Slipping Rib Syndrome

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Introduction

Slipping rib syndrome (SRS) is characterized by pain in the lower chest or upper abdominal region caused by intercostal nerve impingement as a result of abnormal movement of false ribs (8-12) related to unstable costal cartilaginous attachments

Slipping rib syndrome goes by many names, including:

• Clicking rib
• Displaced ribs
• Rib tip syndrome
• Costal margin syndrome
• Floating rib syndrome
• Nerve nipping
• Painful rib syndrome
• Slipping-rib-cartilage syndrome
• Gliding ribs
• Traumatic intercostal neuritis
• Twelfth rib syndrome
• Cyriax syndrome
• Interchondral subluxation, among others.

Epidemiology

• It is considered to be a rare syndrome and accounts for approximately five percent of all musculoskeletal chest pain in primary care.
• Higher prevalence among women than men by a ratio of 3：1
• May occur at any age, more common in middle-aged women, and is a relatively uncommon, but recognized cause of recurrent lower chest and/or upper abdomen pain in adolescents.
• It’s been reported in people as young as 7 years and as old as 86, but it mostly affects middle-aged people.

Clinically Relevant Anatomy

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

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 increased mobility and greater susceptibility to trauma . Anterior rib hypermobility is also likely to cause problems in the posterior thoracic area, because it’s a closed system .

Pathophysiology

Subluxation of the rib tips caused by disrupted articulation causes ends of ribs to curl up inside and impinge on the intercostal nerves.  The impingement causes the pain as the result of repeated irritation of the intercostal nerves.

Etiology

It can be caused by:

• Congenital anomaly of the chest wall
• The destruction of the fibrous articulation of the rib or their cartilage portion
• Hypermobility of the costal cartilages of the false ribs

Risk Factors

• overuse
• direct trauma that causes the pain.
• Sudden extension or flexion, repeated one-sided weight bearing or exercise such as throwing a ball, vigorous swimming, or swinging a bat.

Clinical Presentation

Slipping rib syndrome is presented through the following characteristics

• 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.

Signs and Symptoms

Following signs and symptoms can be observed:

• Upper abdominal and lower anterior chest wall pain.
• Flank pain
• Tenderness over the affected costal margins
• Clicking, popping or slipping sensation can also be present.
• Pain was preceded by certain activities such as sitting, leaning forward, and interestingly she found that using a swing machine was especially likely to produce discomfort.
• Pain associated with slipping rib syndrome has distinct characteristics which can be used in identifying the syndrome:
  • Intermittent sharp stabbing pain followed by a constant monotonous pain that may last from several hours to many weeks.
  • Range of severity of pain varies from being a minor nuisance, moderately severe to interfering with activities of daily living.
  • May also be reported to radiate from the costochondral area to the chest or to the same level in the back .
  • 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.
  • May affect sporting activities involving trunk movements and deep breathing, but in particular running, horseback riding, arm abduction, or swimming. 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.

Physical 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)

• 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.
• A painful click is sometimes felt over the tip of the involved costal cartilage with certain movements.
• The Hooking manoeuvre - positive test.

Diagnostic Procedures

Diagnosing SRS is the main challenge, which is based on the careful patient history, physical examination, and knowledge of its existence. However, following procedures can be use for diagnosis:

• Hooking maneuvre: 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
• Intercostal nerve blocks can be performed after positive hooking manoeuvre, to confirm the diagnosis.
• Dynamic ultrasound of the ribs can be performed with valsalva, coughing, twisting, crunch and push manoeuvres to diagnose SRS.

Outcome Measures

• The physiotherapist can reproduce chest pain by palpation of the ribs and chest wall .
• Hooking manoeuvre
• Patient-specific functional scale ( PSFS).
• The Global rating of change (GROC) - To measure the patient’s subjective rate of improvement, the GROC has been stated to be reliable .

Differential Diagnosis

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
• Hepatosplenic issues
• Peptic ulcer
• Renal colic
• Pancreatitis

Management

In some cases, slipping rib syndrome resolves on its own without treatment if not, the choice of treatment depends on the severity of patient’s symptoms. There are different approaches in Conservative and non-conservative management that can be taken into account when treating SRS.

Conservative Management

Conservative management includes the following:

• Rest.
• Avoiding strenuous activities.
• Applying heat or ice to the affected area.
• Oral medications like NSAIDS.
• Topical analgesics.
• Physical Therapy.
• Nerve blocks.

Activities to Avoid

Reassurance of the benign nature of the disease combined with explanation and advice concerning postural avoidance Following activities should be avoided:

• Heavy lifting.
• Twisting.
• Pushing.
• Pulling.

Oral Medications

• Acetaminophen (Tylenol)
• Nonsteroidal anti-inflammatory drug (NSAID), such as ibuprofen (Advil, Motrin IB) or naproxen (Aleve)

Physical Therapy Management

• Manual therapy: manipulation of the costovertebral joint and electric stimulation can help manage the pain, but probably no long term relief .

• Taping 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 ^.

• 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 as3pect 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 .

• 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

Intercostal Nerve Blocks

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

Non-conservative Management

If the condition persists or causes severe pain, surgery may be recommended. Following surgical procedures can be done

• Partial rib resection can be done to alleviate the symptoms. Following video demonstrates the surgical procedure:

• Minimally Invasive Repair of Adult Slipped Rib Syndrome Without Costal Cartilage Excision . Following video demonstrates the surgical procedure:

• Vertical rib plating with bioabsorbable plates significantly decreased the rate of recurrence in our early experience. Following video demonstrate the said surgical procedure:

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 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.