Patient Presentation
A 17-year-old female came to clinic after she had a problem when doing her regular gym routine. She was lying on a mat to do some leg and abdominal exercises and had a sharp or tingling sensation along her left lower rib. When she got up she could see that the rib seemed to be more prominent on the left than the right side. She wasn’t actively moving or pushing on the area when it occurred, she was just moving from her abdomen rolling towards her back. She stated that it felt “weird.” She denied the ribs making a sound when she would breathe, or would push on the rib or try to manipulate the rib. The past medical history showed that she was a former gymnast.
The pertinent physical exam revealed normal vital signs and growth parameters. Her chest wall had a prominence of the lower left ribs laterally around the insertion of the 9th rib into the costal cartilages. There was normal chest wall expansion. The mild pain could be elicited when “hooking” the physician’s fingers under the lower costal cartilages and gently pulling the ribs anteriorly and superiorly. She had a normal abdominal examination.
The diagnosis of slipping rib syndrome was made. She was advised that she could rest and use some ibuprofen in the short term, and a referral to physical therapy was made. At followup with her regular physician, she did not have any abnormal position of the ribs and was having only intermittent discomfort that was random but easily managed with rest. “The physical therapy really seems to help and is making my core muscles very strong,” she noted.
Discussion
There are 12 pairs of ribs that attach posterior to the thoracic vertebrae by the costovertebral joints. Anteriorly ribs 1-7 (true ribs) attach directly to the sternum and ribs 8-10 (false ribs) attach indirectly to the sternum though the costal cartilage. Ribs 11-12 are floating ribs as they do not attach to the sternum.
Slipping rib syndrome (SRS) occurs when there is laxity of the attachments of the anterior sterno-costal structures allowing rib hypermobility which can cause pain. Although any rib can have this problem, ribs 8-10 are classically involved as these are attached to the sternum by a relatively larger cartilaginous structure. In children the attachment is a cartilaginous cap and is a fibrous band in adults. SRS can cause discrete localized pain, stinging or other types of sensations and often is worse with particular movements which recreate the rib subluxation such as the hooking maneuver described above. The rib can be in an abnormal position or can cause a popping or cracking sound/sensation. True neurological problems are not common. Some patients will some describe chest pain or abdominal pain and therefore SRS may not be considered and may undergo unnecessary evaluation and treatment can be delayed. In one study, athletes, who are more likely to get SRS, had pain for 15 months before being diagnosed. The most common athletic activity associated with pain onset was no activity in the same study. SRS is more common in female patients and usually is unilateral but can be bilateral.
Learning Point
Reassurance that SRS is a benign syndrome can greatly help patients. However some patients will have intense pain and therefore do not have a benign course. Short term relief interventions usually are recommended.
Common other treatment can include:
- Rest, ice, massage
- Short course of oral pain reliever
- Diclofenac gel
- Physical therapy and/or osteopathic manipulative treatment
- Nerve block
- Botulinum toxin injection
- Surgery – excision or plating of costal cartilage
Questions for Further Discussion
1. What anatomical rib variations can cause pain? A review can be found here
2. Who is more at risk for spontaneous pneumothorax?
3. What are indications for surgical treatment of pectus excavatum or carinatum?
Related Cases
- Disease: Slipping Rib Syndrome | Chest Injuries and Disorders
- Symptom/Presentation: Chest Pain
- Specialty: General Pediatrics | Orthopaedic Surgery and Sports Medicine | Physical Medicine and Rehabilitation / Physical Therapy
- Age: Teenager
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for this topic: Chest Injuries and Disorders
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
To view videos related to this topic check YouTube Videos.
Bonasso PC, Petrus SN, Smith SD, Jackson RJ. Sternocostal slipping rib syndrome. Pediatr Surg Int. 2018;34(3):331-333. doi:10.1007/s00383-017-4221-1
Foley CM, Sugimoto D, Mooney DP, Meehan WPI, Stracciolini A. Diagnosis and Treatment of Slipping Rib Syndrome. Clinical Journal of Sport Medicine. 2019;29(1):18. doi:10.1097/JSM.0000000000000506
MacGregor RM, Schulte LJ, Merritt TC, Keller MS, Aubuchon JD, Abarbanell AM. Slipping Rib Syndrome in Children: Natural History and Outcomes Following Costal Cartilage Excision. J Surg Res. 2022;280:204-208. doi:10.1016/j.jss.2022.06.061
Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa