Rib-cage injuries can be particularly painful and debilitating. Blunt rib-cage trauma can occur in any sports activity where an individual collides forcefully with balls, pucks, sticks, the ground, objects on the sidelines, and other players. Each year, more than 150,000 football players under the age of 15 seek treatment for injuries in hospital emergency rooms. Studies have shown that 15–20% of players age 8–14 are injured during the football season. Among tackle football players on high school teams, the injury rate is reported as high as 64%. Although many of these injuries are concussions, sprains and strains of the upper and lower extremities, rib-cage injuries constitute from 2.3% to 4.2% of the cases (14).
We report a case of a 14-yr-old victim of a school football spearing incident who sustained a debilitating rib-cage injury that eluded diagnosis for more than 2 yr despite extensive state-of-the-art radiological examination. The ultimate definitive diagnosis was made through a little known, simple clinical examination procedure that could have saved this individual and his family years of pain, medical costs, and disability. In that this injury can occur in any sport with impact to the chest wall from opponents or equipment, including hockey, rugby, gymnastics, etc., clinicians should be more widely aware of this syndrome and diagnostic maneuver. Reporting of this case has received Institutional Review Board approval.
History of symptoms.
A 14-yr-old male walked into a local medical clinic after having been struck in the left flank with the helmeted head of another player during his school football practice. He reported severe pain in the area of blunt trauma. Clinically, he had no wheezing or difficulty in breathing, no light-headedness, no pain radiating to his buttocks or legs, and no loss of muscle tone or strength. His blood pressure was low. Pain resulted upon compression of his left lateral chest wall. His left upper-abdominal quadrant was tender. Erythema over the lower posterior rib cage was apparent. X-rays revealed no rib fractures or splenomegaly.
The pain continued unabated despite 7 d of rest and use of ibuprofen. Pain was noted in the left upper abdomen and over the lower rib cage, both posterior and anterior. No etiology for the pain could be identified, and conservative activity was recommended.
Nineteen months later (1 yr and 220 d after the initial injury), the patient returned complaining that his chronic intermittent pain had worsened after falling off a trampoline and striking his left lower posterior rib cage. The pain was described as stabbing, starting in his back and coming around to his abdomen, and he reported feeling “something moving in there.” Clinically, pain resulted from any pressure over his anterior rib cage. There was also tenderness in his left hypochondrial area with no pain on the right side. There was no tenderness over the spine and no pain on percussion of the spine. There was also some tenderness just below the left rib cage. There was no positive Lloyd’s sign on deep percussion over the kidney.
The pain continued to worsen by day 588, and he was able to pinpoint the pain at the left ninth costochondral junction. He was exquisitely tender over this site. A slight, but palpable ridge was present there. Nine days later, the patient reported that the rib pain had resumed but had been somewhat better with the use of a rib belt. At this time, the rib was visibly projecting out from the rib cage. He remained tender over that rib.
By day 637, he had stopped playing football or doing any other sports. The pain was reported to be 4 on a 1–10 scale. Lifting, yawning, and deep breathing worsened the pain.
Three weeks later, the patient believed that his pain was becoming significantly worse. Marked tenderness over his left lower ribs remained. Two weeks later, the patient reported no pain with sitting but increased pain with twisting or bending. It was recommended that he return to normal daily activities with no gym.
On day 719, the patient continued to have significant pain in his left lower ribs even with ordinary activities like riding in a car, sitting, and walking. Conservative treatment was not helping. On day 725, he reported that he had lost his job at a local grocery store. He repeated that he felt his left lower ribs move when he changed position and when he took a breath. At this point he seemed very depressed with a flat affect.
One week later, the patient was extremely protective and would not allow manipulation. By day 758, the rib pain was such a problem that he no longer tolerated going to school. His grades were being maintained, but he was now in jeopardy of academic probation. To this point, he had been in accelerated high school and some college classes, including calculus. He used to be involved in many sports, but now he could not participate in any. He used to maintain a job but now had none. He had very poor sleep patterns (reportedly 1–2 h·d−1). He now considered himself to be crippled because of the amount of pain in his ribs. He was screened for depression. He denied having depressive symptoms but admitted to a lot of internalized anger because he could not get out and enjoy things.
Seventeen days later he saw a new provider. He no longer had the stabbing pains, but now the pain was persistent. He stated that it never really let up and that it hurt with any kind of movement, including breathing, turning, lifting, and lying. At this point, he reported getting 2–4 h of sleep a night. His mother’s frustration was evident. He was able to point precisely to one exceedingly tender spot at his intercostal space in the midaxillary line on the left as the source of the pain but then followed it laterally. He stated that as the pain became more severe, it migrated along the rib. Once again he reported that he felt as if the ribs were “moving.”
History of examinations.
During the previous 2 yr, the patient had undergone numerous x-rays that revealed no rib fractures or organomegaly. A bone scan utilizing technetium-99m-labeled methylene diphosphonate revealed a normal distribution of radiotracer throughout the skeleton with open growth plates noted in multiple areas. Normal costochondral rosettes were seen at all junctions. The conclusion was that the patient had a normal immature skeleton with no evidence of costochondritis. Computed tomography evaluation of the left lower 10th, 11th, and 12th ribs with extensive sagittal and coronal reconstructions revealed no osseous rib abnormalities, no costochondral disruption, no sternal fractures, no soft tissue abnormalities, no mass, and no significant incidental findings.
For a brief period, partial temporary relief had been obtained by wearing a rib belt. Chiropractic manipulations worsened his pain. A regimen of heat, massage, and physical therapy along with therapeutic rofecoxib for pain management failed to resolve the pain. He had stopped using ibuprofen due to stomach upset, and a 0.75% capsaicin cream and diclofenac did not help.
The only treatment that consistently provided relief was nerve blockade. An initial injection of the costochondral junction with methylprednisolone acetate and bupivacaine provided immediate relief. A repeated bupivacaine and methylprednisone injections around the inferior portion of the 10th rib, just inferior to the costochondral junction near the area of tenderness, again resulted in immediate, albeit temporary (2 to 3 h) relief. Two other intracostal injections were performed, the first of which did not help significantly, whereas a second improved the pain by only approximately 50%.
He reported that the use of a 5% lidocaine patch numbed the skin area, but he could still feel the costochondral joint moving, and it was this movement that was causing most of the pain. Gabapentin therapy with a gradually increasing dosage regimen was attempted, but after 12 d, at which point he was up to 400 mg of gabapentin per day, the patient experienced what he felt to be a slowed heart rate followed by palpitations. He felt that the gabapentin was making no difference in his pain, so he was given propoxyphene, which relieved his pain to a great extent.
Acupuncture and further attempts at physical therapy, a neurology or rheumatology consult, and a psychology consult for depression were all discussed but not elected. Eventually, the patient was advised to attempt dealing with the debilitating chronic pain and to try to resume normal activities.
Final diagnosis and treatment.
On day 778 (2 yr and 58 d after the initial injury), he was home from school again with rib pain and was referred to a different thoracic surgeon who correctly diagnosed and treated the condition. This surgeon was able to reproduce the patient’s pain by pulling the 10th rib up underneath the costicartilages of the ninth rib (the hooking maneuver) (Fig. 1). The patient was again able to pinpoint that the pain originated in the confluence of the costicartilages in the area that he had originally sustained his football spearing injury. From this clinical maneuver, a definitive diagnosis of slipping rib syndrome was made. The family was provided with articles on the syndrome and invited to obtain a second opinion.
Nineteen days later, a clinician who had published on this syndrome was consulted and concurred in the diagnosis. More than 2 yr and 3 months after his initial injury, the 10th rib was surgically resected.
Eight days later, the patient reported that the surgery had completely taken away all the pain he had experienced. He was smiling for the first time in a long time. At 1 month of follow-up, the surgical wound had healed and he was doing very well. At 3 months follow-up, he remained pain free and was once again very active.
The slipping rib syndrome is a rarely recognized cause of abdominal pain in both the pediatric and adult patient populations. The entity was first described in 1919 by Cyriax (4) but not officially named until 1922 by Davis-Colley (5). It was not until 1941 in papers by Holmes that a series of cases was first reported (9,10). McBeath and Keene reported a second series of cases in 1975 (12). In the clinical literature, the syndrome has been variously referred to as Cyriax’s syndrome or sign, Davies-Colley’s syndrome, slipping rib syndrome, slipping rib-cartilage, rib syndrome, rib-tip syndrome, and clicking rib syndrome. Even though the syndrome has been explained anatomically, and there have been successful treatment interventions of the entity, there are still skeptics that insist that the syndrome does not exist and that the syndrome is only found in psychoneurotic types of individuals (1,17).
Most patients with the slipping rib syndrome present to their provider with complaints of pain in their abdomen or chest area. There may be a history of trauma to the chest, but this history may not be obtainable. The trauma may be of a significant nature, or it may have consisted of a minor incident. The pain may be described as a dull sensation, or it may be described as a full-scale stabbing- and shooting-type of pain that radiates from the costochondral area to the chest or to the back. The pain may mimic many visceral types of discomfort, leading to the ordering of many needless laboratory and radiological tests. Surgical procedures such as laparotomies have been done in attempts to unsuccessfully diagnose and treat the abdominal pain (3,17).
Slipping rib syndrome is caused by weakness of the rib-sternum (sternocostal), rib-cartilage (costochondral), and/or rib-vertebral (costovertebral/costotransverse) ligaments allowing areas of rib hypermobility. Unlike ribs one through seven that attach to the sternum, the 8th, 9th, and 10th ribs are attached anteriorly to each other by a cartilaginous cap in children and a fibrous band in adults. This provides both increased mobility and a greater susceptibility to trauma. Most often, the tenth rib is affected because of this loose connection.
A loose rib in the front is also likely to be loose in the back. In a closed system, no motion can occur at one site in a ring without motion somewhere else (e.g., try to break a lifesaver candy and move it without creating a second break and displacement in the ring). In slipping rib syndrome, the rib intermittently slips out of place causing a stretching of the ligamentous support of the rib in the front and back.
Without muscles to hold the ribs in place, loose ligaments allow extended rib movement that can cause further stretching of the ligaments, manifested as periodic episodes of severe pain and underlying chronic chest and/or upper back pain. Sternocostal and costochondral ligaments refer pain from the front of the chest to the mid-back. The loose ribs can also pinch intercostal nerves, sending excruciating pains around the chest into the back (2,13,15,16,18,19). A large proportion of people will have some symptoms posteriorly, even if overshadowed by the anterior dysfunction. Likewise, costovertebral ligament sprains refer pain from the back of the rib segment to the sternum where the rib attaches. Unexplained upper-back pain between the shoulder blades, and costovertebral, rib-vertebrae pain, is likely due to joint laxity and/or weakness in the costotransverse ligaments.
The diagnosis can be based on history (location of the pain—costochondral, retroscapular, association with breathing, pain, and paraesthesia referred to arm); physical findings (tenderness of the specific ribs, reproduction of the index pain by pressure over the ribs, asymmetry of the rib position—comparing side to side and with ribs above and below the index rib(s), restrictions of rib-cage motion); and imaging studies (usually negative) ruling out referred pain from a cervical disk (which can refer to the scapular border). Many of these signs were present in the current case.
However, utilizing the “hooking maneuver” on the affected side of the chest can easily make the diagnosis of the slipping rib syndrome. The technique is a simple one but highly accurate in making the diagnosis. Fingers are placed under the costochondral junction on the side in question, and the hand is pulled in an anterior direction. This maneuver will reproduce the pain. After this diagnostic maneuver, it is then recommended that the patient be given a rib block to see whether the pain can be relieved. If both these tests are positive, the diagnosis of slipping rib syndrome is made. There are no other laboratory or radiology tests that will aid with the diagnosis; thus, the diagnosis is made by these simple techniques alone (8,13).
Injury to the cartilage tissue in the lower ribs or the sternocostal ligaments in the upper ribs seldom completely heals naturally. Treatment of the slipping rib syndrome is divided into three possibilities. If the pain is only a minor irritation, then simple reassurance may be all that is needed. Many times this treatment mode is adequate once the patients are assured that there is nothing seriously wrong with them. For more major cases of pain, it is recommended that rib blocks be tried. In some cases, these blocks will break the pain cycle and the patient will do well. Correction of the posterior dysfunction may remedy the anterior symptoms. The majority of severe pain cases will require resection or repair of the rib and cartilage that slip under the rib above causing the pain to exist. Most of the time the procedure can be done in an outpatient setting, but in other cases, the patients may need to be kept in the hospital overnight (2,11,17).
It is interesting that the slipping rib syndrome, which has been well described, is not mentioned in most major medical textbooks. It is well covered in the osteopathic literature, however (6,7). Practitioners who deal with adult and pediatric age groups, particularly those groups susceptible to rib-cage trauma, need to be aware of the syndrome as a potential cause of abdominal and chest pain. Knowledge of this syndrome can lead to a quick diagnosis, omit the need for many costly diagnostic tests, and lead to quicker definitive care for the patient (2,17).
The authors wish to thank Marshfield Clinic Research Foundation for its support through the assistance of Alice Stargardt, Doreen Luepke, and Graig Eldred in the preparation of this manuscript.
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