Slipping rib syndrome is a painful medical condition that occurs as a result of the instability of the lower ribs (1). This causes impingement of soft tissue and intercostal nerves. Pain is typically at the lower, anterior border of the rib cage. It is most commonly unilateral with pain that involves the right or left ribs. Slipping rib syndrome is often misdiagnosed. It is also known as rib dislocation, rib subluxation, Dave-Colley’s syndrome, rib-tip syndrome, painful rib syndrome, costochondral separation, and clicking or moving rib syndrome.
Rib Popped Out Upper Back? Likely A Rib Subluxation
Ribs provide important protection of the heart, lungs, and other organs in the thoracic cavity in addition to aiding in respiration. Ribs 1-7 also called the true ribs and attach to the sternum by costosternal joints and ligaments. The false ribs, numbers 8-10 unlike the ribs 1-8 do not connect directly to the sternum. Rather they are connected to each other through costal cartilage and ligaments. Defects or laxity in the costal cartilage and ligaments cause hypermobility of the anterior ends of the false ribs, number 8-10. This instability allows slippage of one rib underneath the one above it. The slipped rib leads to injury of ligaments, tendons, and muscles and irritation or injury of the intercostal nerve. The intercostal nerves are important nerves that run on the under surface of the ribs and control the muscles of respiration.
Symptoms of Rib Subluxation
The pain associated with slipping rib syndrome can vary significantly. Patients typically present with sudden-onset pain secondary to fast, jerking motions that include sneezing, sneezing, laughing, or leaning over. Pain may be
Intermittent Sharp Stabbing Pain
Constant Diffuse Low-Grade Pain
Pulsatile Diffuse Pain
The pain may be localized in a number of different locations that include:
Around the belly button (umbilicus)
Across the chest wall extending to the spine
Arm Pain at Night
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Upper back pain between the shoulder blades is also known as interscapular pain. Fifteen percent of the population suffers from chronic upper back pain. Finding the source of interscapular pain can be tricky because the upper back houses many important structures like the heart, the upper lobes of the lung, the cervical spine, the scapulas, and a dozen or so of muscles and nerves.
Ribs # 8, 9, 10 also known as the false ribs are held in place by ligaments, fascia, and costochondral cartilage. Injury to any can cause slipping rib syndrome.
Thick pieces of connective tissue that connect bone to bone. In the thoracic spine, there are lots of ligaments that attach the ribs to the thoracic spine. These include attachments between the rib head and the transverse process of the vertebral body. They include the lateral and superior costotransverse ligaments which are illustrated below in yellow and red. Two important joints are formed where the rib head joins the vertebral body: costotransverse and costovertebral.
Costochondral cartilage are bars of hyaline cartilage that connect the front portion of the rib with the sternum (3). They extend the ribs forward and provide elasticity for the thoracic chest wall. The cartilage can become weak either trauma, congenital deformities, or hypermobility. Costochondral cartilage weakness allows the rib to slip underneath the adjacent superior rib creating injury to the muscles, tendons, ligaments, fascia, and intercostal nerves.
Fascia is sheets of connective tissue that attach and support various structures throughout the body. In the thoracic spine, the fascia connects all the ribs and controls local movement along with the intercostal muscles. Slipping rib syndrome can occur when there is damage to the thoracic fascia with one or more ribs moving too much.
Anatomical Review: How A Rib Gets Popped Out Of Your Upper Back
The rib cage is made up of 24 total ribs, with 12 on each side. There are 3 principal types of ribs:
True Ribs: Ribs 1-7th. They attach anteriorly to the sternum by ligaments and costosternal joints. Posteriorly they attach to the thoracic vertebral body and form two joints: costotransverse and costovertebral.
False Ribs: Ribs 8-10. They are connected to each other through the costochondral cartilage.
Floating Ribs: Ribs 11-12. They aren’t attached anteriorly to the sternum. Rather they are floating.
Slipping rib syndrome is a condition that affects ribs 8-10, the false ribs. Due to weakness or injury of the costochondral cartilage, ligament, or fascia, one rib slips underneath the superior rib creating injury to muscles, tendons, ligaments, and intercostal nerves. The result is pain, inflammation, and dysfunction.
How A Slipped Rib Can Be Misdiagnosed
The thoracic cavity contains many structures such as ribs, thoracic spine, nerves, muscles, ligaments, tendons, discs, facet joints, costotransverse, costovertebral joints, and costochondral cartilage. Unlike the cervical and lumbar spine, it also contains vital organs such as the lungs, the heart, the kidney, the liver, and the pancreas.
Each of these structures is susceptible to injury with resultant pain. Is the pain coming from the rib, the disc, or an internal organ such as the heart? Accordingly, It is not uncommon for patients with slipping rib syndrome sot have multiple unnecessary diagnostic tests to rule out problems with the heart, lungs, stomach, and gallbladder before finally getting diagnosed with rib dysfunction. Many patients have seen multiple physicians and multiple medical specialists that include cardiologists (heart), pulmonologists (lungs), and gastroenterologists (stomach). Research has found that as high as 3% of all patients that have seen a gastroenterologist have rib instability as the cause of their symptoms.
A slipped rib can also be misdiagnosed or missed altogether due to the vague nature and location of the pain. For some patients, the pain is diffuse and intermittent. For others, it may be localized along the abdomen. This can make the diagnosis of slipped rib difficult.
Questions Your Doctor Should Be Asking About Your Ribs
Patients with rib dysfunction and pain that does not respond to conservative care and rest should seek medical attention. Given that slipping rib syndrome can be difficult to diagnose it is important that your physician take a detailed history. Specific questions should include:
How did the pain start?
Did the pain start slowly over time or was there a specific injury with immediate onset of pain? What was the injury and how did it occur? Did you hear a pop?
What makes the pain worse?
Activities or postures that aggravate the pain need to be identified. Is the pain worse with coughing, twisting, and side bending?
What makes the pain better?
Alleviating factors are important to identify and can help with making an accurate diagnosis. Does rest or heat help?
Where is the pain?
Is the pain vague and diffuse in character? Or are you able to specifically point to it? Does it involve the rib near the spine or anteriorly near the sternum (chest plate)?
Any significant past medical history?
Do you have a history of lung diseases such as asthma, emphysema, or pneumonia? Any cardiac history such as heart attack, arrhythmias, or blood vessel blockage?
Any treatments to date?
A list of any and all treatments to date can be helpful. Did they help the pain and dysfunction? How long did the relief last?
Do Slipping Ribs Show Up on X-Rays?
Slipping rib syndrome occurs as a result of hypermobility of the costochondral and associated ligaments (2). X-rays are static radiographic tests that do not evaluate hypermobility. Slipping rib syndrome typically does not show up on x-rays or CT scans and exposes patients to unnecessary radiation. In a small number of patients, the extra motion may be so severe that it can be seen on an x-ray as a misaligned rib.
The diagnosis is made by a thorough physical examination of the ribs. the most common finding is tenderness along the costal cartilage. The diagnosis is confirmed by the Hooking maneuver. During this maneuver, the clinician’s fingers are placed under the affected rib which is then pulled forward. If this reproduces the pain, it confirms the diagnosis of slipping rib syndrome.
Dynamic ultrasound however has been demonstrated to be effective in diagnosing slipping rib syndrome (4). High-resolution ultrasound can demonstrate the movement of the ribs, and compression of muscles, tendons, and intercostal nerves.
When appropriate conservative therapy should be the first treatment. The benefit of these treatments is they are readily available in most communities with no permanent side effects. Options include:
Avoiding heavy lifting, pushing, and pulling can reduce muscle spasms and pain. Rest allows the body time to heal.
Heat or Ice
Ice can reduce inflammation and pain whereas heat can improve blood flow and healing.
Ibuprofen, naproxen and diclofenac are oral NSAIDs that can reduce inflammation and swelling. They have serious side effects which have been previously discussed.
Topical analgesics are creams, gels, or lotions that contain different analgesics such as lidocaine, capsaicin, and NSAIDs.
Physical therapy can provide stability and muscular strengthening.
Rib Braces and Chest Binders
Braces and binders limit rib movement thereby minimizing tissue damage.
Osteopathic Manipulative Therapy
Osteopathic manipulative therapy has been found helpful in the treatment of slipping rib syndrome (5). OMT can improve lymphatic and circulatory function and calm autonomic responses.
The Chiropractic Approach
Chiropractors and osteopathic physicians have a detailed understanding of anatomy, physiology, and the importance of symmetry and stability. Each is equipped with special manual adjustment techniques to restore symmetry and balance. In the case of slipping rib syndrome, a small adjustment may be able to relocate the slipped rib. Unfortunately, if there is a defect or weakness in the costocartilage the rib more likely than not will simply slip out again due to instability. Patients then are forced to return for continuous adjustments weekly or in some cases daily. There is a better solution which is discussed below.
Advanced Medical Treatments
There is a major difference between treating the symptoms associated with slipping rib syndrome and actually addressing and treating the underlying problem. Addressing the underlying problem is best.
If the underlying problem is the instability of the costochondral cartilage and ligaments, why not treat these areas with something that can strengthen both thereby effectively reducing the instability? Two treatment options exist.
Prolotherapy is the injection of an irritant solution, typically high concentrations of glucose that have been utilized extensively to treat ligament laxity (5). The injected irritant creates an inflammatory response which kicks starts the healing cascade. Unfortunately, many prolotherapy practittioners do not x-ray or ultrasound during the injections. Rather they palpate boney landmarks and inject based on palpation. In the thoracic spine, this is a poor choice given the proximity of the lungs
PRP stands for platelet-rich plasma. At the Centeno-Schultz Clinic, this is one of many different treatment options for slipping rib syndrome. All injections are performed by board-certified physicians using ultrasound and or x-ray guidance. PRP contains a large number of growth factors from your own blood that promotes your body’s natural ability to repair itself. Both PRP and bone marrow concentrate have been demonstrated to be effective advanced medical treatments in patients with slipping rib syndrome and other types of rib disorders (6).
How Long Does It Take For A Slipped Rib to Heal?
It is very common for athletes involved in contact sports to get a slipped rib. Trauma causes stretching and injury of the costochondral and ligaments leading to rib instability. It is also frequently seen in patients who have been involved in motor vehicle accidents. Once damaged, it can take several months to resolve after PRP or prolotherapy. Why? This is due to the 3 phases of healing which are reviewed below.
The other day I was evaluating a patient and reviewing the treatment options for their spine condition. After discussing prior treatments, we got to the topic of medications taken for pain relief. She explained that she mainly utilized anti-inflammatory (NSAID) medications and then she told me to hold much she takes and has been for many years…..she takes close to 2 grams (2000 milligrams) on a daily basis which equated to about 9-10 capsules of medication per day. I was shocked, considering she was pre-diabetic and with high blood pressure plus the kicker of it is that her PCP (primary care physician) is ok with this…
PRP is short for platelet-rich plasma, and it is autologous blood with concentrations of platelets above baseline values. The potential benefit of platelet-rich plasma has received considerable interest due to the appeal of a simple, safe, and minimally invasive method of applying growth factors. PRP treatments are a form of regenerative medicine that utilizes the blood healing factors to help the body repair itself by means of injecting PRP into the damaged tissue. In regenerative orthopedics, it is typically used for the treatment of muscle strains, tears, ligament and tendon tears, minor arthritis, and joint instability. There have been more than 30 randomized controlled trials of PRP…
Prolotherapy is an injection based regenerative therapy used in the treatment of ligament, tendon, muscle and spine injuries. It is minimally invasive and involves the injection of an irritant such as dextrose into the damaged or painful area. The injected irritant stimulates a delayed or frozen healing cycle thereby increasing blood flow and tissue healing. The thoracic spine is that section of the spine that is below the neck and above the low back. It is also referred to as the mid back. It has multiple components that include: Vertebral Bodies: Boney building blocks that stack one upon another…
It has been successful in the treatment of many disorders including neck, shoulder, knee, and ankle pain. Dr. Centeno recently published an article in The Journal of Prolotherapy in which he discusses the use of x-ray guidance with prolotherapy. This ensures that the injection is in the correct place to maximize clinical results. Dr. Centeno discusses the use of prolotherapy for the treatment of neck, knee, sacroiliac joint, ankle, ischial tuberosity, and shoulder pain. At the Centeno-Schultz Clinic x-ray guided prolotherapy is just one of the therapies utilized in the successful treatment of pain. Regenerative injection therapy (RIT) or prolotherapy…
Don’t Let A Slipped Rib Get In The Way of Having a Normal Life
Slipping rib syndrome is a painful medical condition that occurs as a result of the instability of the lower ribs. Pain is highly variable but typically involves only one side. Causes of slipping rib syndrome include ligament, costochondral cartilage, or fascia injury or weakness leading to instability. There are three principal types of ribs: true, false, and floating. A slipped rib can also be misdiagnosed or missed altogether due to the vague nature and location of the pain. X-rays and CT scans are both static tests that do not demonstrate a slipped rib. Dynamic ultrasound is effective in the diagnosis and treatment of a slipped rib. Advanced medical treatments for slipping rib syndrome include ultrasound-guided prolotherapy and PRP.
While rib instability can be disabling at times, we have created a treatment option aimed at identifying and treating the underlying issue to resolve symptoms and improve function. If you feel you have been dealing with rib dysfunction, please contact us for an evaluation and candidacy for rib stabilization treatment. At the Centeno-Schultz Clinic, we are experts in the evaluation and nonsurgical treatment of rib injuries.
John R. Schultz M.D. is a national expert and specialist in Interventional Orthopedics and the clinical use of bone marrow concentrate and PRP for orthopedic injuries. He is board certified in Anesthesiology and Pain Medicine and underwent fellowship training. Dr. Schultz has extensive experience with same day as well as culture expanded bone marrow concentrate and sees patients at the CSC Broomfield, Colorado Clinic, as well the Regenexx Clinic in Grand Cayman. Dr. Schultz emphasis is on the evaluation and treatment of thoracic and cervical disc, facet, nerve, and ligament injuries including the non-surgical treatment of Craniocervical instability (CCI).
The Spine Owner’s Manual: How to Avoid Back Pain & Life-Altering Surgery
This e-book from Dr. Chris Centeno focuses on the spine and how it functions within the human musculoskeletal system and the body as a whole. Everything in our bodies works together like a well-tuned symphony to support our well-being, and a strong spine (including all of its component parts, such as spinal nerves, ligaments, muscles, etc.) is critical to complete health.
Using the Regenexx SANS approach, The Spine Owner’s Manual provides a series of tests and clearly defined exercises that you can do on your own to measure and monitor your own spinal health. These musculoskeletal tests will allow you to monitor where your own body might be struggling to maintain proper stability, articulation, symmetry, and neuromuscular function.
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