Expert: Dr. J. Shawn Leatherman - 4/30/2008

Question
I am 23 years old and i suffered an injury in 10th grade when i fell on my ribs and hurt them very badly.I never told anyone because i was sneaking out of my parents house.I've always had some mild discomfort for a breif time here and there but recently over the last week it seems to be worse than ever.When i sneeze it pops and it feels like it is pinching something on the inside of my body.As well my bottom 2 ribs are slightly pertruding..i'm kind of worried! What should i be concearned about that could happen to me if i let it go without treatment.I do not have medical insureance.

Answer
Dear Jessica,

It sounds like you have slipping rib syndrome.  Slipping rib syndrome is a condition that is often misdiagnosed or undiagnosed and can subsequently lead to months or years of unresolved abdominal and/or thoracic pain. Surgical findings suggest the condition arises from hypermobility of the anterior ends of the false rib costal cartilages, which often leads to slipping of the affected rib under the superior adjacent rib. This slippage or movement can lead to an irritation of the intercostal nerve, strain of the intercostal muscles, sprain of the lower costal cartilage, or general inflammation in the affected area.

The medical literature primarily refers to this condition as slipping rib syndrome. However, it has also been referred to as clicking rib, displaced ribs,interchondral subluxation, nerve nipping, painful rib syndrome, rib tip syndrome, slipping rib cartilage syndrome, traumatic intercostal neuritis,11 and 12th rib syndrome. Many cases have been described in the medical literature, but this condition is rarely mentioned in present-day medical textbooks and often is not clinically known by doctors.

The syndrome may be the result of trauma, but many cases have been reported in which no thoracic or abdominal trauma had occurred. Clinically, patients often note intermittent sharp 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 the symptoms.

The differential diagnosis of slipping rib syndrome includes a variety of medical conditions, such as cholecystitis (gall bladder inflammation), esophagitis, gastric ulcer, hepatosplenic abnormalities, stress fracture, inflammation of the chondral cartilage, and pleuritic chest pain. A quick way to rule out these conditions is to look for an association between certain movements or postures and pain intensity, determining if the patient has experienced recent trauma (although not always present), and reproduce the symptoms (eg, pain, clicking) with the hooking maneuver. The hooking maneuver is a relatively simple clinical test. The clinician places his or her fingers under the lower costal margin and pulls the hand in an anterior direction. Pain or clicking indicates a positive test. It is recommended that the hooking maneuver be followed with a rib block (injection) to see if the pain can be relieved. Radiologic imaging is generally not useful in the diagnosis of slipping rib syndrome but may be of value in ruling out other conditions in the differential diagnosis.

Once the diagnosis of slipping rib syndrome has been made, you have to realize that nothing is seriously wrong. Avoidance of movements or postures that exacerbate symptoms may be sufficient in eliciting a successful outcome. However, in patients with more severe pain and dysfunction, nerve blocks, prolotherapy and surgical intervention may be necessary. Conservative and surgical outcomes reported in the literature have generally been good. Yet these results should be viewed with some caution, as clinicians may not be as forthcoming in reporting failed case reports and case series.

Bottom line:  rest and restrict activity that makes the pain worse.  If you cannot do this, prolotherapy or nerve block injections may offer immediate help and resolve the issue.  Surgical resolution is the last option by may be indicated if no appreciable improvement is noted.  Hope this helps Jessica.

Respectfully,
Dr. J. Shawn Leatherman
www.suncoasthealthcare.net