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Diagnosis and Treatment of Slipping Rib Syndrome

Foley, Cassidy M., DO*; Sugimoto, Dai, PhD†,‡,§,¶; Mooney, David P., MD, MPH¶,‖; Meehan, William P. III, MD†,‡,§,¶; Stracciolini, Andrea, MD†,‡,§,¶

Clinical Journal of Sport Medicine: January 2019 - Volume 29 - Issue 1 - p 18–23
doi: 10.1097/JSM.0000000000000506
Original Research

Objective: (1) To investigate the clinical presentation, diagnosis, and treatment of slipping rib syndrome in athletes; (2) to investigate the hooking maneuver for diagnosis of slipping rib syndrome.

Design: Retrospective chart review of 362 athletes with rib pain.

Setting: Pediatric-based sports medicine clinic between January 1, 1999, and March 1, 2014.

Patients: Costochondritis, Tietze, fractures, rib tip syndrome, and unclear diagnoses were excluded. Athletes were included who had a palpable rib subluxation, mechanical rib symptom, positive hooking maneuver, or resolution of pain after the resection of a slipping rib segment.

Main Outcome Measures: Slipping rib syndrome is associated with athletic performance.

Results: Fifty-four athletes were diagnosed with slipping rib syndrome, of which 38 (70%) were females. Mean age at presentation was 19.1 years (range 4-40 years). Mean number of previous specialist consultations per athlete was 2.3 and mean time from symptom onset to diagnosis was 15.4 months. The hooking maneuver was attempted 21 times (38.9%). Unilateral symptoms presented in 49 athletes (90.7%). The most symptomatic rib was the 10th, affecting 24 athletes (44.4%), eighth and ninth were affected in 17 athletes (31.5%) each. Most, 39 (72.2%), reported insidious onset of symptoms. Running, rowing, lacrosse, and field hockey were frequently associated activities. Twelve athletes had psychiatric diagnoses (22.2%), 10 (19.2%) were hypermobile. Sixty-six total imaging studies were performed. The most successful treatment options included: osteopathic manipulative treatment (71.4%), surgical resection (70%), and diclofenac gel (60%).

Conclusions: Most athletes with slipping rib syndrome were active females with insidious onset of unilateral pain, a high prevalence of hypermobility and prolonged pain. The hooking maneuver was underused.

*Pediatric Orthopedic Associates, Next Level Sports Medicine, Atlanta, Georgia;

The Micheli Center for Sports Injury Prevention, Waltham, Massachusetts;

Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts;

§Division of Emergency Medicine, Department of Medicine, Boston Children's Hospital, Boston, Massachusetts;

Harvard Medical School, Boston, Massachusetts; and

Department of Surgery, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts.

Corresponding Author: Cassidy M. Foley, DO, Nemours Children's Hospital, 13535 Nemours Parkway, Orlando, FL 32827 (

W. P. Meehan receives royalties from ABC-CLIO publishing for the sale of his book, Kids, Sports, and Concussion: A guide for coaches and parents and royalties from Wolters Kluwer for working as an author for UpToDate. His research is funded, in part, by a grant from the National Football League Players Association and by philanthropic support from the National Hockey League Alumni Association through the Corey C. Griffin Pro-Am Tournament.

The authors report no conflicts of interest.

Received March 11, 2017

Accepted July 22, 2017

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