Slipping Rib Syndrome: Symptoms, Diagnosis and Treatment

01What

What is slipping rib syndrome?

Ribs 1 to 7 attach to the breastbone through their own cartilage. Ribs 8 to 10 are called false ribs: their cartilage joins the rib above rather than the breastbone, held by fibrous tissue. Ribs 11 and 12 are “floating ribs” with no front attachment. In slipping rib syndrome, the fibrous attachment of one of the false ribs is lax or torn, so the rib tip can slip under or over the rib above, pinching the intercostal nerve that runs along each rib. The condition has been described for more than a century but remains under-recognised.

02Symptoms

Symptoms

• Sharp, stabbing pain under the lower ribs at the front or side, usually on one side.
• A dull, aching pain that lingers after the sharp pain.
• A clicking, popping or slipping sensation.
• Pain triggered by bending, twisting, lifting, reaching, coughing, deep breathing or sitting slouched.
• Pain lying on the affected side.
• Tenderness over the lower rib margin.
• Pain may be mistaken for gallbladder, stomach or other abdominal problems.

03Causes

Causes and who is affected

• Sports involving twisting and contact, such as swimming, rowing, hockey and rugby.
• Direct trauma to the lower ribs or a fall.
• Forceful coughing or vomiting.
• Hypermobility of joints in some people.
• It can affect children and teenagers, particularly athletes, as well as adults.
• Often there is no clear cause.

04Diagnosis

How it is diagnosed

Diagnosis is mainly clinical. In the hooking manoeuvre, the clinician hooks their fingers under the lower rib margin and pulls it gently forward; reproduction of the typical pain, sometimes with a click, supports the diagnosis. Dynamic ultrasound, performed while you move or strain, can show the rib slipping. X-rays and CT scans are usually normal but help exclude other causes. Because the pain can mimic abdominal conditions, some people have many tests before the diagnosis is made. Other rib and chest wall problems are discussed in chest muscle strain.

05Conservative

Non-surgical treatment

• Avoid or modify movements that trigger pain, such as deep twisting or heavy lifting.
• Use good sitting posture and avoid slouching.
• Apply heat or ice for comfort.
• Take paracetamol or anti-inflammatories if suitable.
• Physical therapy: posture work, trunk stability exercises and manual techniques around the ribs.
• Rib belts or taping may help some people during activity.
• Intercostal nerve blocks with local anaesthetic, with or without steroid, can provide relief and help confirm the diagnosis.

06Surgery

Surgery

If pain persists despite conservative treatment and significantly affects life, surgery may be considered. The traditional operation removes the mobile segment of cartilage (costal cartilage excision); newer techniques stabilise the rib with sutures or plates. Studies in children and adolescents report that most patients have meaningful pain relief after cartilage excision, although some have recurrence and need further treatment. Surgery is usually performed by thoracic or paediatric surgeons experienced in the condition.

07Living

Living with slipping rib syndrome

• Learn which movements trigger your pain and adapt them rather than avoiding activity altogether.
• Strengthen the core and upper back to support the ribcage.
• Warm up before sport and progress training gradually.
• Sleep on the unaffected side or your back, with pillows for support.
• Pain flares often settle within days with rest from triggers.
• Support from a physical therapist familiar with the condition helps.

08Cases

Three common situations

• Teenage swimmer with sharp pain under the ribs and a click: slipping rib syndrome should be considered after other causes are excluded.
• Adult with months of “stomach” pain and normal scans: pain at the rib margin reproduced by the hooking manoeuvre points to a rib cause.
• Rugby player with recurrent pain after a tackle: a physical therapy programme and, if needed, a nerve block can help.

09Exercises

Exercises that may help

• Diaphragmatic breathing: slow breaths into the belly and lower ribs, 5 minutes a day, to reduce rib-cage tension.
• Posture resets: sit tall with the ribs stacked over the pelvis, several times an hour.
• Dead bug and bird dog: build trunk control without heavy twisting, 3 × 8 each side.
• Side-lying thoracic rotation (open book) within a pain-free range, 8 each side.
• Scapular retraction with a band, 3 × 12, to support the upper back.
• Avoid deep crunches, heavy rotational lifts and positions that reproduce the click until a physical therapist has assessed you.

10Summary

Key points to remember

• Slipping rib syndrome involves loose cartilage of the lower ribs irritating a nerve.
• It causes sharp pain with a click, often mistaken for abdominal problems.
• The hooking manoeuvre and dynamic ultrasound help diagnose it.
• Activity changes, physical therapy and nerve blocks help; surgery is for persistent cases.