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Year : 2019  |  Volume : 52  |  Issue : 6  |  Page : 229-231

Slipping rib syndrome: A neglected cause of hypochondrial pain

Department of Cardiothoracic Surgery, Faculty of Medicine, Minia University, El-Minya, Egypt

Date of Submission17-Jun-2019
Date of Decision10-Jul-2019
Date of Acceptance18-Sep-2019
Date of Web Publication05-Dec-2019

Correspondence Address:
Dr. Yasser Ali Kamal
Department of Cardiothoracic Surgery, Faculty of Medicine, Minia University, El-Minya, 61519
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/fjs.fjs_49_19

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Slipping rib syndrome (SRS) is an under-recognized cause of lower chest and upper abdominal pain. We described this rare condition in a 27-year-old female with chronic right hypochondrial pain. The condition was initially diagnosed as irritable bowel. Extensive imaging studies and laboratory investigations failed to determine the underlying cause of pain for 2 years. The diagnosis was made clinically by hooking maneuver and on ultrasound. After the failure of nonsteroidal anti-inflammatory drugs therapy and intercostal nerve block to improve symptoms, surgical resection of the anterior end of the free-floating right 10th rib was performed. Awareness of SRS can help rapid diagnosis and treatment of a benign cause of abdominal upper quadrant pain.

Keywords: Abdominal pain, chest pain, hooking maneuver, slipping rib syndrome

How to cite this article:
Kamal YA. Slipping rib syndrome: A neglected cause of hypochondrial pain. Formos J Surg 2019;52:229-31

How to cite this URL:
Kamal YA. Slipping rib syndrome: A neglected cause of hypochondrial pain. Formos J Surg [serial online] 2019 [cited 2020 Jul 8];52:229-31. Available from: http://www.e-fjs.org/text.asp?2019/52/6/229/272317

  Introduction Top

Slipping rib syndrome (SRS), also known as painful rib syndrome, clicking rib syndrome, rib-tip syndrome, twelfth rib syndrome, or Cyriax syndrome, was described for the first time by Cyriax in 1919.[1] It is an under-recognized cause of lower chest and upper abdominal pain. The true prevalence of SRS is unknown, but it can occur at any age with more frequency in middle-aged adults.[2]

  Case Report Top

A 27-year-old female with a 2-year history of recurrent right hypochondrial and lower chest pain was referred for evaluation. She complained an intermittent, sharp pain preceded by abdominal distension, deep inspiration, or bending and relieved by lying flat. This condition significantly affected the daily activities of the patient. There was no history of trauma or common systematic disease. The patient was diagnosed previously to have irritable bowel. Previous evaluations revealed unremarkable findings on abdominal ultrasound, chest radiograph and computed tomography (CT), bone scan, intravenous pyelogram, and laboratory investigations. On examination, there was tenderness in the right subcostal area. Hooking maneuver [Figure 1] was positive with reproduced pain when the fingers of the examiner were placed under the right lower costal margin with pulling of the hand in an outward and upward direction. On high-definition ultrasound, the 10th cartilage costal moves underneath the upper rib while pushing on the lower costal cartilages [Figure 2]. There was temporary relief of pain after nonsteroidal anti-inflammatory drugs (NSAIDs) therapy and two attempts of an intercostal nerve block. The final diagnosis was SRS, and the decision was for surgical removal. The incision was made a lower right chest wall corresponding to the site of pain [Figure 3]a. During surgery, there was free-floating of the right 10th rib [Figure 3]b. After the preservation of the intercostal neurovascular bundle [Figure 3]c, the anterior end of the rib was resected [Figure 3]d. During 9 months of postoperative follow-up, the patient was pain-free with no complications.
Figure 1: Hooking maneuver

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Figure 2: High-definition ultrasound shows the movement of the 10th cartilage costal (large arrow) underneath the upper rib (small arrow) while pushing on the lower costal cartilages

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Figure 3: (a) Intraoperative marking of the incision at the right lower chest wall, (b) Intraoperative view of the slipped rib (arrow), (c) Preserved intercostal neurovascular bundle after rib resection, (d) Resected anterior end of the right 10th rib

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  Discussion Top

SRS is a rare and benign cause of chest and abdominal pain which may be confused with life-threatening conditions [Table 1]. The underlying mechanism of pain in SRS is impingement of the intercostal nerve associated with rib hypermobility after the weakness of costochondral, sternocostal, or costovertebral ligaments. The false ribs (8th–10th) are often affected as they had cartilaginous or fibrous anterior attachment to each other, resulting in an increase of its mobility and a greater susceptibility to trauma and subluxation.[2],[3]
Table 1: Causes of chest wall pain

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The diagnosis of SRS is based on its clinical identification by hooking maneuver, while imaging studies could help ruling out other conditions.[3],[4] The differential diagnosis of SRS includes rib fracture, Tietze syndrome, costochondritis, pleuritic pain, biliary disease, hepatosplenic issues, peptic ulcer, renal colic, esophagitis, and pancreatitis.[5] In some reports, ultrasonic image was helpful for the evaluation of the dynamic condition of slipping ribs, as it could determine the displaced cartilages and the level of rib abnormalities.[5],[6]

The treatment of SRS includes reassurance, NSAIDs, physical therapy, and intercostal nerve block. However, failure of the conservative treatment indicates surgical resection of the anterior end of the rib and costal cartilage, with favorable postoperative outcome.[3],[7]

  Conclusion Top

Awareness of SRS can help rapid diagnosis and treatment of chronic lower chest and/or abdominal pain and prevent unnecessary extensive investigations and interventions.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Cyriax EF. On various conditions that may simulate the referred pains of visceral disease, and a consideration of these from the point of view of cause and effect. Practitioner 1919;102:314-22.  Back to cited text no. 1
Turcios NL. Slipping rib syndrome in an adolescent: An elusive diagnosis. Clin Pediatr (Phila) 2013;52:879-81.  Back to cited text no. 2
Turcios NL. Slipping rib syndrome: An elusive diagnosis. Paediatr Respir Rev 2017;22:44-6.  Back to cited text no. 3
Heinz GJ, Zavala DC. Slipping rib syndrome. J Am Med Assoc 1977;237:794-5.  Back to cited text no. 4
McMahon LE. Slipping rib syndrome: A review of evaluation, diagnosis and treatment. Semin Pediatr Surg 2018;27:183-8.  Back to cited text no. 5
Van Tassel D, McMahon LE, Riemann M, Wong K, Barnes CE. Dynamic ultrasound in the evaluation of patients with suspected slipping rib syndrome. Skeletal Radiol 2019;48:741-51.  Back to cited text no. 6
Fares MY, Dimassi Z, Baydoun H, Musharrafieh U. Slipping rib syndrome: Solving the mystery of the shooting pain. Am J Med Sci 2019;357:168-73.  Back to cited text no. 7


  [Figure 1], [Figure 2], [Figure 3]

  [Table 1]


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