Thoracic Spine Series: Slipping Rib Syndrome
Slipping Rib Syndrome can be incredibly painful and is often misdiagnosed. It’s also also known as rib dislocation, rib subluxation, Tietze syndrome, Davies–Colley’s syndrome, rib-tip syndrome, painful rib syndrome, costochondral separation, and clicking or moving rib syndrome.
The rib cage is made up of 24 total ribs, with 12 on each side, and these ribs connect to the vertebral column at the back of the rib cage, and connect to the sternum which is the chest plate, at the front of the rib cage. The ribs are connected to the spine (costo-transverse joint) and sternum (costo-chondral joint) through a network of ligaments, with the exception of the bottom two ribs on each side known as floating ribs, because they only connect to the spine and do not connect to the sternum.
Ribs become slipping ribs due to hypermobility (too much motion) of the ribs at their attachment sites. The underlying issue is thought to be due to damaged or stretched ligaments that connect the ribs to both the spine and sternum (1). This is commonly caused by seat belt injuries in car accidents, and collisions in contact sports.
Slipping ribs can create many different types of pain. Common symptoms are:
- Intermittent sharp stabbing pain in the upper abdomen or back, followed by a dull, achy sensation
- Intermittent sharp stabbing pain in upper back, mid back or even lower back
- Slipping, popping, or clicking sensations in the lower ribs
- Difficulty breathing
- Numbness in arm or around the chest or abdomen
- Worsening of symptoms when bending, lifting, coughing, sneezing, deep breathing, stretching, or turning in bed
Since ribs can cause many different symptoms, it is not uncommon for patients to have multiple unnecessary diagnostic tests to rule out problems with heart, lungs, stomach, gallbladder or kidneys before finally getting diagnosed with rib dysfunction (1). Many patients have seen multiple physicians through multiple specialties (cardiologists-heart doctor, gastroenterologists-stomach doctor, pulmonologist-lung doctor). Scott found that as high as 3% of all patients that see a gastroenterologist (GI doctor) have rib instability as the cause of their symptoms.
Does Slipping Rib Syndrome show up on X-ray?
The condition is characterized by hypermobility at the sterno-costal, costochondral or rib-vertebral sites caused by weakness or damage of the associated ligaments (2, 3). This condition does NOT show up on x-rays and typically a diagnosis through exclusion.
The diagnosis is made by a simple clinical test-hooking maneuver, during which the clinician’s fingers are placed under the affected rib margin and pull forward. If this reproduces the pain, clicking or a moving sensation the test is positive (4).
How long does it take for a slipped rib to heal?
It’s very common for athletes involved in contact sports to get a slipped rib. Trauma causes stretching and sometimes tearing of the ligament attachments of the rib, creating the instability. We also see this in many of our motor vehicle accident patients, caused by the seat belt and/or airbag. Once damaged, it can take several weeks to resolve (4-12 weeks). After 3 months, if the rib continues to be problematic it’s unlikely that it will heal on its own.
Can a chiropractor fix a slipped rib? How do you treat a slipped rib?
As an Osteopathic Physician, I have extensive training in manual medicine and manipulation techniques. If a rib is dislocated and causing pain, the simple treatment would be a single small adjustment to re-locate the rib. The problems arise when the rib then subsequently goes back out of place and needs continuous adjustments weekly, or in some cases daily.
A New Treatment Approach: Perc-Orthobiologic Rib Stabilization (PORS)
Prolotherapy, platelet rich plasma, and in some cases bone marrow concentrate, can be used to treat this condition. If the underlying problem is hypermobility of the ligaments that control the rib, why not treat these ligaments with something that can strengthen the ligaments, effectively reducing the hypermobility? Prolo therapy is a solution of high concentration of glucose (sugar water) that has been utilized for the last century to treat laxity in ligaments (5).
Here is a link describing more about prolo therapy: https://centenoschultz.com/prolotherapy/
In recent years advancement in ligament treatment options have advanced to include both platelet rich plasma and bone marrow concentrate treatment (6, 7).
While these can be excellent alternatives compared to more invasive surgeries, these injections are not without risks and you need to consider who is able to perform these injections safely and effectively. Many prolotherapists still utilize a “feel and poke” method for injecting.
Clink on link, where Dr. Schultz explains the importance of utilizing the most advanced imagine guidance to allow precise injections into the desired structures.
Please be aware, the risk of complications from blind injections can increase drastically if no direct visualization is used. The advent of musculoskeletal ultrasound has made it possible to visualize soft tissue structures and avoid the things we don’t want to inject (nerves, blood vessels) and directly inject the ligament! These treatments are high level advanced injections and you need to have the proper training to do these safely – here is a video done by Dr. Centeno explaining interventional orthopedics.
While rib instability can be disabling at times, we have created a treatment option aimed at treating the underlying issue to resolve symptoms and improve function. If you feel you have been dealing with a rib issue, feel free to contact the Centeno-Schultz Clinic to set up an evaluation so we can assess your candidacy for rib stabilization treatment.
1. Turcios NL. Slipping Rib Syndrome: An elusive diagnosis. Paediatr Respir Rev. 2017;22:44-6. https://www.ncbi.nlm.nih.gov/pubmed/27245407
2. Peterson LL, Cavanaugh DG. Two years of debilitating pain in a football spearing victim: slipping rib syndrome. Med Sci Sports Exerc. 2003;35(10):1634-7. https://www.ncbi.nlm.nih.gov/pubmed/14523297
3. Udermann BE, Cavanaugh DG, Gibson MH, Doberstein ST, Mayer JM, Murray SR. Slipping Rib Syndrome in a Collegiate Swimmer: A Case Report. J Athl Train. 2005;40(2):120-2.
4. Kaczynski J, Dillon M, Hilton J. Superior subluxation of an anterior end of the first rib in a trauma patient. BMJ Case Rep. 2012;2012:bcr0220125796.
5. Rabago D, Reeves KD, Doherty MP, Fleck M. Prolotherapy for Musculoskeletal Pain and Disability in Low- and Middle-Income Countries. Phys Med Rehabil Clin N Am. 2019;30(4):775-86.
6. Hevesi M, LaPrade M, Saris DBF, Krych AJ. Stem Cell Treatment for Ligament Repair and Reconstruction. Curr Rev Musculoskelet Med. 10.1007/s12178-019-09580-4
7. Sit RWS, Wu RWK, Law SW, et al. Intra-articular and extra-articular platelet-rich plasma injections for knee osteoarthritis: A 26-week, single-arm, pilot feasibility study. Knee. 10.1016/j.knee.2019.06.018