Slipping Rib Syndrome

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Keywords: Slipping rib syndrome (+ Diagnosis / Therapy / Epidemiology / Rehabilitation / Examination / Symptoms / Characteristics / Clinical), clicking rib, painful rib syndrome, 12th rib syndrome, cyriax syndrome

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Definition/Description

The slipping rib syndrome was first reported in 1919 by Cyriax.6 It is a condition, often misdiagnosed or underdiagnosed and can consequently cause months and even years of unresolved pain in the lower chest or upper abdomen, above the costal margin. Other features of the syndrome are a tender spot on the costal margin and reproduction of the pain on pressing the tender spot.1,2,9 The intensity of pain is related to mechanical conditions, such as bearning loads or coughing.1

The slipping rib syndrome, far more common than realized, is also known by other names like clicking rib1,2,9, painful rib syndrome1,9, displaces ribs1, interchondral subluxation1, slipping rib cartilage syndrome1, nerve nipping at the intercostal margin2, Cyriax's syndrome14,15, traumatic intercostal neuritis1, rib-tip syndrome1,2,9 and 12th rib syndrome.8,11,16   

The condition will lead to a slipping rib under the superior adjacent rib. This because of the hypermobility of the anterior ends of the false rib costal cartilages1,7 (the 8th to 10th ribs, which are not directly insert into the sternum)9. The syndrome can be diagnosed by a clinical test (the hooking maneuver) and is often related to trauma (which can be neglected or forgotten), constrained posture and previous abdominal surgery.1,2,15

Differential Diagnosis

The differential diagnosis of slipping rib syndrome includes:1,10,12
• Cholecystitis
• Esophagitis
• Gastric ulcer
• Hepatosplenic abnormalities
• Stress fracture
• Inflammation of the chondral cartilage
• Pleuritic chest pain
• Pleuritis
• Pneumonia
• Radiculitis
• Herpes zoster
• Aortic aneurysm
• Tietze syndrome (syndrome typically affects one joint and is associated with swelling)
• Costochondritis (may affect numerous costochondral joints with no swelling)
• Abscesses
• Metastases
• Muscle tears
• Abdominal diseases
 

Diagnostic Procedures

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 has almost replaced a thorough clinical examinations for patients with flank pain.1,12,16

• Sonography
Interchondral joints can be precisely depicted with sonography and sequential scanning allows an accurate count of them. On the other hand, high-resolution sonography of the thoracic wall shows accurately the luxation of the cartilaginous rib.

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.12,13

•Physical examination
The hooking maneuver, first described in 1977, is a relatively simple clinical test which can be used to diagnose the syndrome. For more information see examination.1,8

•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.1

Examination

The slipping rib syndrome is often misdiagnosed or underdiagnosed. 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).^[1][12]

Picture: Hook maneuver ^[3]

1. Signs and symptoms
Classically, the pain occurs in the upper abdomen or lower chest, above the costal margin.^[12] Severe, sharp pain is felt in the anterior costal margin and abdominal wall. A painful click is sometimes felt over the tip of the involved costal cartilage with certain movements. The involved costal cartilage is tender and moves more freely than normal.^[9]
See clinical presentation

2. Physical examination
There are two tests for investigating Slipping rib syndrome: the Hook maneuver^[3] and Valsalva maneuver.^[12] Palpation can reproduce chest pain when the patient has the slipping rib syndrome. The diagnosis of this disease is one of exclusion.^[8]
The hook maneuver
This test was described by Heinz and Zavala. 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 the patient’s pain and can cause a click.^[1][8] The condition is always unilateral, performing the maneuver on the contralateral side will serve as a control.^[8][9][16]

https://www.youtube.com/watch?v=j38Sfn_1syU

Valsalva maneuver
The physiotherapist can look for rib restriction by observing a lack of symmetry of the posterior chest wall movements on deep breathing.^[12] During the Valsalva maneuver, it is possible to palpate the slipping of the rib as the abdominal muscles contract.^[12]
https://www.youtube.com/watch?v=SC29GbWbN-M
Palpation
At physical examination, the most common finding in a case of SRS is tenderness above the costal margin.^[12] The physiotherapist can reproduce chest pain by palpation. This is the most important characteristic to diagnose CWS (this is not pathognomonic).^[17]