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Case Report

Slipping rib syndrome: A neglected cause of hypochondrial

pain
Yasser Ali Kamal
Department of Cardiothoracic Surgery, Faculty of Medicine, Minia University, El‑Minya, Egypt

Abstract 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

Address for correspondence: Dr. Yasser Ali Kamal, Department of Cardiothoracic Surgery, Faculty of Medicine, Minia University, El‑Minya, 61519, Egypt.
E‑mail: yaser_ali_kamal@yahoo.com
Received: 17‑Jun‑2019, Revised: 10‑Jul‑2019, Accepted: 18‑Sep‑2019, Published: 05-Dec-2019

INTRODUCTION disease. The patient was diagnosed previously to

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
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
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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 3a].
During surgery, there was free‑floating of the right
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DOI:
10.4103/fjs.fjs_49_19 How to cite this article: Kamal YA. Slipping rib syndrome: A neglected cause
of hypochondrial pain. Formos J Surg 2019;52:229-31.

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Kamal: Slipping rib syndrome

10th rib [Figure 3b]. After the preservation of the intercostal DISCUSSION

neurovascular bundle [Figure 3c], the anterior end of the rib
was resected [Figure 3d]. During 9 months of postoperative
follow‑up, the patient was pain‑free with no complications.
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]

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
Figure 1: Hooking maneuver 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]

Table 1: Causes of chest wall pain

Diseases associated with chest wall pain
Musculoskeletal diseases
Chest trauma
Figure 2: High‑definition ultrasound shows the movement of the
Costochondritis
10th cartilage costal (large arrow) underneath the upper rib (small arrow)
Tietze syndrome
while pushing on the lower costal cartilages
SRS
Intercostal muscle strain or pulled chest muscle
Stress fracture
Nerve entrapment
Fibromyalgia
Rheumatic diseases
Rheumatoid arthritis
Ankylosing spondylitis
Psoriatic arthritis
Lung diseases
a b Pneumonia
Pulmonary embolism
Cardiovascular diseases
Heart attack
Angina
Pericarditis
Myocarditis
Gastrointestinal diseases
Peptic ulcer
c d Esophagitis
Figure 3: (a) Intraoperative marking of the incision at the right Gastroesophageal reflux disease
lower chest wall, (b) Intraoperative view of the slipped rib (arrow), Gallstones
(c) Preserved intercostal neurovascular bundle after rib resection, Pancreatitis
(d) Resected anterior end of the right 10th rib SRS: Slipping rib syndrome

230 Formosan Journal of Surgery | Volume 52 | Issue 6 | November-December 2019

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Kamal: Slipping rib syndrome

CONCLUSION Conflicts of interest

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.
Financial support and sponsorship
Nil.
There are no conflicts of interest.
REFERENCES
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3. Turcios NL. Slipping rib syndrome: An elusive diagnosis. Paediatr
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4. Heinz GJ, Zavala DC. Slipping rib syndrome. J Am Med Assoc
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5. McMahon LE. Slipping rib syndrome: A review of evaluation, diagnosis
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6. 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.
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syndrome: Solving the mystery of the shooting pain. Am J Med Sci
2019;357:168‑73.

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