Slipping rib syndrome

Ross Hauser, MD

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.

Symptoms of Slipping Rib Syndrome


Slipping Rib Syndrome X-ray

Slipping Rib Syndrome Pain Causes

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.

Back muscles that attach to spine

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 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.

Surgical options and non-surgical options

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. Even surgeons consider these options “aggressive.”(1)

Non-surgical treatments may include recommendations for chiropractic manipulation, cortisone or nerve block. Typically these treatments have not found great success.

Prolotherapy for Slipping Rib Syndrome and rib attachments

slipping rib prolotherapy injection ultrasound

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 published research that showed positive results for Prolotherapy.

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.(2)

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. 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 was 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.

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 the 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 a 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 pain from the front of the chest to the mid back. Likewise, costovertebral ligament sprains refer pain from the back of the rib segment to the sternum where the rib attaches.

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

1 González Temprano N, Ayuso González L, Hernández Martín S, Molina Caballero AY, Pisón Chacón J, Martínez Bermejo MA. Slipping rib syndrome. An aggressive but effective treatment. An Sist Sanit Navar. 2015 May-Aug;38(2):329-32.

2 Şentürk E, Şahin E, Serter S. Prolotherapy: An effective therapy for Tietze syndrome. J Back Musculoskelet Rehabil. 2017 May 5.


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