Slipping Rib Syndrome

Evaluating patients and developing a differential diagnosis list can be a slippery slope. Multiple cognitive errors (ex, premature closure, confirmation bias) are potentially just waiting to push you down that slope in the wrong direction. One region that can be particularly challenging to assess is the “Ch-Abdomen” (AKA, Chest/Abdomen). There are so many entities that may present with similar and overlapping symptoms. Is that “pleuritic” chest pain due to a Pulmonary Embolism or is it really acute pain due to Cholecystitis? Chest pain may certainly be due to intra-abdominal pathologies (ex, pancreatitis, cholelithiasis) and upper abdominal pain may be due to intra-thoracic issues (ex, pneumonia, pleural effusion, myocarditis). What if, though, the cause is not that deep? What if it is right beneath the skin? Let’s digest a morsel on Slipping Rib Syndrome:

Slipping Rib Syndrome: Basics

Slipped Rib Syndrome is: [Foley, 2019; Bolanos-Vergaray, 2015]
  • A cause of recurrent and/or chronic abdominal or chest pain
  • Due to a defect in the dense cartilaginous attachments of the lower ribs (particularly ribs 8 through 10, although 11 and 12 can also be involved)
    • Hypermobility of the false ribs allows for the inferior rib to slip behind the superior rib.
    • The slipping of the rib can compress the interposed intercostal nerve.
  • More commonly diagnosed in:
    • Athletes
    • Women
    • Patients with hyper-mobility of joints and tissues
  • A diagnosis of exclusion:
    • Clearly there are many other life-threatening considerations on the Ddx that may warrant evaluation.
    • There often is a delay in diagnosis of Slipped Rib Syndrome and patients will often have had extensive evaluations prior to diagnosis.
    • Diagnosis can be aided by history, physical exam, and ultrasound. [PMID, 30612161: Tassel, 2019]
Slipped Rib Syndrome presents with: [Foley, 2019; Bolanos-Vergaray, 2015]
  • Insidious onset
  • Sharp, stabbing, or shooting pain
  • Unilateral most often (right side > than left)
  • Localized to the region of the costonchondral junctions of the anterior ribs and/or back
  • Worsened by movement (ex, running, swimming, arm abduction, twisting, deep breaths)
  • Improved with rest (ex, lying down or sleeping).
On examination you may find: [Foley, 2019; Bolanos-Vergaray, 2015]
  • Point tenderness over the affected rib(s) without swelling.
  • Reproducible discomfort with compression of the lateral border of the rib.
  • Positive “Hooking Maneuver:”
    • Hooking your fingers underneath the costal margin and pulling superiorly and anteriorly
    • Recreates the subluxation of the cartilage
    • Reproduction of pain or notable clicking is considered positive.
    • Can use the contralateral side for comparison

Slipping Rib Syndrome: Management

  • Symptomatic management should include: [PMID, 29023277: Foley, 2019; PMID, 26528703: Bolanos-Vergaray, 2015]
    • Topical lidocaine patches
    • NSAIDs
    • Ice
    • Decreased activity (or alterations to activities)
    • Physical Therapy
  • For refractory cases: [PMID, 29023277:Foley, 2019; Bolanos-Vergaray, 2015]
    • Injection of steroids and/or anesthetic
    • Intercostal nerve block
    • Surgical excision has also been successful [PMID 33546899: Fraser, 2021]

Moral of the Morsel

  • Keep that Ddx open. Consider Slipped Rib Syndrome for the patient who has “ch-abdominal” pain.
  • Try Hooking Maneuver. Your examination may help avoid repeating another set of LFTs, chest x-ray, or abdominal CT.
  • Think globally, but act locally. Alleviation of symptoms by injection of lidocaine into the region may a help support the diagnosis.

References

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Sean M. Fox
I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renowned educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.
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