Despite the fact that slipping rib syndrome (SRS) was first described by Cyriax1 in 1919 as part of nonvisceral abdominal pain and that many cases of SRS have been published, this entity usually remains undiagnosed or misdiagnosed for months or years, during which the patient has recurrent abdominal or chest pain with needless evaluations.2,3
SRS also is referred to in the medical literature as rib-tip syndrome,4 twelfth rib,5 clicking rib,6 painful rib syndrome,7 interchondral subluxation,8 and nerve nipping9 and is associated with hypermobility of the anterior end of the costal margins of the 8th, 9th, and 10th ribs,2,10,11 which, in contrast to the other ribs, are not attached to the sternum and are only joined to each other by loose fibrous tissue. The prevalence is 1% to 5% in general medical practice,11 but this could be an underestimation because of the lack of knowledge of this syndrome12 and the lack of diagnostic testing to corroborate the clinical findings of the hooking maneuver.13 The treatment approach to this condition requires medical information about the nature of pain,13,14 administration of local anesthetic medication,4,11 and surgical excision of the rib.3,4,15–17 We present a 41-year-old woman who was diagnosed with SRS after 7 months of abdominal and chest pain.
Written consent was obtained from the patient to publish this case report.
A 41-year-old woman presented to the clinic with 1 week of abdominal pain and general malaise. The abdominal pain was diffuse, came suddenly with cramps, lasted 4 to 6 hours, was exacerbated by physical activity and Valsalva maneuvers, and nothing relieved it. The patient had no history of fever, diarrhea, constipation, nausea, vomiting, acholia, or choluria. She had a previous cholecystectomy and had no drug allergies. Findings of the patient’s examination were unremarkable. She was treated with 10 mg hyoscine butylbromide daily and diagnosed as having nonspecific abdominal pain.
Three months after the onset of pain with no changes in its characteristics, the patient was referred to a gastroenterologist, who requested a laboratory evaluation including blood tests of hepatic function; hepatitis A, B, and C serology; C-reactive protein; celiac disease and thyroid hormones; chest radiograph; abdominal ultrasound; magnetic resonance imaging; and magnetic resonance cholangiography. The findings of these studies were normal, and she was discharged with nonsteroidal anti-inflammatory drugs.
Seven months later, the patient’s pain persisted. She was referred by the gastroenterologist to the pain unit, where she was given opioids and experienced partial relief of her abdominal symptoms. She then returned to our clinic because the characteristics of her pain had changed. She described continuous dull pain at the right anterior inferior rib margin, radiating along the costal margin, which was exacerbated by right arm movements. On examination, a tender spot at the tip of the 10th rib was found and the hooking maneuver reproduced her pain. On the basis of her history, clinical, and laboratory findings, the patient was diagnosed with SRS and treated successfully with local infiltration of 1 mL betamethasone acetate and 2 mL of 1% lidocaine hydrochloride along the right subcostal margin. The pain was completely eased and has not recurred.
SRS is a relatively unknown cause of mechanical pain. Its pathophysiology could be explained by the hypermobility of the false ribs (8th, 9th, and 10th) because of the loose fibrous tissue that connects these ribs to each other.1,2,11,15 If this fragile junction increases its laxity, this triggers repetitive subluxation of the interchondral cartilages and allows a rib to slip behind the rib above it.1,2
SRS is a diagnosis of exclusion; for that reason, thoracic and abdominal diseases must be excluded.3,12,14 Radiologic images are useful to exclude diseases in the differential diagnosis.12–14 High-resolution sonography has been proposed as a tool to confirm the clinical findings.13 The etiology is often unknown, but apparently recognized3,4,12 or unrecognized6,7,13 trauma to the chest wall could precipitate this syndrome.
The characteristic pain is described as an intermittent sharp stabbing in the lower thoracic or upper abdominal region that increases with activities such as breathing, coughing, bending, or twisting the trunk.3,11,12,15 It is generally unilateral, but bilateral cases also have been published.6,7 An important characteristic of our case is the initial presentation as abdominal pain and its change 7 months after onset.
Once the entire diagnostic workup is completed, the patient should be re-examined. On physical examination, the hooking maneuver15 usually reproduces the pain (Fig. 1). This maneuver is more complicated to perform in obese patients and children. The physician places the fingers under the inferior rib margin and pulls the hand in an anterior direction. Pain or clicking indicates a positive test and the contralateral side will serve as a control.3
There are some reasons why the diagnosis of SRS is delayed. First, it is a diagnosis of exclusion that involves a workup with consequent waiting time. Second, physicians may be inexperienced with respect to this entity. Physicians usually are not trained to look for painful points on the abdominal or thoracic wall and more commonly focus their efforts to find pain of visceral origin. When physicians do not find an obvious reason for the pain, they tend to minimize the patient’s symptoms and only consider psychiatric explanations. Third, SRS is neglected in undergraduate clinical training and medical textbooks, so physicians are unfamiliar with it and do not consider it as a possible diagnosis.7,18 Fourth, physicians tend to display medical skepticism about a patient’s pain. Despite the anatomical explanation of this pathophysiology, skeptics argue that SRS does not exist,18 or is part of a psychological disorder, and they refuse to consider this clinical diagnosis. Fifth, there is often a lack of a multidisciplinary approach3,16 to the diagnosis of unexplained abdominal or chest pain. To avoid needless tests and diminish the patient’s ordeal, an SRS diagnosis should be considered by thoracic surgeons, gastroenterologists, radiologist, psychiatrists, and anesthesiologists. Sixth, the inconsistency of SRS pain because of variable anatomy and uncertain location is the main reason for misdiagnosis. Damage to the accompanying intercostal nerve may explain the variability in pain and could cause a problem in accurately localizing the pain. Finally, the lack of a diagnostic test to corroborate the clinical findings has been considered one of the most important reasons why the diagnosis is missed.13
The management of SRS depends on the severity of its symptoms.3,15–17 In mild pain, avoiding activities that exacerbate the pain should be enough.13 Patients with moderate-to-severe pain may benefit from intercostal nerve block or local anesthetic infiltration. In refractory cases, surgery is the definitive treatment. Botulinum toxin also has been considered when patients are unresponsive to medical treatments or before surgical options are used.12 Because of the lack of follow-up of many of the patients reported, data regarding the efficacy of the treatment options are sparse.
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