Slipping Rib Syndrome

What is slipping rib syndrome?

Slipping rib syndrome is a little-known cause of musculoskeletal chest pain that comes and goes. It comes on suddenly and severely before tapering off. Sometimes there’s a popping or clicking sensation with it.

It happens when the cartilage that attaches two of your lower ribs together loosens or becomes unstable. This causes one of the ribs to slip in and out of place, irritating your intercostal nerve.

Slipping rib syndrome goes by many other names. Just a few of them include displaced rib, clicking rib syndrome, floating rib syndrome, gliding rib syndrome, rib-tip syndrome and Cyriax syndrome.

The medical term is interchondral subluxation. Subluxation is a partial dislocation of a joint. Your interchondral joints are where the cartilage (chondral) tips of your lower ribs connect to the rib above.

How common is this condition?

Recent data suggests that slipping rib syndrome accounts for about 5% of all cases of chest wall pain. Unfortunately, not all healthcare providers are aware of the condition, so it often goes undiagnosed.

What does a slipping rib feel like?

When your rib first slips, the pain can feel sudden, sharp and stabbing. You may feel or hear your rib “clicking” or “popping” as it moves across your other rib. After that, the pain may linger as a dull ache.

Most people notice this pattern repeating over time. Your rib might slip when you cough or sneeze or move in a certain way. Even something like reaching overhead or rolling out of bed might trigger it.

A slipping rib can irritate the intercostal nerve that runs between your ribs. This probably triggers the sharp, localized pain you feel at first. Eventually, it may also inflame the soft tissues around your rib.

This may cause a more diffuse type of pain that’s harder to locate in one place. It might feel like lower chest pain or upper abdominal pain. Sometimes, it radiates to your upper back or one of your flanks.

Which ribs does slipping rib syndrome affect?

You have twelve ribs, numbered from top to bottom. Slipping rib syndrome affects ribs eight through ten. These are called your “false ribs,” because they don’t attach directly to your breastbone (sternum).

Instead, each false rib attaches to the rib above it. These attachment sites, made of cartilage, are your interchondral joints. Weakening of one of these joints causes one of your false ribs to slip out of place.

The terms “floating rib syndrome” and “floating rib pain” are misnomers for slipping rib syndrome. Your “floating ribs” are your bottom ribs eleven and twelve. These ribs don’t have interchondral joints.

They’re called “floating ribs” because they don’t attach to your breastbone or your other ribs, only to your spine. These ribs can’t “slip” in the same way. But you may feel pain in the tissues around them.

What causes slipping rib syndrome?

Your rib slips when the cartilage at the interchondral joint is weakened or displaced. This might happen suddenly or gradually. In some cases, it might be present at birth. Possible contributing causes include:

• Congenital weakness (birth defect)
• Joint hypermobility (when your joint or joints have an abnormally wide range of motion)
• Overuse of your joints (repetitive strain injury)
• Traumatic injury (such as an accident or sports injury)

How do you test for slipping rib syndrome?

A healthcare provider investigating your pain will often start by taking images, like a chest X-ray or CT scan. But a slipping rib usually won’t show up in still images. Your provider will need to see it in action.

One way it might show up is on a dynamic ultrasound — an ultrasound taken while you perform certain movements. Twisting, coughing, the Valsalva maneuver, or others might make your rib slip in real time.

But if your healthcare provider already suspects slipping rib syndrome, they can check for it during a physical exam. They do this by reproducing your symptoms with a test called the “hooking maneuver.”

For this simple test, your provider hooks their fingers under the lower boundary of your ribcage and gently lifts it upward. This reproduces the pain of slipping rib syndrome, and sometimes the pop or click.

How do you fix a slipping rib?

Sometimes, a slipping rib heals on its own. If it’s not bothering you too much, your provider might suggest waiting and watching to see if it does. They’ll suggest conservative treatments to ease your pain, like:

• Hot/cold therapy
• Over-the-counter pain medications, like NSAIDs
• A period of rest, followed by physical therapy

If this approach isn’t working, they might suggest an intercostal nerve block — an injection of medication to calm your irritated nerve. This provides temporary relief, and sometimes it helps the healing process.

Surgery

If your symptoms don’t improve over the long term, you might need surgery to fix slipping rib syndrome. Surgeons use minimally invasive methods, like video-assisted thoracic surgery (VATS), whenever possible.

Surgery to fix a slipping rib might mean:

• Tightening or repairing loose ligaments or cartilage with stitches (stabilization)
• Removing the damaged or detached cartilage tip (partial rib resection)
• Using metal plates to separate ribs that are sliding together (rib plating)

What can I expect if I have this condition?

Getting a diagnosis for slipping rib syndrome is half the battle. Once your healthcare provider recognizes the condition, healing can begin. Many people find relief over time through conservative treatments.

Not everyone will need surgery for slipping rib syndrome, but surgery is usually successful if you do. Occasionally, there’s an unrecognized cause that leads to symptoms returning later in another rib.