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Welcome to Vrije Universiteit Brussel's Evidence-based Practice project.
This space was created by and for the students in the Rehabilitation Sciences and Physiotherapy program of the Vrije Universiteit Brussel, Brussels, Belgium.
Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!! 


= Search Strategy  =
<div class="editorbox">
'''Original Editor '''- [[User:Jeroen Verwichte|Jeroen Verwichte]]


We used the VUB library to access databases such as Pubmed, Web of science and Google scholar to find articles related to slipping rib syndrome. As search keywords we used terms like ‘slipping rib’, ‘Cyriax syndrome’, ‘clicking rib’, ‘twelfth rib’, ‘rib-tip syndrome’, ‘painful rib syndrome’, ‘syndrome of hypersensitive xiphoid’, ‘intercostal neuralgia’ and other synonyms in combination with the following titles and their synonyms. 
'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}}<br>
</div>


Search engines: Pubmed, Web of knowledge,  PEDro <br><br>  
== Introduction  ==
[[File:Slipping Rib Syndrome Example.svg.png|thumb|450x450px|alt=]]
Slipping rib syndrome (SRS) is characterized by [[Pain-Modulation|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<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><ref name=":0">Panka CT, Tchebegna PY. [http://www.scielo.org.za/scielo.php?pid=S1015-51632020000100018&script=sci_arttext&tlng=es Cyriax syndrome in a young male professional soccer player: A case report.] South African Journal of Sports Medicine. 2020;32(1):1-2.</ref><ref>Holmes JF. [https://www.sciencedirect.com/science/article/abs/pii/S000296104190034X Slipping rib cartilage: with report of cases.] The American Journal of Surgery. 1941 Oct 1;54(1):326-38.</ref>


= Definition/Description<br> =
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.<ref name=":7" /><ref name=":30">McMahon LE. [https://pubmed.ncbi.nlm.nih.gov/30078490/ Slipping rib syndrome: a review of evaluation, diagnosis and treatment.] InSeminars in Pediatric Surgery 2018 Jun 1 (Vol. 27, No. 3, pp. 183-188). WB Saunders. </ref><ref>Patel N, John JK, Pakeerappa P, Aiyer R, Zador LN. [https://pubmed.ncbi.nlm.nih.gov/33980032/ Slipping rib syndrome: case report of an iatrogenic result following video-assisted thoracic surgery and chest tube placement.] Pain Management. 2021 May;11(5):555-9.</ref>


The slipping rib syndrome or Cyriax’ syndrome<ref>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)</ref> 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) <ref name=":0">[/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</ref> .This may cause a disruption and allows the costal cartilage tips to subluxate and irritate the intercostal nerves <ref name=":1">Saltzman D.A. et al. The slipping rib syndrome in children. Pediatric Anesthesia. Volume 11, Issue 6, November 2001, Pages 740–743 (LoE 4) </ref>. It’s an often mis- or underdiagnosed condition and can consequently cause months and even years of unresolved pain.  
== Epidemiology ==
Slipping rib syndrome is a rare condition that affects both men and women of all ages.  A review of slipping rib syndrome by Gress et al states that the available evidence relating to the epidemiology is often conflicting and anecdotal.<ref>Gress K, Charipova K, Kassem H, Berger AA, Cornett EM, Hasoon J, Schwartz R, Kaye AD, Viswanath O, Urits I. A Comprehensive Review of Slipping Rib Syndrome: Treatment and Management. Psychopharmacology Bulletin. 2020 Oct 15;50(4 Suppl 1):189.</ref>
Patients may sometimes describe a “slipping” movement of the ribs or a “popping sensation” <ref name=":2">McBeath A.A. et al.; The rib-tip syndrome; J. Bone Joint Surg. Am., 57 (1975), pp. 795–797 (LoE 3A)</ref><ref name=":3">Mynors J.M. et al.; Clicking rib; Lancet, 1 (1973), p. 674 (LoE 1B)</ref>. This condition may mimic many visceral types of discomfort, leading to ordering of many needless laboratory and radiological tests <ref name=":4">Spence E.K. et al.;The slipping rib syndrome; Arch. Surg., 18 (1983), pp. 1330–1332 (LoE 1A)</ref>. The syndrome can be diagnosed by a clinical test (the hooking maneuver) and is often related to direct or indirect trauma (which can be neglected or forgotten), constrained posture and previous abdominal surgery.<ref name=":5">Udermann B.E. et al.; Slipping Rib Syndrome in a Collegiate Swimmer: A Case Report; J Athl Train, 2005 (LoE 3B)</ref><ref name=":6">Scott E.M. et al.; Painful rib syndrome: a review of 76 cases; Gut 1993 July (LoE 3A)</ref><ref>Barki J. et al.; Painful rib syndrome (or Cyriax syndrome): Study of 100 patients; Europe PMC, 1996 (LoE 3A)</ref><br><br>  
* It is considered to be a rare syndrome and accounts for approximately five percent of all musculoskeletal chest pain in primary care. <ref name=":7" /><ref name=":4">Gress K, Charipova K, Kassem H, Berger AA, Cornett EM, Hasoon J, Schwartz R, Kaye AD, Viswanath O, Urits I. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7901126/ A Comprehensive Review of Slipping Rib Syndrome: Treatment and Management.] Psychopharmacology bulletin. 2020 Oct 15;50(4 Suppl 1):189.</ref>
* 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. <ref name=":14">Porter GE. [https://pubmed.ncbi.nlm.nih.gov/4058991/ Slipping rib syndrome: an infrequently recognized entity in children: a report of three cases and review of the literature.] Pediatrics. 1985 Nov;76(5):810-3. </ref><ref>Lum-Hee N, Abdulla AJ. [https://pubmed.ncbi.nlm.nih.gov/9287271/ Slipping rib syndrome: an overlooked cause of chest and abdominal pain. International journal of clinical practice.] 1997 Jun 1;51(4):252-3.</ref><ref>Turcios NL. [https://journals.sagepub.com/doi/10.1177/0009922812469290?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed Slipping rib syndrome in an adolescent: an elusive diagnosis.] Clinical Pediatrics. 2013 Sep;52(9):879-81.</ref>
* It’s been reported in people as young as 7 years and as old as 86, but it mostly affects middle-aged people.<ref name=":7" /><ref name=":30" />


= Clinically Relevant Anatomy <br> =
== Clinically Relevant Anatomy  ==
[[File:False ribs - Kenhub.png|alt=False ribs (highlighted in green) - posterior view|right|frameless|500x500px|False ribs (highlighted in green) - posterior view]]
The slipping rib syndrome is a condition affecting the [[Ribs|false ribs]].   


The slipping rib syndrome is a condition in the area of the thorax, which consist out of a lot of structures: a sternum, different kinds of ribs, thoracic vertebrae, muscles, nerves, arteries and veins (see figure 1 - 3).   
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, [[Intercostal Muscle Strain|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 <ref name=":5">Udermann B.E. et al.; [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1150226/pdf/i1062-6050-40-2-120.pdf Slipping Rib Syndrome in a Collegiate Swimmer: A Case Report;] J Athl Train, 2005 (LoE 3B)</ref><ref name=":2">McBeath A.A. et al.; [https://pubmed.ncbi.nlm.nih.gov/1158917/ The rib-tip syndrome]; J. Bone Joint Surg. Am., 57 (1975), pp. 795–797 (LoE 3A)</ref>.  Anterior rib hypermobility is also likely to cause problems in the posterior thoracic area, because it’s a closed system <ref name=":5" />.   


There are 3 types of ribs: <br>• Ribs which are attached to the sternum by costosternal joints and ligaments (true ribs - 1-7th)<br>• Ribs which are connected to each other through a weaker cartilaginous or fibrous band (false ribs – 8-10th)<br>• Ribs which aren’t attached to the sternum or to each other (floating ribs – 11-12th) 
Image: False ribs (highlighted in green) - posterior view <ref > False ribs (highlighted in green) - posterior view image - © Kenhub https://www.kenhub.com/en/library/anatomy/the-ribs</ref>


All the ribs are attached to the thoracic vertebrae.
== 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.<ref name=":4" /><ref name=":8">Romano R, Gavezzoli D, Gallazzi MS, Benvenuti MR. [https://academic.oup.com/icvts/article/34/2/331/6374795?login=false A new sign of the slipping rib syndrome?]. Interactive CardioVascular and Thoracic Surgery. 2022 Feb;34(2):331-2. </ref><ref name=":9">SANGHANI RR, ZESTOS MM, THOMAS ST. [https://www.aub.edu.lb/fm/Anesthesiology/meja/Documents/a%20case%20report%20of%20slipping%20rib%20syndrome%20an%20uncommon%20and%20underdiagnosed%20cause%20of%20abdominal%20pain.pdf A CAse RepoRt of slipping Rib syndRome: An UnCommon And UndeRdiAgnosed CAUse of AbdominAl pAin.]</ref> <ref name=":10">Hussain A. [https://www.scitechnol.com/abstract/diagnosing-and-treating-slipping-rib-syndrome-an-unusual-case-of-undiagnosed-pain-for-5-years-13288.html Diagnosing and treating Slipping Rib Syndrome: An unusual case of undiagnosed pain for 5 years.] COPD. 2020.</ref><ref name=":22">Fu R, Iqbal CW, Jaroszewski DE, Peter SD. [https://pubmed.ncbi.nlm.nih.gov/23084191/ Costal cartilage excision for the treatment of pediatric slipping rib syndrome.] Journal of pediatric surgery. 2012 Oct 1;47(10):1825-7. </ref>


In most cases the slipping rib syndrome has an impact on the false ribs, mostly the 10th, occasionally the 8th or 9th rib. Because of their weak connection, there is an increased mobility and greater susceptibility to trauma <ref name=":5" /><ref name=":2" />.
== Etiology ==


[[Image:33.jpg]]<br><sup>Figure 1: The Thoracic Cage: Anterior view</sup> <sup><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></sup>
It can be caused by:  


Also a weakness of some ligaments of the rib can lead to a subluxation. Those ligaments can be <ref name=":8">Veeram S.R. et al.; Chest Pain in Children and Adolescents; Pediatrics in Review, 2013. (LoE 4) </ref><ref name=":9">Kumar R. et al.; The painful rib syndrome; Indian Journal of Anaesthesia, 2013 (LoE 4)</ref>:<br>• Sternocostale ligament (rib-sternum)<br>• Costochondral ligament (rib-cartilage)<br>• Costovertebral or radiate ligaments (rib-vertebral)<br>• Costotransversal ligament (rib-vertebral)<br>  
* Congenital anomaly of the chest wall<ref name=":8" />  
* The destruction of the fibrous articulation of the rib or their cartilage portion<ref name=":8" />  
* Hypermobility of the costal cartilages of the false ribs<ref name=":30" /><ref name=":4" />


Anterior rib hypermobility is also likely to cause problems in the posterior thoracic area, because it’s a closed system <ref name=":5" />.
== Risk Factors ==
Following factors can contribute to the risk of developing SRS<ref name=":30" />
* 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.


[[File:Figure 2 Costovertebral joints.png]]
== Clinical Presentation ==
 
[[File:Ashkan-forouzani-oxaIBWkrGXE-unsplash.jpg|thumb|alt=|250x250px]]
<sup>Figure 2: Costovertebral joints</sup> <sup><ref>Drake, Richard; Vogl, A. Wayne; Mitchell, Adam W. M. Gray's Anatomy for Students E-Book. London: Churchill Livingstone; 2009. (LoE 5)</ref></sup>
Slipping rib syndrome is presented through the following characteristics <ref name=":5" /><ref name=":9" /><ref name=":6">Scott EM, Scott BB. [https://pubmed.ncbi.nlm.nih.gov/8344569/ Painful rib syndrome--a review of 76 cases]. Gut. 1993 Jul 1;34(7):1006-8.</ref><ref name=":17">Keoghane SR, Douglas J, Pounder D. [https://pubmed.ncbi.nlm.nih.gov/18990157/ Twelfth rib syndrome: a forgotten cause of flank pain.] BJU international. 2009 Mar;103(5):569-70.</ref>
 
* 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).
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" /><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
 
[[Image:Afbeelding34.jpg|415x415px]]<br><sup>Figure 3: Intercostal structures</sup> <sup><ref name=":0" /></sup>
 
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>
 
= Epidemiology/Etiology  =
 
The ‘Slipping rib syndrome’ affects 20% to 40% of the general population during their lifetime <ref>Nilsson S et al.; Chest pain and ischaemic heart disease in primary care; Br J Gen Pract 2003; 53: 378–82 (LoE 1A)</ref><ref>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)</ref><ref>Verdon F. et al.; Chest pain in daily practice: occurrence, causes and management; Swiss Med Wkly 2008 (LoE 1B)</ref>. The syndrome appears to be a fairly common and underdiagnosed chronic pain syndrome. It is 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 <ref name=":5" /><ref name=":10" /><ref name=":11" />. Other causes could be constrained postures and previous abdominal surgery <ref name=":5" /><ref name=":6" /><ref name=":13">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)</ref><ref>Barki J. et al.; Painful rib syndrome (or Cyriax syndrome): Study of 100 patients; Europe PMC, 1996 (LoE 3A)</ref>. Also people who play sports with higher risks for chest wall impacts (e.g. rugby, hockey, football players,…) have a higher probability to get the syndrome <ref name=":5" />. There also may be a history of minor or significant trauma to the chest, but this history may not be obtainable.
 
This condition may occur at any age, but is reportedly 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 <ref name=":14">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)</ref><ref>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)</ref><ref>Turcios N.L. et al.; Slipping rib syndrome in an adolescent: an elusive diagnosis; Clin. Pediatr., 52 (9) (2012), pp. 879–881 (LoE 2B)</ref>. This disorder appears to be less common in young children because of the flexibility of their chests <ref name=":11" /><ref name=":15">Van Delft E.A.K. et al.; The Slipping Rib Syndrome: A case report; International Journal of Surgery Case Reports, 2016. (LoE 4)</ref><ref name=":8" /><ref name=":9" /><ref name=":4" />. There is no difference in prevalence of the syndrome between men and women <ref>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)</ref>
 
= Characteristics/Clinical Presentation  =
 
Slipping rib syndrome is presented through the following characteristics <ref name=":5" /><ref name=":6" /><ref name=":16">Adel G. et al.; Musculoskeletal chest wall pain; Can Med Assoc J, 1985 (LoE 5)</ref><ref>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)</ref>:
* 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
* A tender spot on the costal margin
* Reproduction of the pain by pressing the tender spot or by external influences
* 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<ref name=":5" /><ref name=":6" /><ref name=":17">Keoghane S.R. et al.; Twelfth rib syndrome: a forgotten cause of flank pain; BJUI International, 2008 (LoE 5)</ref>.
* 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:<ref name=":30" /><ref name=":8" /><ref name=":14" /><ref name=":5" /><ref name=":22" /><ref name=":6" /><ref name=":11">Cranfield KA, Buist RJ, Nandi PR, Baranowski AP. [https://pubmed.ncbi.nlm.nih.gov/9114637/ The twelfth rib syndrome]. Journal of pain and symptom management. 1997 Mar 1;13(3):172-5.</ref><ref name=":18">Mooney DP, Shorter NA. [https://pubmed.ncbi.nlm.nih.gov/9247238/ Slipping rib syndrome in childhood.] Journal of pediatric surgery. 1997 Jul 1;32(7):1081-2. </ref><ref name=":19">Arroyo JF, Vine R. [https://pubmed.ncbi.nlm.nih.gov/7883201/ Slipping rib syndrome: don't be fooled.] Geriatrics. 1995;50(3):46-9.</ref><ref name=":20">Copeland GP, Machin DG, Shennan JM. [https://pubmed.ncbi.nlm.nih.gov/6733425/ Surgical treatment of the ‘slipping rib syndrome’]. British journal of surgery. 1984 Jul;71(7):522-3.</ref><ref name=":1">Saltzman DA, Schmitz ML, Smith SD, Wagner CW, Jackson RJ, Harp S. [https://pubmed.ncbi.nlm.nih.gov/11696155/ The slipping rib syndrome in children.] Pediatric Anesthesia. 2001 Nov 9;11(6):740-3.</ref><ref name=":26">Machin DG, Shennan JM. [https://pubmed.ncbi.nlm.nih.gov/6411237/ Twelfth rib syndrome: a differential diagnosis of loin pain]. British Medical Journal (Clinical research ed.). 1983 Aug 27;287(6392):586.</ref><ref name=":15">Van Delft EA, Van Pul KM, Bloemers FW. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4855817/ The slipping rib syndrome: a case report]. International Journal of Surgery Case Reports. 2016 Jan 1;23:23-4.</ref><ref name=":3">Mynors J.M. et al.; [https://pubmed.ncbi.nlm.nih.gov/4121886/ Clicking rib]; Lancet, 1 (1973), p. 674 (LoE 1B)</ref><ref name=":21">Bass J. et al.; [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2537485/ Slipping Rib Syndrome]; Journal of the National Medical Association, 1979;71(9):863-865. (LoE 4) </ref><ref name=":27">Cyriax E, et al., [https://scholar.google.com/scholar?hl=en&as_sdt=0%2C5&q=Cyriax+E%2C+et+al.%2C+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%2C+Practitioner%2C+1919&btnG= 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</ref><ref name=":31">Germanovich A;Ferrante FM. [https://pubmed.ncbi.nlm.nih.gov/27008303/ “Multi-Modal Treatment Approach to Painful Rib Syndrome: Case Series and Review of the Literature.”] ''Pain Physician'', vol. 19, no. 3, 2016,</ref><ref name=":34">Kumar R, Ganghi R, Rana V, Bose M. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3748696/ The painful rib syndrome.] Indian Journal of Anaesthesia. 2013 May;57(3):311. </ref><ref>Davies-Colley R. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2415737/ Slipping rib]. British Medical Journal. 1922 Mar 18;1(3194):432.  </ref><ref>Arya S, Verma AK, Gupta BK, Hifzur M, Gupta S, Singh N. [https://www.ijrcog.org/index.php/ijrcog/article/view/839 Twelfth rib syndrome-an often missed differential diagnosis of hypogastric and lumbar pain: case series.] Int J Reprod Contracept Obstet Gynecol. 2014 Mar 1;3:263-5. </ref><ref>Mazzella A, Fournel L, Bobbio A, Janet-Vendroux A, Lococo F, Hamelin EC, Icard P, Alifano M. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6995823/ Costal cartilage resection for the treatment of slipping rib syndrome (Cyriax syndrome) in adults.] Journal of Thoracic Disease. 2020 Jan;12(1):10. </ref><ref name=":28">Kamal YA. [https://www.e-fjs.org/article.asp?issn=1682-606X;year=2019;volume=52;issue=6;spage=229;epage=231;aulast=Kamal;type=0#:~:text=Slipping%20rib%20syndrome%3A%20A%20neglected,Kamal%20YA%20%2D%20Formos%20J%20Surg&text=Slipping%20rib%20syndrome%20(SRS)%20is,with%20chronic%20right%20hypochondrial%20pain. Slipping rib syndrome: A neglected cause of hypochondrial pain.] Formosan Journal of Surgery. 2019 Nov 1;52(6):229. </ref><ref>Migliore M, Signorelli M, Caltabiano R, Aguglia E. [https://d1wqtxts1xzle7.cloudfront.net/40268087/Flank_pain_caused_by_slipping_rib_syndro20151122-796-fisq0g-with-cover-page-v2.pdf?Expires=1644313403&Signature=TrhburBwTzxO2i1kSEPIfcmTAQdsDjNbEidgfwlWvVUfSOYRF73OQzElGYhqtXKCzF1Oifu5~doeSFzxnJPoq9dN2mGSZOxQEcapMNc4Y08f6s-cLbHeQtxt9xtZOseS0bGAGaILsuX3m2qiMQRQYWPv1pDdVWldqtdl9hMWMuHytzf7B-trV-mKxRczM7d0pkqDuQ9KDHHlfgVWn66Qy4WdhhHGxCK0tKCSb7WEhXS4oj4Xay7VZrvSH9kOnyFHEr1htLbP4dkawMQQ4ZQPxNj0XOzTsXV59uK49EJympeKsrY5V7IJfA9RPMyeGXw7A6x2JsNo37zI4pNJ50tA~g__&Key-Pair-Id=APKAJLOHF5GGSLRBV4ZA Flank pain caused by slipping rib syndrome.] The Lancet. 2014 Mar 1;383(9919):844.</ref><ref name=":29">Turcios NL. [https://pubmed.ncbi.nlm.nih.gov/27245407/#:~:text=Slipping%20rib%20syndrome%20remains%20rarely,and%20avoid%20chronic%20debilitating%20pain. Slipping rib syndrome: an elusive diagnosis.] Paediatric Respiratory Reviews. 2017 Mar 1;22:44-6.</ref><ref>Hughes KH. [https://journals.sagepub.com/doi/10.1177/216507999804600303 Painful rib syndrome: a variant of myofascial pain syndrome]. AAOHN Journal. 1998 Mar;46(3):115-20.</ref><ref>Bong J, Healey D. [https://pubmed.ncbi.nlm.nih.gov/34053201/ Slipping rib syndrome.] Journal of Medical Imaging and Radiation Oncology. 2021 May 30. </ref>


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" />.
* 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 Assessment|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.


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.
== 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) <ref name=":5" /><ref name=":13">Meuwly JY, Wicky S, Schnyder P, Lepori D. [https://pubmed.ncbi.nlm.nih.gov/11883545/#:~:text=Conclusions%3A%20Slipping%20rib%20syndrome%20should,cases%20of%20nonspecific%20abdominal%20pain. 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 Mar;21(3):339-43.</ref><ref name=":16">Fam AG, Smythe HA. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1346531/ Musculoskeletal chest wall pain]. CMAJ: Canadian Medical Association Journal. 1985 Sep 1;133(5):379.</ref><ref name=":32">Khan NA, Waseem S, Ullah S, Mehmood H. [https://pubmed.ncbi.nlm.nih.gov/30057619/ Slipping rib syndrome in a female adult with longstanding intractable upper abdominal pain.] Case Reports in Medicine. 2018 Jul 2;2018.</ref>
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" />.
*[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.
*[https://www.youtube.com/watch?v=j38Sfn_1syU <sup></sup>][https://www.youtube.com/watch?v=SC29GbWbN-M <sup></sup>]A pai[https://www.youtube.com/watch?v=j38Sfn_1syU <sup></sup>][https://www.youtube.com/watch?v=SC29GbWbN-M <sup></sup>]nful click is sometimes felt over the tip of the involved costal cartilage with certain movements.
* The Hooking manoeuvre - positive test.<ref name=":6" /><ref name=":17" /><ref name=":1" /><ref name=":23">Ronga A, Vaucher P, Haasenritter J, Donner-Banzhoff N, Bösner S, Verdon F, Bischoff T, Burnand B, Favrat B, Herzig L. [https://bmcprimcare.biomedcentral.com/articles/10.1186/1471-2296-13-74 Development and validation of a clinical prediction rule for chest wall syndrome in primary care.] BMC family practice. 2012 Dec;13(1):1-9.</ref>


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" />.
== Diagnostic Procedures ==
Diagnosing SRS is the main challenge, which is based on the careful patient history, physical examination, and knowledge of its existence. <ref name=":10" /> <ref name=":35">Hansen AJ, Toker A, Hayanga J, Buenaventura P, Spear C, Abbas G. [https://pubmed.ncbi.nlm.nih.gov/32330472/ Minimally Invasive Repair of Adult Slipped Rib Syndrome Without Costal Cartilage Excision.] The Annals of thoracic surgery. 2020 Sep 1;110(3):1030-5.</ref> However, following procedures can be use for diagnosis:<ref name=":30" /><ref name=":5" /><ref name=":10" /><ref name=":22" /><ref name=":34" /><ref name=":32" /><ref>Foley CM, Sugimoto D, Mooney DP, Meehan III WP, Stracciolini A. [https://pubmed.ncbi.nlm.nih.gov/29023277/#:~:text=The%20most%20successful%20treatment%20options,of%20hypermobility%20and%20prolonged%20pain. Diagnosis and treatment of slipping rib syndrome.] Clinical Journal of Sport Medicine. 2019 Jan 1;29(1):18-23.</ref><ref>Van Tassel D, McMahon LE, Riemann M, Wong K, Barnes CE. [https://pubmed.ncbi.nlm.nih.gov/30612161/ Dynamic ultrasound in the evaluation of patients with suspected slipping rib syndrome.] Skeletal Radiology. 2019 May;48(5):741-51.</ref>


= Differential 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.


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" />.  
== Outcome Measures ==
* The physiotherapist can reproduce chest pain by palpation of the ribs and chest wall <ref name=":5" />.
* Hooking manoeuvre<ref name=":5" /><ref name=":17" /><ref name=":21" /><ref name=":16" />
*[[Patient Specific Functional Scale|Patient-specific functional scale]] ( PSFS)<ref name=":24">Westrick RB, Zylstra E, Issa T, Miller JM, Gerber JP. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3362990/ Evaluation and treatment of musculoskeletal chest wall pain in a military athlete.] International Journal of Sports Physical Therapy. 2012 Jun;7(3):323.</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 AM, Zryd TW. [https://pubmed.ncbi.nlm.nih.gov/19817327/ Costochondritis: diagnosis and treatment]. American family physician. 2009 Sep 15;80(6):617-20.</ref>.


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> 
== Differential Diagnosis ==
The differential diagnosis of slipping rib syndrome includes a variety of conditions<ref name=":7" /><ref name=":10" /><ref name=":22" /><ref name=":28" /><ref name=":29" />  
* [[Cholecystitis]]
* [[Gastroesophageal Reflux Disease|Esophagitis]]
* Gastric ulcers
* [[Stress Fractures|Stress fractures]]
* Muscle tears
* Pleuritic chest pain
* [[Bronchitis]]
* [[Asthma]]
* [[Costochondritis]], or [[Tietzes|Tietze syndrome]]
* [[Appendicitis]]
* Heart conditions
* Bone metastases
* Hepatosplenic issues
* [[Peptic Ulcers|Peptic ulcer]]
* Renal colic
* [[Pancreatitis]]


= Diagnostic Procedures  =
*


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" />.
== 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.<ref name=":7" /><ref>Telford KM. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1821399/pdf/canmedaj00644-0042.pdf Slipping rib syndrome.] Canadian Medical Association Journal. 1950 May;62(5):463.</ref><ref name=":33">Davelaar CM. [https://pubmed.ncbi.nlm.nih.gov/33655998/ A Clinical Review of Slipping Rib Syndrome.] Current Sports Medicine Reports. 2021 Mar 1;20(3):164-8.</ref><ref>Fares MY, Dimassi Z, Baydoun H, Musharrafieh U. [https://pubmed.ncbi.nlm.nih.gov/30509726/ Slipping rib syndrome: solving the mystery of the shooting pain.] The American journal of the medical sciences. 2019 Feb 1;357(2):168-73.</ref>
=== Non-conservative Management ===
If the condition persists or causes severe pain, surgery may be recommended. Following surgical procedures can be done  <ref name=":7" /><ref name=":0" /><ref name=":10" /><ref name=":22" /><ref name=":28" /><ref name=":35" /><ref>McMahon LE, Salevitz NA, Notrica DM. [https://www.sciencedirect.com/science/article/abs/pii/S0022346820307119 Vertical rib plating for the treatment of slipping rib syndrome.] Journal of Pediatric Surgery. 2021 Oct 1;56(10):1852-6.</ref>


• '''Sonography'''
* Partial rib resection can be done to alleviate the symptoms. Following video demonstrates the surgical procedure:
{{#ev:youtube|v=MTTURcc3DIs&t=19s}}<ref>reference</ref>


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" />.
* Minimally Invasive Repair of Adult Slipped Rib Syndrome Without Costal Cartilage Excision .  
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'''
* Vertical rib plating with bioabsorbable plates significantly decreased the rate of recurrence in our early experience.
=== Conservative Management ===
Conservative management includes the following:<ref name=":30" /><ref name=":33" />[[File:Dane-wetton-t1NEMSm1rgI-unsplash.jpg|right|frameless]]
* Rest.
* Avoiding strenuous activities.
* Applying heat or ice to the affected area.
* Oral medications like NSAIDS.
* Topical analgesics.
* Physical Therapy.
* Nerve blocks.


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" />.
==== Activities to Avoid ====
Reassurance of the benign nature of the disease combined with explanation and advice concerning postural avoidance<ref name=":32" /> <ref name=":25">Gregory PL, Biswas AC, Batt ME. [https://pubmed.ncbi.nlm.nih.gov/11929353/ Musculoskeletal problems of the chest wall in athletes.] Sports Medicine. 2002 Apr;32(4):235-50.</ref>Following activities should be avoided:<ref>[https://www.ucsfhealth.org/medical-tests/slipping-rib-syndrome “Slipping Rib Syndrome.”] ''Ucsfhealth.org'', 25 Mar. 2020,</ref>


• '''Radiologic investigation'''
* Heavy lifting.
* Twisting.
* Pushing.
* Pulling.


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" />.
==== Oral Medications ====


Laparoscopies have been performed in attempts to unsuccessfully diagnose and treat the upper abdominal pain <ref name=":4" />.
* Acetaminophen (Tylenol)<ref name=":7" />
= Outcome Measures  =
* Nonsteroidal anti-inflammatory drug (NSAID)<ref name=":28" /><ref name=":33" />, such as ibuprofen (Advil, Motrin IB) or naproxen (Aleve)<ref name=":7" />
* 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
=== Intercostal Nerve Blocks ===
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).
If the pain continues despite taking a painkiller following can be done to elicit the symptoms:<ref name=":7" /><ref name=":30" /><ref name=":31" /><ref name=":28" /><ref>Ayloo A, Cvengros T, Marella S. [https://www.primarycare.theclinics.com/article/S0095-4543(13)00088-2/fulltext Evaluation and treatment of musculoskeletal chest pain]. Primary Care: Clinics in Office Practice. 2013 Dec 1;40(4):863-87.</ref>
* [http://www.physio-pedia.com/Cervicothoracic_tests Valsalva maneuver]
* A corticosteroid injection to help reduce the swelling
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).
* An intercostal nerve block (an injection of an anesthetic in the intercostal nerve) to relieve pain<br />
* Patient-specific functional scale ( PSFS)
== Physical Therapy Management ==
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>.
[[File:30 3.jpg|right|230x230px]]
* 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>.


= Examination  =
* 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 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>
[[File:Picture 1- rib mwm.png|right|230x230px]]


1. '''Signs and symptoms'''
* 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 <ref name=":12">Bahram J. et al.; [https://www.aptei.ca/wp-content/uploads/Ribs-Dont-Go-Out-2015.pdf Ribs don’t sublux, ribs don’t “go out” … so what’s going on?]; Advanced Physical Therapy Education Institute, 2015 (LoE: 4)</ref><sup>.</sup>


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" />.
[[File:30 2.jpg|right|230x230px]]
A painful click is sometimes felt over the tip of the involved costal cartilage with certain movements. See clinical presentation for more information.


2. '''Physical examination'''
* 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 <ref name=":12" />.


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" />.
* 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 <ref name=":12" />
* 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]
* [[Cervicothoracic tests|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
* [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" />.


= Medical Management =
{{#ev:youtube|cvPIKZ5IsJw|300}}<ref name=":36">[https://www.youtube.com/watch?v=cvPIKZ5IsJw|Thoracic Rib MWM]. [Accessed 16 May 2020] </ref>
== 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. 


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).
== References  ==
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).
** ''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)''   
** ''Supplementation of corticosteroids can give varying amounts of relief <ref name=":25" /><ref name=":21" /> (LoE 3A,4).''   


* Analgesics <ref name=":16" />: NSAID might be value <ref name=":1" /> (LoE 5).     
<references />
 
* Wiring of a ‘slipping rib’ through the costo-chondral junction has been described but is rarely required <ref name=":17" /> (LoE 5).
 
* 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>
 
= Physical Therapy Management  =
 
'''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).
* Reassurance of the benign nature of the disease combined with explanation and advice concerning postural avoidance <ref name=":25" /> (LoE 3A).
* 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).
* 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" />.
* 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).
* Wiring of a ‘slipping rib’ through the costo-chondral junction has been described but is rarely required <ref name=":16" /><ref name=":17" />.
 
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.
 
'''Chest Wall 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).
[[Category:Thoracic Spine]]  
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" />.
[[Category:Conditions]]
 
[[Category:Thoracic Spine - Conditions]]
'''Treatment of a Subluxated Rib'''<ref name=":12" />
[[Category:Thoracic Spine - Conditions]]
 
[[Category:Musculoskeletal/Orthopaedics‏‎]]
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).
[[Category:Vrije_Universiteit_Brussel_Project]]  
* 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.
[[Category:Primary Contact]]  
* 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 <ref name=":12" />. 
[[Category:Syndromes]]
https://www.youtube.com/watch?v=cvPIKZ5IsJw
 
[[File:Picture 1- rib mwm.png|286x286px]]<br><sup>Picture 1: rib mwm</sup> <ref name=":12" />
* 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 <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>Taping of rib 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).   
 
= Key Research  =
 
[[Www.ncbi.nlm.nih.gov/pubmed|Pubmed]]<br>[[Www.pedro.org|Pedro]]<br>[[Www.webofknowledge.com|Web of knowledge]]  
 
Google scholar<br>
 
= Resources  =
 
All information used for this physiopedia subject is found on Pubmed, Physiopedia and Web Of Science. 
 
= 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. 
 
= Recent Related Research (from Pubmed)  =
 
= References  =
 
<references />
__FORCETOC__

Latest revision as of 11:12, 29 November 2022

Original Editor - Jeroen Verwichte

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

Introduction[edit | edit source]

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[1][2][3]

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.[1][4][5]

Epidemiology[edit | edit source]

Slipping rib syndrome is a rare condition that affects both men and women of all ages. A review of slipping rib syndrome by Gress et al states that the available evidence relating to the epidemiology is often conflicting and anecdotal.[6]

  • It is considered to be a rare syndrome and accounts for approximately five percent of all musculoskeletal chest pain in primary care. [1][7]
  • 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. [8][9][10]
  • It’s been reported in people as young as 7 years and as old as 86, but it mostly affects middle-aged people.[1][4]

Clinically Relevant Anatomy[edit | edit source]

False ribs (highlighted in green) - posterior view

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 [11][12]. Anterior rib hypermobility is also likely to cause problems in the posterior thoracic area, because it’s a closed system [11].

Image: False ribs (highlighted in green) - posterior view [13]

Pathophysiology[edit | edit source]

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.[7][14][15] [16][17]

Etiology[edit | edit source]

It can be caused by:

  • Congenital anomaly of the chest wall[14]
  • The destruction of the fibrous articulation of the rib or their cartilage portion[14]
  • Hypermobility of the costal cartilages of the false ribs[4][7]

Risk Factors[edit | edit source]

Following factors can contribute to the risk of developing SRS[4]

  • 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[edit | edit source]

Slipping rib syndrome is presented through the following characteristics [11][15][18][19]

  • 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[edit | edit source]

Following signs and symptoms can be observed:[4][14][8][11][17][18][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34][35][36][37][38][39]

  • 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[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) [11][40][41][42]

  • 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.[18][19][24][43]

Diagnostic Procedures[edit | edit source]

Diagnosing SRS is the main challenge, which is based on the careful patient history, physical examination, and knowledge of its existence. [16] [44] However, following procedures can be use for diagnosis:[4][11][16][17][31][42][45][46]

  • 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[edit | edit source]

  • The physiotherapist can reproduce chest pain by palpation of the ribs and chest wall [11].
  • Hooking manoeuvre[11][19][28][41]
  • Patient-specific functional scale ( PSFS)[47].
  • The Global rating of change (GROC) - To measure the patient’s subjective rate of improvement, the GROC has been stated to be reliable [48].

Differential Diagnosis[edit | edit source]

The differential diagnosis of slipping rib syndrome includes a variety of conditions[1][16][17][35][37]

Management[edit | edit source]

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.[1][49][50][51]

Non-conservative Management[edit | edit source]

If the condition persists or causes severe pain, surgery may be recommended. Following surgical procedures can be done [1][2][16][17][35][44][52]

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

[53]

  • Minimally Invasive Repair of Adult Slipped Rib Syndrome Without Costal Cartilage Excision .
  • Vertical rib plating with bioabsorbable plates significantly decreased the rate of recurrence in our early experience.

Conservative Management[edit | edit source]

Conservative management includes the following:[4][50]

Dane-wetton-t1NEMSm1rgI-unsplash.jpg
  • 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[edit | edit source]

Reassurance of the benign nature of the disease combined with explanation and advice concerning postural avoidance[42] [54]Following activities should be avoided:[55]

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

Oral Medications[edit | edit source]

  • Acetaminophen (Tylenol)[1]
  • Nonsteroidal anti-inflammatory drug (NSAID)[35][50], such as ibuprofen (Advil, Motrin IB) or naproxen (Aleve)[1]

Intercostal Nerve Blocks[edit | edit source]

If the pain continues despite taking a painkiller following can be done to elicit the symptoms:[1][4][30][35][56]

  • 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 Management[edit | edit source]

30 3.jpg
  • Manual therapy: manipulation of the costovertebral joint and electric stimulation can help manage the pain, but probably no long term relief [11].
Picture 1- rib mwm.png
  • 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 [57].
30 2.jpg
  • 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 [57].
  • 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 [57]


[58]

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. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 Healthline Slipping Rib Syndrome Available from:https://www.healthline.com/health/slipping-rib-syndrome#symptoms (last accessed 6.5.2020)
  2. ↑ 2.0 2.1 Panka CT, Tchebegna PY. Cyriax syndrome in a young male professional soccer player: A case report. South African Journal of Sports Medicine. 2020;32(1):1-2.
  3. ↑ Holmes JF. Slipping rib cartilage: with report of cases. The American Journal of Surgery. 1941 Oct 1;54(1):326-38.
  4. ↑ 4.0 4.1 4.2 4.3 4.4 4.5 4.6 4.7 McMahon LE. Slipping rib syndrome: a review of evaluation, diagnosis and treatment. InSeminars in Pediatric Surgery 2018 Jun 1 (Vol. 27, No. 3, pp. 183-188). WB Saunders.
  5. ↑ Patel N, John JK, Pakeerappa P, Aiyer R, Zador LN. Slipping rib syndrome: case report of an iatrogenic result following video-assisted thoracic surgery and chest tube placement. Pain Management. 2021 May;11(5):555-9.
  6. ↑ Gress K, Charipova K, Kassem H, Berger AA, Cornett EM, Hasoon J, Schwartz R, Kaye AD, Viswanath O, Urits I. A Comprehensive Review of Slipping Rib Syndrome: Treatment and Management. Psychopharmacology Bulletin. 2020 Oct 15;50(4 Suppl 1):189.
  7. ↑ 7.0 7.1 7.2 Gress K, Charipova K, Kassem H, Berger AA, Cornett EM, Hasoon J, Schwartz R, Kaye AD, Viswanath O, Urits I. A Comprehensive Review of Slipping Rib Syndrome: Treatment and Management. Psychopharmacology bulletin. 2020 Oct 15;50(4 Suppl 1):189.
  8. ↑ 8.0 8.1 Porter GE. Slipping rib syndrome: an infrequently recognized entity in children: a report of three cases and review of the literature. Pediatrics. 1985 Nov;76(5):810-3.
  9. ↑ Lum-Hee N, Abdulla AJ. Slipping rib syndrome: an overlooked cause of chest and abdominal pain. International journal of clinical practice. 1997 Jun 1;51(4):252-3.
  10. ↑ Turcios NL. Slipping rib syndrome in an adolescent: an elusive diagnosis. Clinical Pediatrics. 2013 Sep;52(9):879-81.
  11. ↑ 11.0 11.1 11.2 11.3 11.4 11.5 11.6 11.7 11.8 Udermann B.E. et al.; Slipping Rib Syndrome in a Collegiate Swimmer: A Case Report; J Athl Train, 2005 (LoE 3B)
  12. ↑ McBeath A.A. et al.; The rib-tip syndrome; J. Bone Joint Surg. Am., 57 (1975), pp. 795–797 (LoE 3A)
  13. ↑ False ribs (highlighted in green) - posterior view image - © Kenhub https://www.kenhub.com/en/library/anatomy/the-ribs
  14. ↑ 14.0 14.1 14.2 14.3 Romano R, Gavezzoli D, Gallazzi MS, Benvenuti MR. A new sign of the slipping rib syndrome?. Interactive CardioVascular and Thoracic Surgery. 2022 Feb;34(2):331-2.
  15. ↑ 15.0 15.1 SANGHANI RR, ZESTOS MM, THOMAS ST. A CAse RepoRt of slipping Rib syndRome: An UnCommon And UndeRdiAgnosed CAUse of AbdominAl pAin.
  16. ↑ 16.0 16.1 16.2 16.3 16.4 Hussain A. Diagnosing and treating Slipping Rib Syndrome: An unusual case of undiagnosed pain for 5 years. COPD. 2020.
  17. ↑ 17.0 17.1 17.2 17.3 17.4 Fu R, Iqbal CW, Jaroszewski DE, Peter SD. Costal cartilage excision for the treatment of pediatric slipping rib syndrome. Journal of pediatric surgery. 2012 Oct 1;47(10):1825-7.
  18. ↑ 18.0 18.1 18.2 Scott EM, Scott BB. Painful rib syndrome--a review of 76 cases. Gut. 1993 Jul 1;34(7):1006-8.
  19. ↑ 19.0 19.1 19.2 Keoghane SR, Douglas J, Pounder D. Twelfth rib syndrome: a forgotten cause of flank pain. BJU international. 2009 Mar;103(5):569-70.
  20. ↑ Cranfield KA, Buist RJ, Nandi PR, Baranowski AP. The twelfth rib syndrome. Journal of pain and symptom management. 1997 Mar 1;13(3):172-5.
  21. ↑ Mooney DP, Shorter NA. Slipping rib syndrome in childhood. Journal of pediatric surgery. 1997 Jul 1;32(7):1081-2.
  22. ↑ Arroyo JF, Vine R. Slipping rib syndrome: don't be fooled. Geriatrics. 1995;50(3):46-9.
  23. ↑ Copeland GP, Machin DG, Shennan JM. Surgical treatment of the ‘slipping rib syndrome’. British journal of surgery. 1984 Jul;71(7):522-3.
  24. ↑ 24.0 24.1 Saltzman DA, Schmitz ML, Smith SD, Wagner CW, Jackson RJ, Harp S. The slipping rib syndrome in children. Pediatric Anesthesia. 2001 Nov 9;11(6):740-3.
  25. ↑ Machin DG, Shennan JM. Twelfth rib syndrome: a differential diagnosis of loin pain. British Medical Journal (Clinical research ed.). 1983 Aug 27;287(6392):586.
  26. ↑ Van Delft EA, Van Pul KM, Bloemers FW. The slipping rib syndrome: a case report. International Journal of Surgery Case Reports. 2016 Jan 1;23:23-4.
  27. ↑ Mynors J.M. et al.; Clicking rib; Lancet, 1 (1973), p. 674 (LoE 1B)
  28. ↑ 28.0 28.1 Bass J. et al.; Slipping Rib Syndrome; Journal of the National Medical Association, 1979;71(9):863-865. (LoE 4)
  29. ↑ 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
  30. ↑ 30.0 30.1 Germanovich A;Ferrante FM. “Multi-Modal Treatment Approach to Painful Rib Syndrome: Case Series and Review of the Literature.” Pain Physician, vol. 19, no. 3, 2016,
  31. ↑ 31.0 31.1 Kumar R, Ganghi R, Rana V, Bose M. The painful rib syndrome. Indian Journal of Anaesthesia. 2013 May;57(3):311.
  32. ↑ Davies-Colley R. Slipping rib. British Medical Journal. 1922 Mar 18;1(3194):432.
  33. ↑ Arya S, Verma AK, Gupta BK, Hifzur M, Gupta S, Singh N. Twelfth rib syndrome-an often missed differential diagnosis of hypogastric and lumbar pain: case series. Int J Reprod Contracept Obstet Gynecol. 2014 Mar 1;3:263-5.
  34. ↑ Mazzella A, Fournel L, Bobbio A, Janet-Vendroux A, Lococo F, Hamelin EC, Icard P, Alifano M. Costal cartilage resection for the treatment of slipping rib syndrome (Cyriax syndrome) in adults. Journal of Thoracic Disease. 2020 Jan;12(1):10.
  35. ↑ 35.0 35.1 35.2 35.3 35.4 Kamal YA. Slipping rib syndrome: A neglected cause of hypochondrial pain. Formosan Journal of Surgery. 2019 Nov 1;52(6):229.
  36. ↑ Migliore M, Signorelli M, Caltabiano R, Aguglia E. Flank pain caused by slipping rib syndrome. The Lancet. 2014 Mar 1;383(9919):844.
  37. ↑ 37.0 37.1 Turcios NL. Slipping rib syndrome: an elusive diagnosis. Paediatric Respiratory Reviews. 2017 Mar 1;22:44-6.
  38. ↑ Hughes KH. Painful rib syndrome: a variant of myofascial pain syndrome. AAOHN Journal. 1998 Mar;46(3):115-20.
  39. ↑ Bong J, Healey D. Slipping rib syndrome. Journal of Medical Imaging and Radiation Oncology. 2021 May 30.
  40. ↑ Meuwly JY, Wicky S, Schnyder P, Lepori D. 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 Mar;21(3):339-43.
  41. ↑ 41.0 41.1 Fam AG, Smythe HA. Musculoskeletal chest wall pain. CMAJ: Canadian Medical Association Journal. 1985 Sep 1;133(5):379.
  42. ↑ 42.0 42.1 42.2 Khan NA, Waseem S, Ullah S, Mehmood H. Slipping rib syndrome in a female adult with longstanding intractable upper abdominal pain. Case Reports in Medicine. 2018 Jul 2;2018.
  43. ↑ Ronga A, Vaucher P, Haasenritter J, Donner-Banzhoff N, Bösner S, Verdon F, Bischoff T, Burnand B, Favrat B, Herzig L. Development and validation of a clinical prediction rule for chest wall syndrome in primary care. BMC family practice. 2012 Dec;13(1):1-9.
  44. ↑ 44.0 44.1 Hansen AJ, Toker A, Hayanga J, Buenaventura P, Spear C, Abbas G. Minimally Invasive Repair of Adult Slipped Rib Syndrome Without Costal Cartilage Excision. The Annals of thoracic surgery. 2020 Sep 1;110(3):1030-5.
  45. ↑ Foley CM, Sugimoto D, Mooney DP, Meehan III WP, Stracciolini A. Diagnosis and treatment of slipping rib syndrome. Clinical Journal of Sport Medicine. 2019 Jan 1;29(1):18-23.
  46. ↑ Van Tassel D, McMahon LE, Riemann M, Wong K, Barnes CE. Dynamic ultrasound in the evaluation of patients with suspected slipping rib syndrome. Skeletal Radiology. 2019 May;48(5):741-51.
  47. ↑ Westrick RB, Zylstra E, Issa T, Miller JM, Gerber JP. Evaluation and treatment of musculoskeletal chest wall pain in a military athlete. International Journal of Sports Physical Therapy. 2012 Jun;7(3):323.
  48. ↑ Proulx AM, Zryd TW. Costochondritis: diagnosis and treatment. American family physician. 2009 Sep 15;80(6):617-20.
  49. ↑ Telford KM. Slipping rib syndrome. Canadian Medical Association Journal. 1950 May;62(5):463.
  50. ↑ 50.0 50.1 50.2 Davelaar CM. A Clinical Review of Slipping Rib Syndrome. Current Sports Medicine Reports. 2021 Mar 1;20(3):164-8.
  51. ↑ Fares MY, Dimassi Z, Baydoun H, Musharrafieh U. Slipping rib syndrome: solving the mystery of the shooting pain. The American journal of the medical sciences. 2019 Feb 1;357(2):168-73.
  52. ↑ McMahon LE, Salevitz NA, Notrica DM. Vertical rib plating for the treatment of slipping rib syndrome. Journal of Pediatric Surgery. 2021 Oct 1;56(10):1852-6.
  53. ↑ reference
  54. ↑ Gregory PL, Biswas AC, Batt ME. Musculoskeletal problems of the chest wall in athletes. Sports Medicine. 2002 Apr;32(4):235-50.
  55. ↑ “Slipping Rib Syndrome.” Ucsfhealth.org, 25 Mar. 2020,
  56. ↑ Ayloo A, Cvengros T, Marella S. Evaluation and treatment of musculoskeletal chest pain. Primary Care: Clinics in Office Practice. 2013 Dec 1;40(4):863-87.
  57. ↑ 57.0 57.1 57.2 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)
  58. ↑ Rib MWM. [Accessed 16 May 2020]
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