain intensity (signs and symptoms), determines if the patient has experienced recent trauma (not always present), constrained posture, or previous abdominal surgery and reproduces the symptoms (eg, pain, clicking) [7][22].

1. Signs and symptoms

  • Classically, the pain occurs in the upper abdomen or lower chest, in the abdominal wall and above the anterior costal margin.
  • At that place the involved costal cartilage moves more freely than normal and the examiner can typically feel tenderness[24][22]. A painful click is sometimes felt over the tip of the involved costal cartilage with certain movements.
  • Palpation - At physical examination, the most common finding in a case of slipping rib syndrome is the tenderness above the costal margin. The physiotherapist can reproduce chest pain by palpation [8][26][35][3].
  • The Hooking manoeuvre - positive test

Medical Management[edit | edit source]

In some cases, slipping rib syndrome resolves on its own without treatment. Home treatment may include:

  • resting
  • avoiding strenuous activities
  • applying heat or ice to the affected area
  • taking a painkiller like acetaminophen (Tylenol) or a nonsteroidal anti-inflammatory drug (NSAID), such as ibuprofen (Advil, Motrin IB) or naproxen (Aleve)
  • doing stretching and rotation exercises

If the pain continues despite taking a painkiller:

  • a corticosteroid injection to help reduce the swelling
  • an intercostal nerve block (an injection of an anesthetic in the intercostal nerve) to relieve pain
  • physical therapy

If the condition persists or causes severe pain, surgery may be recommended. The procedure, known as costal cartilage excision, has been shown in clinical studies to be an effective treatment for slipping rib syndrome.[32]

Physical Therapy Management[edit | edit source]

Exercises to Avoid

Because of the inherent instability of joints, exercises that put direct pressure on your chest should be avoided. Pushups or exercises that involve pitching or throwing motions increase risk. Sports that involve a potential for contact with other athletes such as football or basketball should be avoided until the condition resolves.

Early Exercise

In the beginning stage of recovery, segmental breathing is used to gain more mobility in the ribs.

Pressure is applied, usually by a therapist, to where the ribs join the sternum. Client needs to breathe in and expand lungs while the pressure is applied. The pressure is moved from one segment to another while long slow breaths are drawn in to put pressure against the therapist's hand.

Expanding Exercises

To increase mobility around the rib joints

Picture 1- rib mwm.png

Thoracic extension and flexion exercises can be used ie arching the back and allowing rib cage to expand, then bend forward and compress chest and ribs. Only perform to the limits of comfort.

Seated rotation exercises can be done by sitting and turning chest and shoulders as far one side as you can ie like turning and looking over your shoulder, then turning to the other side. Use caution advice client to go slowly to avoid injury.

Specific for slipping rib syndrome

  • Recognition and education of the condition [7][36][24][22]. The patient can be taught to avoid movements and positions that provoke the pain without creating asymmetric overcharge in other regions of the body
  • Reassurance of the benign nature of the disease combined with explanation and advice concerning postural avoidance [36]
  • Using heat (hot packs) or cold (ice), ultrasound and NSAID to the affected rib might be of value in relieving the pain for intermittent periods [7][26][3].
  • Manual therapy: manipulation of the costovertebral joint and electric stimulation can help manage the pain, but probably no long term relief [7].
  • Taping of ribs can possibly provide some temporary relief.
    30 3.jpg
    To decide on the location and direction of taping, apply a manual superior compression force through the postero-lateral aspect of the rib cage. Now ask the patient to take in a deep breath or rotate. If the patient notes a significant improvement in symptoms, then apply the tape at that level [13].
  • Rib mobilization with movement (MWM) as proposed by Brian Mulligan. The range of motion and pain level are evaluated. A cranial glide is applied over the lateral aspect of the rib above the painful region. While sustaining this rib elevation (unloading), the patient is asked to rotate again while ROM and pain are once again evaluated. If there is no change, the technique is repeated on a rib above or below. If MWM on a rib at a specific level is found to reduce or eliminate the pain, it is repeated 10 times [13].
  • A home program of self MWM may be provided. Instruction: “lift the rib up with the web space of one hand and actively rotate towards the painful direction, repeat as often as necessary”. The goal is to move the irritated costovertebral joint without pain as often as possible to reduce both the protective muscle spasm and the local inflammation [13]


Treatment of a Subluxated Rib[13]

A subluxating rib is a symptom of slipping rib syndrome

  • Muscle training of the small local muscles, such as the Multifidi, rotatores and levator costalis in an attempt to stabilize the sprained costovertebral and costotransversal joints (LoE 5). For example: Core stability training.
  • Rib mobilization with movement (MWM) as proposed by Brian Mulligan. The range of motion and pain level are evaluated. A cranial glide is applied over the lateral aspect of the rib above the painful region. While sustaining this rib elevation (unloading), the patient is asked to rotate again while ROM and pain are once again evaluated. If there is no change, the technique is repeated on a rib above or below. If MWM on a rib at a specific level is found to reduce or eliminate the pain, it is repeated 10 times [13].

https://www.youtube.com/watch?v=cvPIKZ5IsJw

Clinical Bottom Line[edit | edit source]

The Slipping rib syndrome is an often under diagnosed disease for which sometimes comprehensive diagnostic evaluation is performed.

Knowledge of the slipping rib syndrome can lead to quick and simple diagnosis and prevent months or years of chronic complaints.

The impingement can cause severe constant pain and a slipping sensation provoked by several movements.

It can also lead to an irritation of the intercostal nerve or problems to structures in that area.

Knowledge of the syndrome is important; it can lead to quick and simple diagnosis.

References[edit | edit source]

  1. ↑ Cyriax E, et al., On various conditions that may simulate the referred pains of visceral disease and a consideration of these from the point of view of cause and effect, Practitioner, 1919 (LoE 5)
  2. ↑ [/www.sciencedirect.com.ezproxy.vub.ac.be%3A2048/science/article/pii/S1526054216300094 Nelson L Turcios] et al.; Slipping Rib Syndrome: An elusive diagnosis; [/www.sciencedirect.com.ezproxy.vub.ac.be%3A2048/science/journal/15260542 Paediatric Respiratory Reviews] [/www.sciencedirect.com.ezproxy.vub.ac.be%3A2048/science/journal/15260542/22/supp/C Volume 22], March 2017, Pages 44–46
  3. ↑ 3.0 3.1 3.2 3.3 3.4 3.5 Saltzman D.A. et al. The slipping rib syndrome in children. Pediatric Anesthesia. Volume 11, Issue 6, November 2001, Pages 740–743 (LoE 4) 
  4. ↑ 4.0 4.1 McBeath A.A. et al.; The rib-tip syndrome; J. Bone Joint Surg. Am., 57 (1975), pp. 795–797 (LoE 3A)
  5. ↑ 5.0 5.1 Mynors J.M. et al.; Clicking rib; Lancet, 1 (1973), p. 674 (LoE 1B)
  6. ↑ 6.0 6.1 Spence E.K. et al.;The slipping rib syndrome; Arch. Surg., 18 (1983), pp. 1330–1332 (LoE 1A)
  7. ↑ 7.00 7.01 7.02 7.03 7.04 7.05 7.06 7.07 7.08 7.09 7.10 7.11 7.12 7.13 7.14 7.15 7.16 7.17 Udermann B.E. et al.; Slipping Rib Syndrome in a Collegiate Swimmer: A Case Report; J Athl Train, 2005 (LoE 3B)
  8. ↑ 8.0 8.1 8.2 8.3 8.4 8.5 Scott E.M. et al.; Painful rib syndrome: a review of 76 cases; Gut 1993 July (LoE 3A)
  9. ↑ Barki J. et al.; Painful rib syndrome (or Cyriax syndrome): Study of 100 patients; Europe PMC, 1996 (LoE 3A)
  10. ↑ 10.0 10.1 Malghem J. et al.; Costal Cartilage Fractures as Revealed on CT and Sonography; American Journal of Roentgenology, 2001 (LoE 2B) 
  11. ↑ 11.0 11.1 11.2 11.3 11.4 Cranfield K.A.W. et al.; The twelfth rib syndrome;Journal of Pain and Symptom Management, 1997. (LoE 3B)
  12. ↑ 12.0 12.1 Kumar R. et al.; The painful rib syndrome; Indian Journal of Anaesthesia, 2013 (LoE 4)
  13. ↑ 13.0 13.1 13.2 13.3 13.4 13.5 Bahram J. et al.; Ribs don’t sublux, ribs don’t “go out” … so what’s going on?; Advanced Physical Therapy Education Institute, 2015 (LoE: 4)
  14. ↑ Nilsson S et al.; Chest pain and ischaemic heart disease in primary care; Br J Gen Pract 2003; 53: 378–82 (LoE 1A)
  15. ↑ BÖSNER S. et al. Chest wall syndrome in primary care patients with chest pain: presentation, associated features and diagnosis. Family practice, 2010, 27.4: 363-369. (LoE 5)
  16. ↑ Verdon F. et al.; Chest pain in daily practice: occurrence, causes and management; Swiss Med Wkly 2008 (LoE 1B)
  17. ↑ 17.0 17.1 Porter G.E.  et al.; Slipping rib syndrome: an infrequently recognized entity in children: a report of three cases and review of the literature; Pediatrics, 76 (1985), pp. 810–813 (LoE 3A)
  18. ↑ Lum-Hee N. et al.; Slipping rib syndrome: an overlooked cause of chest and abdominal pain; Int. J. Clin. Pract., 51 (4) (1997), pp. 252–253 (LoE 4)
  19. ↑ Turcios N.L. et al.; Slipping rib syndrome in an adolescent: an elusive diagnosis; Clin. Pediatr., 52 (9) (2012), pp. 879–881 (LoE 2B)
  20. ↑ 20.0 20.1 Van Delft E.A.K. et al.; The Slipping Rib Syndrome: A case report; International Journal of Surgery Case Reports, 2016. (LoE 4)
  21. ↑ 21.0 21.1 Veeram S.R. et al.; Chest Pain in Children and Adolescents; Pediatrics in Review, 2013. (LoE 4) 
  22. ↑ 22.0 22.1 22.2 22.3 Meuwly J. et al.; Slipping Rib Syndrome A Place for Sonography in the Diagnosis of a Frequently Overlooked Cause of Abdominal or Low Thoracic Pain; Journal of ultrasound in medicine, 2002. (LoE 4)
  23. ↑ Barki J. et al.; Painful rib syndrome (or Cyriax syndrome): Study of 100 patients; Europe PMC, 1996 (LoE 3A)
  24. ↑ 24.0 24.1 24.2 24.3 Adel G. et al.; Musculoskeletal chest wall pain; Can Med Assoc J, 1985 (LoE 5)
  25. ↑ Hudes K. et al.; Low-tech rehabilitation and management of a 64 year old male patient with acute idiopathic onset of costochondritis; J Can Chiropr Assoc. Dec 2008, 52(4):224-8. (LoE 4)
  26. ↑ 26.0 26.1 26.2 26.3 Keoghane S.R. et al.; Twelfth rib syndrome: a forgotten cause of flank pain; BJUI International, 2008 (LoE 5)
  27. ↑ 27.0 27.1 27.2 Mooney D.P. et al.; Slipping rib syndrome in childhood; J. Pediatr. Surg., 32 (7) (1997), pp. 1081–1082 (LoE 3B)
  28. ↑ 28.0 28.1 Arroyo JF, Vine R, Reynaud C, Michel JP. Slipping rib syndrome: don’t be fooled. Geriatrics. 1995;50:46–49. (LoE 3A)
  29. ↑ 29.0 29.1 Copeland GP, Machin DG, Shennan JM. Surgical treatment of the ‘‘slipping rib syndrome.’’ Br J Surg. 1984;71:522–523. (LoE 1A)
  30. ↑ Machin D.G. et al.; Twelfth rib syndrome: a differential diagnosis of loin pain; British Medical Journal, 1983 (LoE 4) 
  31. ↑ 31.0 31.1 Bass J. et al.; Slipping Rib Syndrome; Journal of the National Medical Association, 1979;71(9):863-865. (LoE 4)
  32. ↑ 32.0 32.1 32.2 Healthline Slipping Rib Syndrome Available from:https://www.healthline.com/health/slipping-rib-syndrome#symptoms (last accessed 6.5.2020)
  33. ↑ Richard B. Westrick et al.; EVALUATION AND TREATMENT OF MUSCULOSKELETAL CHEST WALL PAIN IN A MILITARY ATHLETE; Int J Sports Phys Ther. 2012 June; 7(3): 323–332 (LoE 4) 
  34. ↑ Proulx A. M. et al.; Costochondritis: Diagnosis and treatment; American Family Physician; 80(6), 617–620. doi:10.1016/S0015-1882(09)70196; 2009 (LoE 5)
  35. ↑ Ronga A. et al.; Development and validation of a clinical prediction rule for chest wall syndrome in primary care; BiomedCentral, 2012. (LoE 2B)
  36. ↑ 36.0 36.1 Gregory P.L. et al.; Musculoskeletal problems of the chest wall in athletes; Sports Med. 2002 (LoE 3A)
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