Slipping rib syndrome in an adolescent: an elusive diagnosis

Costal margin reconstruction for slipping rib syndrome: Outcomes of more than 500 cases and advancements beyond earlier sutured repair technique

Objectives

To evaluate results of sutured repair for slipping rib syndrome (SRS), identify failure points, and discuss technique modifications to improve outcomes through costal margin reconstruction (CMR).

Methods

Patients undergoing repair of SRS between February 2019 and February 2024 at an academic referral institution were retrospectively analyzed. Pain scores, quality of life, pain medication use, and reoperations were evaluated pre- and postoperatively at 1 and 6 months. In patients failing sutured repair we identified specific failure points and devised a new CMR technique to overcome them. Subsequent CMR patients were followed at 1, 6, 12, 18, and 24 months using the same outcome measures.

Results

Four hundred forty-nine patients underwent repair. Two hundred forty-one patients underwent sutured repair with revision required in 66. Median time to revision was 14 months. CMR was developed and performed in 247 patients. In CMR patients, preoperative mean pain score of 7.5 out of 10 dropped postoperatively to 4.0, 2.5, 1.9, 1.3, and 0.9 at 1, 6, 12, 18, and 24 months, respectively (P < .001). Mean quality of life of 38% improved to 73%, 83%, 88%, 93%, and 95% at the same intervals (P < .001). Preoperatively, 29% of patients chronically used opioid medications. Opioid use dropped postoperatively to 11%, 4%, 4%, 0%, and 0% at the same intervals. Use of nonopioid medications followed a similar pattern. One CMR patient required full revision.

Conclusions

SRS is a debilitating, but correctable disorder. Improved pain and quality of life, reduction in chronic opioid use, and freedom from revision surgery suggest that CMR should be considered the standard operation for SRS.

Slipping rib syndrome: A clinical and dynamic-sonographic entity. A serial cases report

BACKGROUND

Slipping rib syndrome (SRS) consists of false or floating rib hypermobility, which can force the ribs to come into contact with each other.

OBJECTIVE

We aimed to examine each case by dynamic ultrasound to determine their ultrasound characteristics and analyze the clinical features of patients with SRS in order to better manage and follow them up.

METHODS

Retrospectively, we collected 14 case series presenting to SRS between June 2016 and September 2018. The diagnosis was clinical and confirmed by dynamic ultrasound maneuvers.

RESULTS

The mean age was 35.00 ± 10.66 years and 64.29% was male. The pain mechanism was caused by repetitive movements or a traumatic event. Dynamic ultrasound was considered a very useful tool for the diagnosis. Different conservative treatments were applied in most cases. Eco-guided infiltration was also an option.

CONCLUSIONS

SRS should initially be based on a clinic suspicion in order to achieve a correct diagnosis and management. It is an underdiagnosed syndrome, so these case series contribute to our knowledge regarding this syndrome.

Slipping rib syndrome: case report of an iatrogenic result following video-assisted thoracic surgery and chest tube placement

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.

Slipping rib syndrome in an adolescent wrestler

Slipping rib syndrome is a commonly missed diagnosis of upper abdominal pain. It results from hypermobility of the anterior rib due to the disruption of the interchondral ligaments, most likely secondary to repetitive motions or some inciting event. The hypermobility leads to impingement of the intercostal nerves resulting in significant pain.A 10-year-old adolescent male child was evaluated for 4 months of intermittent, left-sided, upper abdominal pain following a wrestling injury. His paediatrician referred him for further evaluation after a negative workup given the patient was still having intermittent bouts of short-lasting pain that would spontaneously resolve. Physical examination demonstrated a positive hooking manoeuvre with associated swelling and prominence over the lower left ribs.In conclusion, a broad differential diagnosis, thorough clinical examination, and knowledge of slipping rib syndrome are important to appropriately diagnose and treat patients symptoms.

Diagnosis and Treatment of Slipping Rib Syndrome

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.

Peripheral neuropathic mimics of visceral abdominal pain: Can physical examination limit diagnostic testing?

BACKGROUND

The emergency department evaluation of patients with abdominal pain is most appropriately directed at identifying acute inflammation, infection, obstruction, or surgical disease. Doing so commonly involves "routine" (and often extensive) diagnostic imaging and laboratory testing. Benign mimics of serious visceral abdominal pain that can be diagnosed by physical exam and confirmed with local anesthetic injections have been identified over the last century. These syndromes derive from painful irritation of the intercostal nerves by a mobile rib below, or from impingement of the cutaneous branches of those same intercostal nerves as they penetrate the abdominal wall. These peripheral neuropathic mimics of visceral abdominal pain continue to go unrecognized and underdiagnosed.

METHODS

Our purpose is to review the affirmative diagnosis of non-visceral abdominal pain by physical examination.

RESULTS

The consequences of failure to identify these conditions are considerable. In the search for a diagnosis that is literally at the provider's fingertips, patients frequently undergo months to years of fruitless and often invasive diagnostic tests, not uncommonly including unsuccessful surgeries.

CONCLUSIONS

With proper consideration of and appropriate testing for visceral etiologies, a carefully directed physical examination may yield an affirmative diagnosis in a percentage of these common emergency department patients.

Slipping Rib Syndrome in a Female Adult with Longstanding Intractable Upper Abdominal Pain

Slipping rib syndrome is a rare cause of abdominal or lower chest pain that can remain undiagnosed for many years. Awareness among health care personnel of this rare but significant disorder is necessary for early recognition. Prompt treatment can avoid unnecessary testing, radiographic exposure, and years of debilitating pain. A 52-year-old female was evaluated for a 3-year history of recurrent abdominal and lower chest pain. Pain was sharp, primarily located in the lower chest and subcostal region left more than right, waxing and waning, nonradiating, and aggravates with specific movements. She underwent frequent physical therapies, treated with multiple muscle relaxants and analgesics with minimal improvement. Imaging modalities including CT scan, MRI, and X-rays performed on multiple occasions failed to signify any underlying abnormality. Complete physical examination was unremarkable except for positive hooking maneuver. Dynamic flow ultrasound of lower chest was performed which showed slipping of the lowest rib over the next lowest rib bilaterally left worse than right, findings consistent with slipping rib syndrome. Slipping rib syndrome is caused by hypermobility of the floating ribs (8 to 12) which are not connected to the sternum but attached to each other with ligaments. Diagnosis is mostly clinical, and radiographic tests are rarely necessary. Hooking maneuver is a simple clinical test to reproduce pain and can aid in the diagnosis. Reassurance and avoiding postures that worsen pain are usually helpful. In refractory cases, nerve block and surgical intervention may be required.

Sternocostal slipping rib syndrome

PURPOSE

Classical slipping rib syndrome (SRS) can be subclassified based on anatomical location. We describe our experience with three patients suffering from symptomatic sternocostal slipping rib syndrome (SCSRS), a much less common variant of SRS.

METHODS

This was a retrospective review of patients with SRS from 1988 to 2016. Described is our experience.

RESULTS

Of 44 patients identified with SRS, three patients underwent operations for SCSRS variant. All three had significant pain and point tenderness at the sternocostal junction, and all experienced a popping sensation localized to this area. The mean age at onset was 14.3 years and mean time to diagnosis was 1.3 years. All patients experienced total resolution of symptoms following localized excision of the offending cartilage.

CONCLUSIONS

A high index of suspicion based on history and physical examination are key to the early diagnosis of SCSRS. Excision of the symptomatic cartilage is effective for treatment.

Thoracoabdominal Injuries

Trauma to the thorax and abdomen can occur during participation in sports. This chapter reviews some of the more common presentations of such injuries and how such injuries should be best managed. Thoracic injuries reviewed include internal injuries such as pneumothorax, pulmonary contusion, hemothorax, commotio cordis, and cardiac contusion. Chest wall injuries are also reviewed such as rib fractures, costochondritis, and slipping rib syndrome plus sternal and scapular fractures. Abdominal injuries reviewed are focused on internal organ trauma to the spleen and liver, kidney, pancreas, and bowel. There is attention to the effect of Epstein-Barr virus and infectious mononucleosis, seen very frequently in high school and collegiate athletes. Finally, groin pain and athletic pubalgia are described.

In addition to anatomy and clinical presentation, imaging modalities that characterize such trauma are reviewed for each diagnosis. Prevention of thoracoabdominal injuries and return-to-play decisions are described at the chapter conclusion.

Slipping Rib Syndrome: An elusive diagnosis

Slipping rib syndrome remains rarely recognized and frequently undiagnosed or misdiagnosed. Awareness of this condition may prevent extensive and unnecessary diagnostic evaluation and avoid chronic debilitating pain. Persistent lower chest and/or upper abdomen pain after analgesic treatment may suggest the possibility of this disorder. The diagnosis of this syndrome, is a clinical one, based on history and the hooking maneuver. A few cases have been published in the literature, giving no clear consensus about the treatment of this condition. In this overview article, clinical manifestations, diagnostic approach, and treatment modalities of this syndrome will be discussed.

The effectiveness of costal cartilage excision in children for slipping rib syndrome

PURPOSE

Slipping rib syndrome (SRS) is an elusive diagnosis. Previous reports have been single cases or small series. We previously reported a small multicenter review with encouraging early results. We now describe our matured experience.

METHODS

This is a follow-up study of patients with SRS from 2006 to 2015. Included are 5 previously analyzed patients and 25 new patients. Patients were called to review current symptoms, course, and satisfaction.

RESULTS

From 2006 to 2015, 30 patients underwent 38 operations. Eight underwent re-operation. All had reproducible pain localized to the costal margin, 60% had a popping sensation, and 23% were bilateral. 86% were female. Median age of symptom onset was 14 (IQR 13.75-15) years, while median age at diagnosis was 16 (IQR 15-17). Contact was possible with 18/30 patients, and mean follow up time was 1.3years. 72% of those felt they were cured, and 44% rated satisfaction a 10/10 (mean 7.84). Of those not cured, all reported significant improvement.

CONCLUSIONS

Costal cartilage excision is an effective treatment for SRS and should be considered early in the workup of costal margin pain in a normally active population. Case Series with no Comparison Group - Level IV.

The slipping rib syndrome: A case report

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The slipping rib syndrome is a condition hard to recognize.

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By performing a hooking maneuver the diagnosis slipping rib syndrome can be made.

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When pain medication is not sufficient, resection of the rib can be performed.

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Knowledge of the syndrome can prevent unnecessary comprehensive treatment.

We present a case report and review of literature about slipping rib syndrome, a syndrome rarely recognized and often un or misdiagnosed. In literature there is no clear consensus about the diagnosis and treatment. We present a case of a 47 year old man who was diagnosed with slipping rib syndrome after a cycling incident 8 years ago. Also, we developed a flow chart according the diagnostic and therapeutic steps in the treatment of slipping rib syndrome.

Central massage

Knowledge and treatment of the slipping rib syndrome can prevent chronic complaints and unnecessary comprehensive treatment.