Slipping rib syndrome

Ross Hauser, MD

A Caring Medical case history

The patient is a 35-year-old female. She had been rushed to the hospital for the fourth time in less than a year complaining of severe chest pain. The obvious concerns were with a cardiac event. After EKGs, blood tests, x-rays, and a stay in the intensive care unit, the cause of her pain were still unknown. Everyone began to wonder if she suffered from problems of mental illness and catastrophizing thoughts.

Upon her visit to us here at Caring Medical, she explained that she was not currently having severe chest pain but did feel a dull ache in her chest. She needed one more diagnostic test, physical examination with palpitation of the chest area to determine if the pain was being caused by problems related to Slipping Rib Syndrome.

Pressure to the left fourth thoracic rib attachment onto the sternum and the patient’s severe crushing chest pain immediately returned.

In this patient’s case, the diagnosis was made very quickly. Pressure to the left fourth thoracic rib attachment onto the sternum and the patient’s severe crushing chest pain immediately returned. Had she ever been examined in this fashion? She said she had not. The patient’s pain was caused by slipping rib syndrome.

An extremely important point illustrated by this case is that even if an x-ray, blood sample, or EKG do not reveal a cause, they do not eliminate the presence of a physical condition as the source of chest pain. It is much more likely that chronic chest pain is due to weakened soft tissue, such as a ligament or tendon. If heart and lung tests prove normal, yet the patient claims to still be experiencing pain, the patient is often given a psychiatric diagnosis.

Depression, anxiety, and other mental illness challenges are not the etiological bases for most chronic pain. They can be associated factors involved in the problem, but they are normally not the cause. Chronic pain should be assumed to be originating from weakened soft tissue.

In this case, a rib was slipping out of place because the ligaments that hold the ribs to the sternum, the sternocostal ligaments, were weak. Without muscles to hold the ribs in place, loose ligaments allow slipping of the rib which causes further stretching of the ligament, manifesting itself by producing severe pain. The loose ribs can also pinch intercostal nerves, sending excruciating pains around the chest into the back. Sternocostal and costochondral ligaments refer to pain from the front of the chest to the mid-back. Likewise, costovertebral ligament sprains refer to pain from the back of the rib segment to the sternum where the rib attaches.

Doctors recognize that slipping rib syndrome is often unrecognized at the time of patient diagnosis and therefore an overlooked cause of chronic pain in the abdominal and/or chest pain area.

Doctors also recognize that misdiagnosis or simply missing slipping rib syndrome as the cause of pain, the misdiagnosis may lead to excessive imaging, laboratory, and other complicated workups.

Here are two recent studies which try to convey the problems of diagnosis and the hunt for clues to help doctors properly diagnose the problem.

A July 2021 paper in the journal Back and Musculoskeletal Rehabilitation (1) recorded doctors’ use of ultrasound to help assess the patient’s cause of pain focused on slipping rib syndrome. The doctors looked at 14 cases with the average age of the patient being 35 and mostly male. What the doctors found was that ultrasound could accurately diagnose slipping rib syndrome. Especially when the patient recreated movements that would cause them distress.

In March 2021 Dr. Cassidy M Foley Davelaar wrote in the Current Sports Medicine Reports. (2)

“Slipping rib syndrome is pain created at the lower, anterior border of the rib cage when performing upper-extremity activities, coughing, laughing, or leaning over. Defects in the costal cartilage of ribs 8 to 10 result in increased movement of the ribs, impinging soft tissue and intercostal nerves. Advancements have been made in the diagnosis of slipping rib syndrome by dynamic ultrasound. Ultrasound can identify abnormalities in the rib and cartilage anatomy, as well as soft tissue swelling. Although the mainstays of treatment continue to be reassurance, nonsteroidal anti-inflammatory drugs, physical therapy, intercostal nerve injections, osteopathic manipulative treatment, surgery for refractory pain, and botulinum toxin injections have been attempted, and there may be a role for prolotherapy in treatment.”

Below we will discuss these treatments with a focus on the role of Prolotherapy, a series of dextrose injections.

A diagnosis with many names

Slipping rib syndrome can be diagnosed as Tietze’s Syndrome, rib subluxation, costal margin syndrome, painful rib syndrome, costochondritis, clicking rib, displaced ribs, painful rib syndrome, traumatic intercostal neuritis, clicking rib, or rib tip syndrome. In patients we see all these diagnoses can typically find a common ground in one of the patient’s ribs intermittently slipping out of place, causing a stretching of the ligaments that support the front and back of the rib.

Slipping rib syndrome can occur where the rib attaches to the thoracic spine (thoraco-rib instability) or anteriorly at the rib-cartilage margin (chondro-rib instability) or sternum-rib margin (sterno-rib instability). When it is the latter, that is when it is called costochondritis or Tietze Syndrome.
It commonly occurs in one of the upper ribs, because ribs one, two, and three take the bulk of the force when a person is bent over reading or doing computer work. When this condition affects the upper ribs, the base of neck pain is common and can be severe, even causing pain down the arm into the hands and fingers, especially the index and little fingers.
The eighth, ninth, and tenth are also common culprits because unlike ribs one through seven, which attach to the sternum, the eighth, ninth, and tenth ribs are attached anteriorly to each other by loose, fibrous tissue. Although this arrangement provides increased mobility of the lower rib cage, it also results in a greater susceptibility to trauma in this area. When the condition affects the lower ribs, such as the eighth, ninth, tenth, chest, and upper abdominal ribs, pain occurs from the recurring subluxation (dislocation) of the costal margins of the eighth, ninth, and tenth ribs due to hypermobility of their anterior edges. This allows a rib to slip behind the rib above it.

Symptoms of Slipping Rib Syndrome

Clinically, patients often note sharp, intermittent, stabbing pain followed by a dull achy sensation for hours or days. “Slipping:” and “popping” sensations are common, and activities such as bending, coughing, deep breathing, lifting, reaching, rising from a chair, stretching, and turning in bed often exacerbate symptoms.

Slipping Rib Syndrome Pain Causes

The cartilaginous ends of these ribs come in close contact with the terminal branches of the intercostal nerves. These nerves are particularly vulnerable to even trivial trauma. The pain can be both excruciating and spontaneous, and it can even simulate a heart attack.
Pain from a slipping rib can travel along the intercostal nerve root and go from the chest to the thoracic area or vice versa. It can also be felt in the abdomen, shoulder, or neck. It may also be precipitated by lying or turning over in bed, sitting in a car seat or armchair, bending forward, breathing deeply, coughing, vomiting, walking, abducting the arm on the affected side, eating, rotating the torso, bending the trunk, or riding in a bouncing automobile.

Rib Instability and Hypermobility

Much of the research surrounds the pediatric and young athlete treatment of slipping rib syndrome as this uncommon disorder is more common in those two groups. However, adults can also acquire slipping rib syndrome with a forcible activity to the rib area including simple coughing to chest surgery for an unrelated cause.

Rib joint instabilities can occur any time there is a violent force on the chest cavity, such as during athletic contact or even a thoracotomy (chest surgery). Rib joint instabilities can also occur when less force occurs over a long period of time, such as when a person has a low-level cough (bronchitis) or poor posture while hunched over a cell phone.
Rib hypermobility is caused by weakness of the rib- sternum (sternocostal), rib cartilage (costochondral), and/ or rib-vertebral (costovertebral/costotransverse) ligaments, allowing the rib to be hypermobile, and it is thought to be the primary cause of slipping rib syndrome. When this occurs, the condition causes chest pain in addition to upper back pain. Without large muscles to hold the ribs in place, loose ligaments allow slipping of the rib, which causes further stretching of the ligament and results in severe pain. A simple coughing attack due to cold may cause the development of slipping rib syndrome. Conditions such as bronchitis, emphysema, allergies, and asthma cause additional stress to the sternocostal and costochondral junctions. Even sinusitis, with its associated nose-blowing, can be the initial event that leads to chronic chest pain from slipping rib syndrome.

Pain with deep breathing during strenuous activity and sport

One clue that the painful conditions are due to rib joint instability is when the pain is increased with deep breathing. The thoracic cage moves up and down to allow breathing, so all the structures of the thoracic cage, including the thoracic-rib-sternal articulations, are never truly at rest.

During inspiration, the upper ribs are elevated, which increases the anterior-posterior diameter of the thorax. The opposite occurs in expiration. When a healthy individual is at rest, the diaphragm and the intercostal muscles produce inspiration. The act of expiration is primarily passive. The action of the abdominals and the accessory muscles of the trunk and the lower neck is usually minimal. However, when there are injuries or more serious oxygen demands, more of the respiratory muscles including the rectus abdominis is called into action as would occur during sporting activities, exercising, or trauma. This puts a greater force on the rib attachments, and when instability is present symptoms increase.

Treatment options – NSAIDs to Surgery. Is this a good path?

Traditional treatment methods surround the notion that slipping rib syndrome pain comes from inflammation in the costochondral junction, causing costochondritis (inflammation of the cartilage that connects a rib to the breastbone (sternum)). Therefore the primary treatment option at the onset is anti-inflammatories.

The path of treatment is described in the journal Psychopharmacology Bulletin. (3) This is a journal that deals mostly with mental health issues. A connection will be made. Here is part of that paper:

“After a positive diagnosis of slipping rib syndrome the initial treatment is decreased activity, oral NSAIDs, and ice. Further, patients should be reassured that this is a benign condition that is treatable. It should be noted that in a study of fifty-four athletes, 22.2% also had an underlying psychiatric or psychological diagnosis, most likely due to their inability to continue to compete; thus, potential mental health issues should also be taken into account. Other conservative treatments include heat, physical therapy, massage, topical NSAIDs, chiropractic manipulation, and electronic stimulation, all of which focus on symptom control. Even in cases of misdiagnosis, such as slipping rib syndrome diagnosed as a rib contusion or vice versa, the hallmark of treatment remains control of inflammation and pain.”

In our experience chronic pain, no matter what the cause, is not due to an NSAID deficiency. Slipping rib syndrome is caused by weakness of the sternocostal, costochondral, or costovertebral ligaments. Treatments for many should focus on strengthening these ligament junctions in all the areas where the ribs are hypermobile.

Surgical options and non-surgical options

A January 2021 study lead by Harvard and Georgetown University medical schools and published in the journal Pain Physician (4) describes the current treatments: “Conservative treatment is usually the first line, including local heat or ice packs, rest, and oral over-the-counter analgesics. Transcutaneous stimulation (TENS unit) and 12th intercostal nerve cryotherapy (freezing the nerve to deaden it) have also been described with some success. Nerve blocks can additionally be tried and are usually effective in the immediate term; there is a (limited amount) of evidence to suggest long-term efficacy. Surgical removal of all or part of the 12th rib and possibly the 11th rib, as well as the next line of therapy, may provide long-lasting relief of pain.”

Surgery to remove a piece of a rib or the costal cartilage, the unique cartilage found only at the ends of the ribs may be recommended if either structure is protruding and sticking into the other ribs. Even surgeons consider these options “aggressive.”(5)

Let’s look at this recap:

“Slipping rib syndrome (SRS) is an unusual cause of recurrent chest or abdominal pain in children. The diagnosis is elusive, including gastroenterological, cardiac, respiratory, infectious, and chest or abdominal muscular pathologies. Two pediatric patients were diagnosed with slipping rib syndrome, both of them were female teenagers with a similar clinical pattern: crippling unilateral chest pain without a traumatic event.

On physical examination, all patients had reproducible pain with the “hooking maneuver” (pulling on the 8-10th rib). Surgical excision (removal) of the costal cartilages was done, preserving the perichondrium. No complications were reported. In both cases we achieve an excellent outcome after one and four years of follow-up, resolving the symptoms completely. The surgical excision of the costal cartilages seems to be an aggressive option but with an excellent outcome. A minimum invasive approach could be a better option in the future.”

Prolotherapy for Slipping Rib Syndrome and rib attachments

Above we spoke about the effectiveness of ultrasound in diagnosis slipping rib syndrome. In the image below, the caption reads, “Musculoskeletal ultrasound is used in our office to guide Prolotherapy injections in cases of slipping rib syndrome.”

Injury to the cartilage tissue in the lower ribs or the sternocostal ligaments in the upper ribs seldom completely heals naturally. The sternocostal, rib-sternum, and costochondral joints undergo stress when the rib cage expands or contracts abnormally or when excessive pressure is applied on the ribs themselves.

The ribs are attached in the front as well as in the back of the body. A loose rib in the front is likely also loose in the back. The rib-vertebral junction is known as the costovertebral junction and is secured by the costotransverse ligaments. Unexplained upper back pain, between the shoulder blades and costovertebral, (rib-vertebrae pain) is likely due to joint laxity and/or weakness in the costotransverse ligaments.

Chronic chest pain, especially in young people, is often due to weakness in the sternocostal and costochondral junctions. Chronic mid-upper back pain is due to weakness at the costovertebral junction. Both conditions may lead to slipping rib syndrome, where the rib intermittently slips out of place, causing a stretching of the ligamentous support of the rib in the front and back. The result is periodic episodes of severe pain and underlying chronic chest and/or upper back pain. Prolotherapy, by strengthening these areas, provides definitive results in the relief of chronic chest pain or chronic upper-back pain from slipping rib syndrome.

Ross Hauser, MD. provides more information in this video. A summary transcript is below

Summary transcript:

Slipping rib syndrome is actually very common. Most people can self-diagnose this condition in themselves or have a loved one do it for them. By gently tracing the thoracic spine you can feel a prominence in a certain rib that is clearly out of place or providing a sensation of fullness. If that is the point where your pain is generating from, then it can be presumed that you have a subluxation or a slippage of a rib. The problem is at the point where the rib attaches to the thoracic vertebrae, the rib has slipped from its normal position.

Treatment options a person could get is manipulation to put the rib back into place and hope that it stays there. If it doesn’t stay in place then it is likely that you have injured one of the ligaments that attaches the ribs to the vertebrae. Those are the costovertebral ligaments.

Prolotherapy can be a treatment for slipping ribs. Typically I would have to see a patient for three or four sessions. Both the sternum and vertebrae attachments in the back that hold the rib in place would normally be treated.

Prolotherapy is an injection technique that stimulates ligament and cartilage repair. Prolotherapy will strengthen the weakened ligament junctions that can cause slipping rib syndrome – the sternocostal, the costochondral, or the costovertebral junctions (the places the ribs meet to form the rib cage). It will also strengthen the costal cartilage.

Doctors writing in the Journal of Back and Musculoskeletal Rehabilitation (6) published research that showed positive results for Prolotherapy.

The doctors examined twenty-one patients who underwent Prolotherapy (group 1) and thirteen who underwent conservative therapy with analgesics (group 2).
A visual analog score (VAS) was recorded for measurement of pain intensity in all patients before and after injection first day, first week, and fourth week.
Group 2 received the systemic nonsteroidal anti-inflammatory drugs. VAS score was recorded similarly at the same time and clinical effects were compared between the two groups.

The Prolotherapy group showed a faster recovery, including significantly reduced clinic findings.

The doctors concluded that Prolotherapy could be performed safely and is a method with favorable long-term treatments for Tietze Syndrome. It may be the ideal procedure for patients with drugs side effects and adverse events especially for those with limited liver and kidney reserve or significant comorbidities.

If you have questions about Slipping rib syndrome? Get help and information from our Caring Medical staff

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This page was updated January 5, 2021