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 rib^1,2,9, painful rib syndrome^1,9, displaces ribs¹, interchondral subluxation¹, slipping rib cartilage syndrome¹, nerve nipping at the intercostal margin², Cyriax's syndrome^14,15, traumatic intercostal neuritis¹, rib-tip syndrome^1,2,9 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 cartilages^1,7 (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) ^[29]
• Costochondritis (may affect numerous costochondral joints with no swelling)^[29]
• 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