Expert: Dr. J. Shawn Leatherman - 9/26/2008

Question
I am 17 years old and in a weight lifting gym class.  Ignorantly, yesterday I put on a weight belt prior to maxing on a front squat.  My 240 lb teacher decided to tighten it as tight as it could possibly get.  It was literally as TIGHT as possible.  I can't stress that enough.  I questioned if it was too tight; he said no.  

So I went down for the squat and something popped in my rib.  It was not necessarily painful, but very uncomfortable.

I asked him about it-- he brushed it off.

The rest of the day, I could move my hand around under my rib and feel the popping.  Again, not painful, but very uncomfortable.

I slept on it fine, and then woke up this morning feeling the same as yesterday.  Throughout the school day, it began to get a little painful, and then the pain would subside.  Occasionally it throbs.

Since this evening, I have been feeling nauseous and I have a headache along with the discomfort under my rib.


I haven't been to a doctor.  
Should I be concerned? Or will this heal easily without me seeing a doctor?

Thanks for your time.

Answer
Dear Hannah,

A few conditions come to mind here:  intercostal muscle strain, rib subluxation, or slipping rib syndrome.  It really sounds like you have either pulled a muscle around the rib area (the intercostal musculature)or you have displaced the rib head away from either the vertebral connection of the sternal connection (subluxation).  Both of these issues are not big concerns, but if the rib has been slightly displaced in position, you should have that re-approximated by a chiropractic physician so that it does not continue to place abnormal stress on the associated joint capsule.  Long term stress on the joint capsule will create laxity and instability that can be chronic.  Now, you could have created a worse situation called slipping rib syndrome which is usually not very painful, however it can be very uncomfortable.

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 Hannah.  By the way, many high school weight lifting coaches injure students because they push them harder than what they are conditioned for.  I see anywhere from 5-10 high school kids a year in my office after they have been injured in weight lifting classes.  Please proceed with caution in this class.

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


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