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Diagnosis and Treatment of Slipping Rib Syndrome

Authors:
  • Waseda University / The Micheli Center for Sports Injury Prevention

Abstract and Figures

Objective: (1) To investigate the clinical presentation, diagnosis, and treatment of slipping rib syndrome in athletes; (2) to investigate the hooking maneuver for diagnosis of slipping rib syndrome. Design: Retrospective chart review of 362 athletes with rib pain. Setting: Pediatric-based sports medicine clinic between January 1, 1999, and March 1, 2014. Patients: Costochondritis, Tietze, fractures, rib tip syndrome, and unclear diagnoses were excluded. Athletes were included who had a palpable rib subluxation, mechanical rib symptom, positive hooking maneuver, or resolution of pain after the resection of a slipping rib segment. Main outcome measures: Slipping rib syndrome is associated with athletic performance. Results: Fifty-four athletes were diagnosed with slipping rib syndrome, of which 38 (70%) were females. Mean age at presentation was 19.1 years (range 4-40 years). Mean number of previous specialist consultations per athlete was 2.3 and mean time from symptom onset to diagnosis was 15.4 months. The hooking maneuver was attempted 21 times (38.9%). Unilateral symptoms presented in 49 athletes (90.7%). The most symptomatic rib was the 10th, affecting 24 athletes (44.4%), eighth and ninth were affected in 17 athletes (31.5%) each. Most, 39 (72.2%), reported insidious onset of symptoms. Running, rowing, lacrosse, and field hockey were frequently associated activities. Twelve athletes had psychiatric diagnoses (22.2%), 10 (19.2%) were hypermobile. Sixty-six total imaging studies were performed. The most successful treatment options included: osteopathic manipulative treatment (71.4%), surgical resection (70%), and diclofenac gel (60%). Conclusions: Most athletes with slipping rib syndrome were active females with insidious onset of unilateral pain, a high prevalence of hypermobility and prolonged pain. The hooking maneuver was underused.
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Original Research
Diagnosis and Treatment of Slipping Rib Syndrome
Cassidy M. Foley, DO,* Dai Sugimoto, PhD,†‡§{David P. Mooney, MD, MPH,{William P. Meehan III, MD,†‡§{
and Andrea Stracciolini, MD†‡§{
Abstract
Objective: (1) To investigate the clinical presentation, diagnosis, and treatment of slipping rib syndrome in athletes; (2) to
investigate the hooking maneuver for diagnosis of slipping rib syndrome. Design: Retrospective chart review of 362 athletes
with rib pain. Setting: Pediatric-based sports medicine clinic between January 1, 1999, and March 1, 2014. Patients:
Costochondritis, Tietze, fractures, rib tip syndrome, and unclear diagnoses were excluded. Athletes were included who had
a palpable rib subluxation, mechanical rib symptom, positive hooking maneuver, or resolution of pain after the resection of
a slipping rib segment. Main Outcome Measures: Slipping rib syndrome is associated with athletic performance. Results:
Fifty-four athletes were diagnosed with slipping rib syndrome, of which 38 (70%) were females. Mean age at presentation was
19.1 years (range 4-40 years). Mean number of previous specialist consultations per athlete was 2.3 and mean time from
symptom onset to diagnosis was 15.4 months. The hooking maneuver was attempted 21 times (38.9%). Unilateral symptoms
presented in 49 athletes (90.7%). The most symptomatic rib was the 10th, affecting 24 athletes (44.4%), eighth and ninth were
affected in 17 athletes (31.5%) each. Most, 39 (72.2%), reported insidious onset of symptoms. Running, rowing, lacrosse, and
field hockey were frequently associated activities. Twelve athletes had psychiatric diagnoses (22.2%), 10 (19.2%) were
hypermobile. Sixty-six total imaging studies were performed. The most successful treatment options included: osteopathic
manipulative treatment (71.4%), surgical resection (70%), and diclofenac gel (60%). Conclusions: Most athletes with slipping
rib syndrome were active females with insidious onset of unilateral pain, a high prevalence of hypermobility and prolonged pain.
The hooking maneuver was underused.
Key Words: slipping rib syndrome, athlete, running, female, rib pain, subluxing rib
(Clin J Sport Med 2017;0:1–6)
INTRODUCTION
Slipping rib syndrome is an under diagnosed cause of chest
wall discomfort, observed in athletes.
9
The diagnosis can be
differentiated from common causes of rib pain such as
costochondritis, Tietze syndrome, and intercostal muscle
strain through familiarity with its unique history and physical
examination. Pain is typically described as sharp, stabbing or
shooting, or it may be more of a dull ache that radiates from
costochondral junctions to the anterior ribs and/or back, often
facilitated by movements.
6,12,21
The history on presentation
may include unilateral costal cartilage pain exacerbated by
movement, with or without a clicking and popping sensation.
7
The pain may persist for long periods of time, disappearing
with lying down or a nights rest.
2,3,6
The physical examina-
tion often elicits point tenderness over the affected rib or
cartilage, and pain may be reproducible by pressing on the
ribs lateral border.
7,16
The physical examination may also
reveal a positive hooking maneuver,where pain is
reproduced by placing fingers under the costal margin and
gently pulling superiorly and anteriorly.
8,11
This maneuver
recreates the subluxation of the offending cartilage and
impingement of the intercostal nerve.
8,11
Slipping rib syndrome has been attributed to a defect in the
dense fibrous costal cartilage attachments, particularly at the
interchondral articulations of ribs 8 through 10, or ribs 11 and
12, which do not attach directly to bone.
9,13,16,20,21,22,24
The
lower rib moves in a greater arch superiorly and posteriorly,
impinging on the intercostal nerve of the above rib.
11,24
Many
muscles insert on the ribcage, including the rectus abdominus,
quadratus laborum, transverse abdominis, and external
oblique abdominal.
6,13
Concentric shortening of the rectus
abdominis musculature over the rib cage applies anterior to
posterior pressure on the inferior margins of the ribs and can
force them to come in contact with each other.
9
Athletes are
particularly at risk for slipping rib syndrome due to the
increased upper extremity movement, contraction of chest and
abdominal wall musculature, and increased risk of trauma to
the chest wall.
Unnecessary tests are often performed on patients with
slipping rib syndrome, secondary to somatovisceral and
vicerosomatic referred pain. Innervation of the intercostal
nerves and visceral sympathetics converge at the same spinal
cord levels as slipping ribs, specifically over the eighth and
ninth ribs.
2,4,18,20
This may cause slipping rib pain to mimic
Submitted for publication March 11, 2017; accepted July 22, 2017.
From the *Pediatric Orthopedic Associates, Next Level Sports Medicine, Atlanta,
Georgia;
The Micheli Center for Sports Injury Prevention, Waltham, Massachusetts;
Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Child-
ren’s Hospital, Boston, Massachusetts;
§
Division of Emergency Medicine, De-
partment of Medicine, Boston Children’s Hospital, Boston, Massachusetts;
{
Harvard Medical School, Boston, Massachusetts; and
Department of Surgery,
Harvard Medical School, Boston Children’s Hospital, Boston, Massachusetts.
W. P. Meehan receives royalties from ABC-CLIO publishing for the sale of his book,
Kids, Sports, and Concussion: A guide for coaches and parents and royalties from
Wolters Kluwer for working as an author for UpToDate. His research is funded, in
part, by a grant from the National Football League Players Association and by
philanthropic support from the National Hockey League Alumn i Association through
the Corey C. Griffin Pro-Am Tournament.
The authors report no conflicts of interest.
Corresponding Author: Cassidy M. Foley, DO, Pediatric Orthopedic Associates, 811
Ponce de Leon Place NE, Atlanta, GA 30306 (cassidymfoley@gmail.com).
Copyright ©2017 Wolters Kluwer Health, Inc. All rights reserved.
http://dx.doi.org/10.1097/JSM.0000000000000506
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that of visceral causes: appendicitis, biliary colic, peptic ulcer
disease, and renal colic.
5,11,14
Given the challenges and delays in making the diagnosis of
slipping rib syndrome in athletes, our aim was to analyze
clinical documentation regarding history, treatment, and out-
come of athletes withslipping rib syndrome. Also, to investigate
the use of the hooking maneuver as a diagnostic tool.
MATERIALS AND METHODS
A retrospective chart review was conducted of 362 athletes who
presented to a sports medicine clinic of a large tertiary-level
childrens hospital between January 1, 1999, and March 1,
2014. The diagnosis of slipping rib syndrome was inconsistent
in the medical documentation, therefore electronic medical
records were searched using the terms costochondritis, Tietze
syndrome, rib tip pain, snapping rib, floating rib, subluxing
rib, and slipping rib syndrome. Patients with the diagnoses
of costochondritis, Tietze, rib fractures, rib tip syndrome,
and those with unclear diagnoses secondary to the lack of
information were excluded. Athletes who demonstrated one of
the followings: palpable rib subluxation, mechanical symptoms
at a mobile rib, positive hooking maneuver, or resolution of
pain after the resection of a slipping rib segment were included
in the final analysis. Data were collected regarding age at
presentation, sex, location of pain, cause of pain, duration of
pain, psychological diagnoses, hypermobility, number of pre-
vious specialists, imaging performed, treatment, and results.
Only those athletes described as hypermobile,”“extremely
flexible,or classified by a standardized scale (Beighton/
Marshall scale) were included in the hypermobile category.
Data were only collected if there was a clear description of the
findings. If a patient was treated with 2 methods, only those
whose medical record included a clear statement as to which
treatment resulted in symptom improvement were included.
For patients lost to follow-up, the treatment was not recorded
as providing improvement. Institutional review board approval
was obtained before study commencement (Figures 1 and 2).
RESULTS
Patient Population
Three hundred sixty-two charts were aggregated initially,
with 54 athletes resulting in the diagnosis of slipping rib. Of
the 54, 38 were female (70.4%), and 16 were male (29.6%).
The mean age at presentation was 19.1 years (range 4-40
years). Before presentation, the mean number of specialist
consultations per patient was 2.3. The mean time from
Figure 1. Data selection of patients with
slipping rib syndrome.
What Are the New Findings?
Most athletes with slipping rib syndrome are females,
presenting with insidious onset of unilateral chest pain.
Over one-fifth of the patients with slipping rib syndrome
carried a psychiatric diagnosis and just under one-fifth of
slipping rib patients were hypermobile.
The hooking maneuver is an underused and sensitive
diagnostic tool for diagnosing slipping rib syndrome
Both surgical and nonsurgical treatment options were
successful in relieving pain in athletes with slipping rib
syndrome.
C.M. Foley et al. (2017) Clin J Sport Med
2
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symptom onset to diagnosis was 15.4 months. The hooking
maneuver was attempted 21 times (38.9%), of which 13
(70.4%) were positive and 8 (29.6%) were negative. The right
side was affected in 26 athletes (48.1%), and the left side in 23
(42.6%). Bilateral symptoms were present in 5 athletes
(9.2%), whereas symptoms were unilateral in 49 (90.7%).
The most symptomatic rib was the 10th, affecting 24 athletes
(44.4%), the eighth and ninth ribs were each affected in 17
athletes (31.5%). Twelve athletes had psychiatric diagnoses
(22.2%) and 10 (19.2%) were described as hypermobile.
Cause
Most athletes with slipping rib syndrome, 39 (72.2%),
reported insidious onset of symptoms, whereas 15 (27.8%)
reported onset after trauma. Of the 21 sports associated with
symptoms, running was the most common, followed by
lacrosse, field hockey, and rowing (Figure 3). Only 11 patients
were inactive, or a sport was not documented.
Diagnostic Evaluation and Treatment
A total of 66 imaging studies were completed for 54 patients:
34 radiographs, 13 magnetic resonance images (MRIs), 9
computed tomography (CT) scans, 4 bone scans, and 6
ultrasounds. Ultrasounds performed before a sports medicine
physician were abdominal ultrasounds. Imagining revealing
pathology: a stress fracture or facet arthropathy, excluded
the patient, a rib protrusion on MRI would not exclude the
patient in isolation. Treatment for athletes with slipping rib
syndrome ranged from conservative measures: nonsteroidal
anti-inflammatory drugs (NSAIDs), topical medications, and
osteopathic manipulative treatment to invasive treatments
including injections and surgical resection. Osteopathic
manipulative treatment is hands-on manipulation of body
parts by stretching, resistance of muscles, gentle pressure, and
realignment (Tables 1 and 2).
DISCUSSION
The main findings of our research are summarized in Table 2.
The hooking maneuver was underused in our cohort of
athletes with slipping rib syndrome, although it has been
documented to be a valuable diagnostic tool.
13
Figure 2. Two rib pain location in athletes with slipping rib syndrome. The
most often affected ribs of T8, T9, and T10, have the longest cartilaginous
connection to the sternum (Reproduced with permission by artist Donald
M. Foley). Adaptations are themselves works protected by copyright. So
in order to publish this adaptation, authorization must be obtained both
from the owner of the copyright in the original work and from the owner of
copyright in the translation or adaptation.
Figure 3. Activity associated with pain onset.
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The mean age of athletes diagnosed with slipping rib
syndrome in our study (19.1 years) was younger than that of
previous studies and most likely related to selection bias at
achildrenshospital.
1,2,13,17
Scott et al
19
studied 76 cases and
reported a mean age of 48 years (range 12-79 years). Wright
et al
23
surveyed 48 patients and described the mean age as
middle-aged(range 16-78 years). Similarly, Copeland et al
5
reported a mean age of 28.8 years (range 13-57 years).
Although reportedly more common in adults, slipping rib has
presented as abdominal pain in children.
11
One of the 2 original
reports documented by Davies-Colley summarized a case of
a 17-year-old female.
6
Other studies performed at childrens
hospitals or studies on a selected population have seen reports of
slipping rib syndrome at a younger age: mean of 12.1 years
(range 10-15.75 years) and 14.8 years (range 13.5-17).
11,14,16,19
Seven patients identified between 2000 and 2011 reported
a mean age of symptom onset at 13.5 63.9 years and mean age
of diagnosis 16.1 63.2 years (range 10-20 years).
7
One of the major findings of this study was disparity by sex.
Our data indicated a female predominance of 70.4%, which is
consistent with previous findings. Scott et al
17
reported 70%
of his patients were women. Saltzman et al
16
found a pre-
dominance of female involvement (2:1) in his review of 12
children. Only 1 reviewed study reported equal numbers of
men and women affected.
23
Hypermobility was common in
our cohort, which may help explain the female predominance.
Of our athletes, 19% were documented as being extremely
flexible,”“hypermobile,or classified by a standardized
scale. Nineteen percent is likely an underrepresentation due to
the limited use of a standardized classification (Beighton/
Marshall scale) regarding hypermobility. Given that females
tend to have more ligamentous laxity when compared with
males, it is possible that hypermobility syndromes affect the
fibrous connections at the interchondral junctions predispos-
ing female athletes to slipping rib syndrome.
15
Females have
also been shown to be more affected than males during their
reproductive years (ratio 14:3).
5
However, a hormonal
connection to slipping rib syndrome, like the connection
between hormones and increased ligament laxity during
pregnancy, remains unexplored.
5
There are consistent findings that suggest the right side of
the body more often involved than the left, and bilateral
symptoms are infrequent.
5,16,17
Cyriax et al first described the
syndrome as affecting rib 8 in 1919. Because of his report, the
most commonly affected rib has been described as the 10th,
a finding supported by our data (44.4%).
21
Another important clinical finding of this study was the
duration of pain. The athletes in our study experienced pain
for 15.4 months before diagnosis. Our results mirrored
previous studies, supporting that patients who present with
slipping rib syndrome have a long-standing history of
symptoms without improvement.
1,6,13,18,23
Fu et al reported
the median time from the onset of symptoms to definitive
therapy as 2 years (range 0-60 months), and Saltzman et al
reported symptoms for 9.9 months (range 1-36 months).
7,16
Several reports documented a wide range of duration of pain
at presentation, from 32 months of symptoms (range 1-28
years) or symptom duration of 5 months to 15 years (mean 2.7
years) to 2 to 25 years of symptoms.
5,17,23
In addition to delayed diagnosis, our data revealed each
athlete, on average, underwent 2.3 consultations. Many
patients with slipping rib syndrome are referred to specialists
unnecessarily.
7
Scott et al
17
reported 3% of new patient
referrals to a general medical/gastroenterology clinic were
diagnosed as slipping rib. Thirty-two of Wrights 46 patients
had received a previous hospital referral for undiagnosed
slipping rib syndrome.
23
Taubman et al
19
reported 4 patients
with slipping rib who were all seen for chest pain.
Extensive diagnostic evaluations of the viscera frequently
result in negative results.
5,7,11,12,23
In a retrospective review
study, imaging of patients with slipping rib revealed negative
results in all but 1 case, where the affected rib was protuberant
TABLE 1. Treatment and Pain Relief
Type of Treatment
Total No. of
Treatments*
(N 5122)
Proportion Each
Treatment Resulted
in Pain Relief†
Physical therapy 35 17 (48.6%)
NSAIDs 23 7 (30.4%)
Injection 18 8 (44.4%)
Surgical resection 10 7 (70%)
Lidoderm patches 10 3 (30%)
OMT‡ 7 5 (71.4%)
Chiropractic treatment 7 2 (28.6%)
Acupuncture 7 2 (28.6%)
Diclofenac gel 5 3 (60%)
* Number of times each treatment was used.
† Proportion of patients who reported pain relief per treatment.
‡ Osteopathic manipulative treatment.
TABLE 2. Summary of Diagnostic Findings for Slipping Rib Syndrome
Prevalence Mean Age Sex Onset
Rare 19.1 yrs Female Insidious
Associated with increased upper extremity use
sports
Area Affected Location Treatment (% Described Relief*) Physical Examination
Unilateral (90.7%) 10th rib (44.4%) OMT† (71.4%), Tenderness at low, nonswollen, ribs and costal
cartilages
8th and 9th ribs (31.5% each) Surgical resection (70%), Pain with side bending, rotation, and/or hooking
maneuver
Diclofenac gel (60%)
* Proportion of patients who reported pain relief per treatment.
† Osteopathic manipulative treatment.
C.M. Foley et al. (2017) Clin J Sport Med
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on CT examination.
7
Another study revealed that among 17
patients, 46 radiological investigative procedures and 6
surgical investigative procedures (average of 2.7 per patient)
were preformed before their diagnosis of slipping rib.
5
One
patient described in the literature suffered with pain for 778
days.
12
Wright et al
23
reported 119 investigationsin 39
patients, averaging 3 tests per patient.
The ongoing pain of patients with slipping rib syndrome is
often associated with psychosocial problems, depressive
symptoms, and subsequent medical management for chronic
pain.
5,11,12
Athletes seem depressed when they cannot partic-
ipate in sports.
12
The results of our study found 22.2% of
athletes have a psychological and emotional overlay to their
diagnosis. These results are in keeping with other reports of
patients with slipping rib syndrome, in that patients may
become less tolerant, more critical of their care, and difficult to
manageafter being told their pain is not explained by the tests
and studies performed.
18
Abbou et al
1
reported one-third of the
cases involved patients considered to be psychoneurotic or who
have undergone a psychiatric evaluation. Wright found 15 of
46 patientshave been regarded as psychoneurotic.
23
One study
of slipping rib syndrome in children reported behavioral or
psychiatric concerns in half of the patients.
7
Our findings support case reports in the literature, which
describe an active young adult with insidious onset not related
to 1 specific activity, but associated with movements during
exercise.
7,21
Wright et al only noted trauma in 2 of his 46
cases, whereas other large studies failed to elicit a history of
chest trauma as a cause of pain.
5,17,23
Fu et al
7
reported all of
his cases presented with unilateral chest pain exacerbated by
activity. Patients may report sporting activities like running,
horseback riding, swimming, arm abduction, twisting or
bending as causes of pain, or simply taking a deep breath.
21
Many different activities may be associated with onset,
running, being the most common in our cohort. Two recent
case reports described the acute onset of slipping rib syndrome
related to football and swimming.
12,22
Many athletes will
report stopping participation in a sport secondary to the
recreation of pain with that activity.
11,21
Finally, the results of our study demonstrate a lack of use of
the hooking maneuver. Based on the positive and negative
results from the hooking maneuver that were documented on
the chart, the test had a sensitivity of 70.4% and a false
negative rate of 29.6%.
The first line of treatment for athletes with slipping rib
syndrome is the reassurance of a benign syndrome.
1,18,23
Several studies have recommended reassurance, ice, decreased
activity, and over-the-counter analgesic medication as suffi-
cient for the treatment of pain and eventual return to normal
activities.
9,17,19
Meuwly et al
9
described 2 cases where
reassurance, explanation, and real-time visual demonstration
of sipping rib by ultrasound as sufficient treatment. The use of
high-resolution sonography of the thoracic wall in the
evaluation and treatment of athletes with slipping rib
syndrome may be valuable. Meuwly et al
9
found that the
movement of the cartilaginous rib can be shown accurately,
excluding other diagnoses. The most effective treatment
modality in our study was osteopathic manipulative treat-
ment, and the most commonly used was physical therapy. It is
our hope that with more practitioner confidence in the
diagnosis, reassurance alone will become more effective.
Few studies in athletes have been performed; however, in 2
case reports, pain was refractory to more conservative
therapies.
12,22
These therapies included a rib belt, chiropractic
manipulation, heat, massage, oral NSAIDs, and topical
NSAIDs. Athletes have previously reported minimal relief of
symptoms with 5% lidocaine patch, and with chiropractic
care, which was consistent with our findings.
12,22
Most literature described immediate resolution of pain with
an injection of steroid and numbing medication (lidocaine and
bupivicaine) at the costochondral junction.
2,10,12,23
Intercostal
nerve block is useful in confirming diagnosis and ablating
symptoms.
7,16
However, often the symptoms will reoccur 2 to
3 weeks after the injection and a repeat nerve block will be
needed.
11,18
Some pediatric patients tolerate a local intercostal
nerve block with a short acting anesthetic.
16
The injection may
be performed under ultrasound guidance.
9
If the injection
produces complete relief of the pain, then the cause of the pain
is likely to be musculoskeletal in origin and not visceral.
14,16
Trigger point and botulinum toxin injections were not foundas
used in this cohort, but there has been reported improvement
with trigger point and botulinum toxin injection for pain
associated with slipping rib syndrome.
10
The pain relief was
shorter (48 hours) than with an intercostal nerve block.
1,10,11
The earliest cases reported were treated with surgical excision
resulting in immediate and lasting reliefof pain.
4,6,18,21
Spence et al
18
favored surgical excision of the slipping rib
segment to the level of the midaxillary line, secondary to
intercostal nerve blocks only providing temporary relief. Porter
reported 3 cases of children (average age 14.8 years), who
underwent surgical excision for their pain and all had
good results.
14
Saltzman et al
16
performed a subperiosteal/
subperichondrial resection of the involved rib and cartilage on
12 children (range 7-21 years) diagnosed with slipping rib
syndrome between 1988 and 1999. An intercostal nerve block
was used diagnostically and later the section of rib, at the point
of maximal tenderness preoperatively, was resected.
16
The
limited excision of the offending rib tip and costal cartilage was
found to provide excellent to a satisfactory relief of symptoms in
9 of 12 patients over an average of 29 months (range 1-96
months).
16
Mooney et al
11
preformed subperichondral resection
of the involved cartilages on 4 patients between the ages of 11
and17years.Henotedthatcarewastakentoprotectthe
intercostal nerves. The case series reported symptom relief
postoperatively from 6 weeks to 2½ years after surgery. Fu et al
7
reviewed the outcomes of 7 patients younger than 18 years, who
underwent costal cartilage excision for slipping rib syndrome
between 2000 and 2011. They excised 2.6 61.1 cartilages to the
bone at the point of maximal tenderness. There were no
postoperative complications. At follow-up, an average of 0.9
years (range 0.2-2 years) postoperatively, 5 of the 7 patients had
a complete resolution of presenting symptoms. Copeland et al
5
surgically resected 5 to 7 cm of the subperiosteum and costal
cartilages of affected ribs in adults through a curved excision
over the point of maximal tenderness. Results showed 82% had
relief of their pain in 7 days, and all 17 patients were pain-free at
6 weeks. At postoperative review, all patients remained
symptom-free at a mean of 2.2 years after their surgery (range
6 months to 6 years).
5
Moststudiesofathletesreportreliefof
symptoms with surgery.
911,12,21,22
Our study reported relief in
70% of those athletes who underwent rib resection.
CONCLUSIONS
In this study, most patients with slipping rib syndrome were
young adult female athletes, presenting with insidious onset of
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Copyright 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
unilateral 10th, ninth, or 8 rib pain often related to a sport
with increased upper extremity use. The hooking maneuver
was attempted in fewer than half the patients diagnosed, but
positive in more than half of those tested. We hope our
summary of diagnostic findings (Table 2) will assist in
identification and treatment of patients with slipping rib
syndrome. A superfluous array of diagnostic testing can be
avoided, and the practitioner can proceed confidently with
treatment including reassurance. Our data also suggest less
invasive treatment options including osteopathic manipula-
tive treatment, diclofenac gel, and physical therapy may be
beneficial. If improvement is not sustained, injections and
surgical excision of the associated cartilage seemed to be an
effective approach often leading to the complete resolution of
preoperative symptoms.
References
1. Abbou S, Herman J. Slipping rib syndrome. Postgrad Med. 1989;86:
7578.
2. Arroyo JF, Vine R, Reynaud C, et al. Slipping rib syndrome: dontbe
fooled. Geriatrics. 1995;50:4649.
3. Ballon HSL. Slipping rib. Can Med Assoc J. 1938;39:355358.
4. Bass J Jr, Pan HC, Fegelman RH. Slipping rib syndrome. J Natl Med
Assoc. 1979;71:863865.
5. Copeland GP, Machin DG, Shennan JM. Surgical treatment of the
slipping rib syndrome.Br J Surg. 1989;71:522523.
6. Davies-Colley R. Slipping rib. Br Med J. 1922;1:432.
7. Fu R, Iqbal CW, Jaroszewski DE, et al. Costal cartilage excision for the
treatment of pediatric slipping rib syndrome. J Pediatr Surg. 2012;47:
18251827.
8. Heinz GJ, Zavala DC. Slipping rib syndrome. JAMA. 1977;237:
794795.
9. Meuwly JY, Wicky S, Schnyder P, et al. Slipping rib syndrome: a place for
sonography in the diagnosis of a frequently overlooked cause of
abdominal or low thoracic pain. J Ultrasound Med. 2002;21:339343.
10. Migliore M, Signorelli M, Caltabiano R, et al. Flank pain caused by
slipping rib syndrome. Lancet. 2014;383:844.
11. Mooney DP, Shorter NA. Slipping rib syndrome in childhood. J Pediatr
Surg. 1997;32:10811082.
12. Peterson LL, Cavanaugh DG. Two years of debilitating pain in a football
spearing victim: slipping rib syndrome. Med Sci Sports Exerc. 2003;35:
16341637.
13. Pirali C, Santus G, Faletti S, et al. Botulinum toxin treatment for slipping
rib syndrome: a case report. Clin J Pain. 2013;29:e1e3.
14. Porter GE. Slipping rib syndrome: an infrequently recognized entity in
children: a report of three cases and review of the literature. Pediatrics.
1985;76:810813.
15. Russek LN, Errico DM. Prevalence, injury rate and symptom frequency in
generalized joint laxity and joint hypermobility syndrome in healthy
college population. Clin Rheumatol. 2016;35:10291039.
16. Saltzman DA, Schmitz ML, Smith SD, et al. The slipping rib syndrome in
children. Paediatr Anaesth. 2001;11:740743.
17. Scott EM, Scott BB. Painful rib syndromea review of 76 cases. Gut. 1993;
34:10061008.
18. Spence EK, Rosato EF. The slipping rib syndrome. Arch Surg. 1983;118:
13301332.
19. Taubman B, Vetter VL. Slipping rib syndrome as a cause of chest pain in
children. Clin Pediatr (Phila). 1996;35:403405.
20. Telford KM. The slipping rib syndrome. Can Med Assoc J. 1950;62:
463465.
21. Turcios NL. Slipping rib syndrome in an adolescent: an elusive diagnosis.
Clin Pediatr (Phila). 2013;52:879881.
22. Udermann BE, Cavanaugh DG, Gibson MH, et al. Slipping rib syndrome
in a collegiate swimmer: a case report. J Athl Train. 2005;40:120122.
23. Wright JT. Slipping-rib syndrome. Lancet. 1980;2:632634.
24. Zbojniewicz AM. US for diagnosis of musculoskeletal conditions in the
young athlete: emphasis on dynamic assessment. Radiographics. 2014;34:
11451162.
C.M. Foley et al. (2017) Clin J Sport Med
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... Slipping rib syndrome (SRS) is a rare, painful condition involving the lower ribs of the thoracic cage [1]. The pain in SRS is due to the loosening of the fibrous tissue connecting the costal cartilage of the false ribs to the ribs right above, allowing the foremost to slip under the anterior ribs, thus irritating the intercostal nerves [2][3][4]. Data regarding the condition are scarce, mostly published as case reports or case series. The mean age varies between studies, depending on whether the population was pediatric (14-19 years old) or adult (40-45 years old). ...
... Osteopathic manipulative treatment (OMT) might be an effective alternative to the previously reported treatment options. In a study conducted in young athletes [2], OMT and surgery were the most effective treatments among the investigated treatment options, with almost the same proportions of pain relief. Interestingly, the third most effective modality in the same study was local NSAIDs (diclofenac). ...
... Interestingly, the third most effective modality in the same study was local NSAIDs (diclofenac). Other treatment options have been reported, namely, acupuncture [2] and repeated botulinum toxin injections [11], with insufficient data regarding their effectiveness. ...
Article
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Slipping rib syndrome (SRS) is an uncommon condition, typically affecting young adults and adolescents. The syndrome is mainly characterized by chronic, restrictive pain, caused by the impingement of the loose false rib tips to the adjacent intercostal nerves. The most commonly involved ribs are the 9th, 10th, and 11th ribs. There are several reports and case series reporting the efficacy of surgical interventions for the treatment of SRS. Costal cartilage excision, rib resection, and rib stabilization-plating procedure are successful surgical approaches for the management of slipping rib syndrome.
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Introduction Slipping rib syndrome (SRS) or subluxation of the medial aspect of the lower rib costal cartilages is an underdiagnosed cause of debilitating pain in otherwise healthy children. Costal cartilage excision may provide definitive symptom relief. However, limited data exist on the natural history, difficulty in diagnosis, and patient-reported outcomes for SRS in children. Methods We performed a single-institution descriptive study using chart review and a patient-focused survey for patients who underwent surgery for SRS from 2012 to 2020. Data regarding demographics, symptoms, diagnostic workup, and patient-reported outcomes were collected. Results Surgical resection was performed in 13 children. The median age at symptom onset was 12.5 y [IQR 9.7, 13.9], with a preponderance of girls (10, 77%). Eight patients participated in competitive athletics at the time of symptom onset. Prior to diagnosis, patients were seen by a median 3 [IQR 2, 5] providers with a median of 4 [IQR 3, 6] non-diagnostic imaging exams performed. The children included in the study underwent surgery for left (8), bilateral (4), and right (1) SRS. Two were lost to follow-up. At median post-op follow-up of 3.5 mo [IQR 1.2, 9.6], 73% (8/11) had returned to full activity. One reported non-limiting persistent pain symptoms. Conclusions Lack of knowledge regarding SRS may result in delayed diagnosis, excessive testing, and limitation of physical activity. Operative treatment appears to provide durable relief and should be considered for children with SRS. The challenge remains to decrease the number of non-diagnostic exams and time to diagnosis.
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Article
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Article
The aim of this case report is to shed light on slipping rib syndrome (SRS), a painful and overlooked condition. A 62-year old man reported intermittent, self-resolving sharp rib pain that began after a video-assisted thoracic surgery and chest tube placement 4 years prior to presentation. The patient’s pain was associated with a rigid protrusion in the right upper quadrant, and home use of acetaminophen provided no relief. After physical examination, multiple imaging and lab tests, the patient was diagnosed with SRS and was referred to physical therapy and thoracic surgery for further evaluation. SRS is an under-recognized cause of upper abdominal and lower thoracic pain that should be considered if a patient’s history includes previous trauma or abdominal surgery.
Chapter
Although optimizing sleep with the goal of optimizing athletic performance is gaining support among the athletic community, sleep and its disorders remain under-recognized and underappreciated. This is critically important as athletic performance is impaired by the presence of inadequate sleep and untreated sleep disorders. Athletes are uniquely at a higher risk for certain sleep disorders such as obstructive sleep apnea, including those in collision sports where athletes with larger body mass and neck size have a distinct advantage.
Chapter
While commonly presenting in concert in the symptomatic athlete, chest pain, and dyspnea have myriad causes requiring careful workup and evaluation. Traditionally, chest pain is separated into typical, atypical, and noncardiac, whereas dyspnea can be separated into exertional or with rest. Among young athletes (<35 years), the vast majority of those presenting with chest pain will not have a serious life-threatening disease. In contract, atherosclerotic coronary artery disease predominates in older athletes (>35 years) presenting to the emergency department with chest pain. Concerns about shortness of breath can often be masked as patients typically present with more vague complaints such as decreased performance or exercise intolerance. This chapter will discuss the differential diagnosis of chest pain and dyspnea associated with exercise as well as the steps needed to perform a thorough evaluation. Finally, it will discuss management techniques including contraindications to competition as well as decisions surrounding return to play.
Chapter
Sideline providers should be familiar with a wide range of trauma to the thorax, and catastrophic threat to cardiopulmonary and mediastinal structures must be evaluated first. This includes commotio cordis, pneumothorax, pulmonary contusion, and fractures of the rib and sternum. High-energy and high-contact sports coverage requires proficiency in the few, but critically life-saving, procedures to be performed prior to EMS arrival. Adequate preparation is key, and prompt interventions such as defibrillation and pneumothorax decompression will prove life-saving. Concomitant injuries occur in the setting of chest wall trauma or repetitive overuse. The proper modalities for diagnosis, management, and unique return to play considerations for pectoralis tear, stress fractures of the rib and sternum, slipping rib syndrome, and scapulothoracic bursitis are included in the differential for chest wall injuries.
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A woman with recurrent abdominal pain was found to have the "slipping rib syndrome" by using the hooking maneuver. The diagnosis of this common but little known cause of abdominal and chest pain can often be made by using this simple technique. Rib resection was required for relief of this patient's symptoms. (JAMA 237:794-795, 1977)
Article
Generalized joint hypermobility (GJH) and joint hypermobility syndrome (JHS) are gaining increased attention as potential sources of pain and injury. The aims of this study were to evaluate prevalence of GJH and JHS and to determine whether musculoskeletal injuries and symptoms commonly attributed to GJH and JHS were more common within a "healthy" college student population. The study involved a convenience sample of 267 college and graduate students, aged 17-26. GJH was assessed using the Beighton score with a cutoff of 5/9, while JHS was assessed using the Brighton criteria. Injury history and symptoms were assessed by recall. Prevalence of GJH was 26.2 % overall (females 36.7 %, males 13.7 %). Prevalence of JHS was 19.5 % overall (females 24.5 %, males 13.7 %). Injury rates were not significantly different for individuals who had GJH vs. those who did not have GJH. Individuals with JHS were significantly more likely to have had sprains, back pain, and stress fractures. Symptoms were no different between those with GJH and those who did not have GJH. However, individuals with JHS were significantly more likely to report clumsiness, easy bruising, and balance problems than those who did not have JHS. GJH and JHS were relatively common in this healthy college student population; GJH was not associated with increased incidence of injury or symptoms commonly attributed to JHS, but JHS was associated with increased incidence of some injuries and symptoms.
Article
Ultrasonography (US) is increasingly recognized as an important tool for diagnosis and therapeutic management of a variety of musculoskeletal conditions. Advantages of US use in the young athlete include the ability to diagnose dynamic conditions that are occult with other modalities, provide additional diagnostic information, and aid in treatment. Uses of US in young patients include evaluation of acquired musculoskeletal conditions that manifest with symptoms and assessment of congenital variants that may manifest with pain or limitations in activity. Acquired conditions in the young athlete include tendon disorders, such as proximal tendinosis, and ligament disorders, such as anterior talofibular ligament or ulnar collateral ligament tears. While static images are frequently able to depict these disorders without difficulty, a dynamic examination that provides stress to the joint of interest may be able to uncover a ligament tear or insufficiency and concurrently provide the clinician with information regarding joint stability. Numerous congenital variants that occur throughout the musculoskeletal system can be associated with awkward sensations such as snapping, popping, and clunking and occasionally with pain. Pathologic processes associated with congenital variants in the upper extremities include slipping rib syndrome, atraumatic anterior subluxation of the sternoclavicular joint, and snapping triceps syndrome. Conditions that affect the lower extremities include internal and external snapping hip syndrome, snapping knee syndrome, and medial plica syndrome. The dynamic capability of US is ideal for diagnosis of many conditions that affect the musculoskeletal system of the young athlete, many of which would be difficult or impossible to identify with use of other imaging modalities. Online supplemental material is available for this article. ©RSNA, 2014.
Article
Background: Slipping rib syndrome (SRS) is a musculoskeletal cause of severe and recurrent thoracic or abdominal pain. The etiology of SRS is unknown, it seems to arise from costal hypermobility with a tendency of one of the ribs (usually from 8th to 10th but also 11th and 12th have been described) to slip under the superior adjacent rib. Its prevalence is underestimated because SRS is mainly a clinical diagnosis, frequently missed. The critical aspect of the diagnosis is knowledge of the condition itself, which, when lacking, often results in the patient being referred to many different specialists and exposed to unnecessary and costly investigations. The management of the condition includes conservative techniques such as manipulation, localized anesthetic, and steroid or anesthetic nerve block. However, where conservative therapy fails, surgical treatment, with excision of the rib, may be performed. Methods: In this paper we describe the case of a patient with persistent and debilitating flank pain who, after many investigations, was diagnosed with SRS. Results: The usual conservative treatment failed, after which we treated the patient with injections of incobotulinumtoxin A into muscles inserting on the inferior side of the rib cage (quadratus lumborum muscle, muscle transversus abdomini, abdominal external oblique muscle, and recto abdomini) achieving a complete relief from pain. Conclusions: To our knowledge botulinum toxin has never been proposed before for the treatment of SRS. We believe that it should be considered as a therapeutic option, especially where other medical treatments have failed or as an intermediate step before surgical intervention.
Article
Three cases of slipping rib syndrome are presented. The pertinent anatomy of the costal margin and nerve supply are reviewed. The treatment of the disease is presented along with case histories. This entity is little known to the medical profession, although first described in 1919. Probably far more common than is realized, it should always be included in the differential diagnosis of thoracic and abdominal pain.