Could Slipping Rib Syndrome Be Causing Your Back Pain?

If you’ve ever read up on back pain, you probably know that your lower back and your neck, which are very mobile, are much more prone to injury than your mid- and upper back (thoracic spine). But that doesn’t help you much when your upper back is a morass of pain.

But what if it wasn’t even your back? If not your back, then what? Could be a rib.

Slipping rib syndrome is a rare disorder known by several alternative names. If you’ve heard terms such as floating rib syndrome, lost rib syndrome, costal chondritis, or costochondritis, they each refer to slipping rib syndrome. In addition, slipping rib syndrome is often called Tietze syndrome, as German surgeon Alexander Tietze discovered the condition.

Slipping rib syndrome is characterized by inflammation of the rib’s cartilage. The inflammation typically causes chest pain in the upper rib area. This benign condition usually affects people under 40 years of age, including some children.

The name “slipping rib syndrome” would seem unlikely to involve your spine. However, this condition can cause severe back pain in your thoracic spine. You feel the pain when one of your ribs shifts out of normal position. For some patients, chest wall pain is their first introduction to slipping rib syndrome.

To learn about the workings of any medical condition, a quick review of the related anatomy is useful. To understand how slipping rib syndrome develops, an explanation of your body’s rib structures is a good starting point.

First, everyone has 12 pairs of ribs, with one set on each side of your body. Starting at the top, the first set of ribs attaches to the first thoracic vertebra (referred to as T1). The remaining ribs make attachments down to the T11 vertebra. Costovertebral ligaments attach the ribs to the thoracic vertebrae.

The first seven rib sets are connected to the thoracic vertebrae in your back and the sternum (or breastbone). In the front of the rib cage, and between the ribs, are the costochondral joints and costal cartilage. These ribs are referred to as true ribs.

The costal cartilage has considerable elasticity, allowing for expansion of the rib cage. When you take a deep breath, for example, the cartilage allows your rib cage to expand to accommodate the extra volume of air.

False Ribs and Floating Ribs

The remaining five ribs are “false ribs.” This unusual term results from the fact that ribs 8-10 are not actually connected to the sternum. Instead, these ribs are connected by a fibrocartilaginous band from the rib above.

The last two ribs have no connection at the front of the body. For this reason, these ribs are sometimes called floating ribs. Because these lower ribs are not completely connected, they are most often involved in slipping rib syndrome.

The thoracic spine’s facet joints are another relevant anatomical feature. Your body contains 24 of these facet joints (12 on either side at the back of each thoracic vertebrae). When a rib slips at T10 or T11, there is an opportunity for facet joint involvement. If this occurs, you can experience considerable pain.

Slipping rib syndrome has several possible causes, but no definitive source has been established. Certain individuals may have an inherited risk for this condition.

In addition, researchers have stated their belief that slipping rib syndrome results from small rib injuries. Following are several potential sources of injury:

• Traumatic rib cage injury (from an auto accident or a fall)

• Fall or collision during contact sports

• Repetitive or demanding physical activities

• Upper respiratory tract infections, including sinusitis or laryngitis

• Respiratory conditions such as asthma or bronchitis

• Excessive or violent coughing episodes

• Severe vomiting episodes

Back pain is a common slipping rib syndrome symptom. The back pain results from abnormal rib movement, which irritates surrounding nerves and muscles. In turn, this triggers inflammation and subsequent pain.

Characteristics of the Inflammation

Pain in the specific area results from inflammation of the affected rib’s cartilage. The inflammation can lead to swelling that can become hard and spindle-shaped. The area may look red or swollen, and it may feel warm and tender.

Patients with slipping rib syndrome also report these symptoms:

• Initially intense abdominal pain (eventually subsides to an ache)

• A “clicking” or “popping” sensation in the rib cage area

• Difficulty breathing or coughing

• Pain with bending or other activities that move the rib cage

Some slipping rib syndrome patients may experience severe pain, making it challenging to perform their daily activities. For example, wearing a bra or turning over in bed can lead to excruciating pain. Breathing difficulties are another potential complication.

If a patient receives an injection during a treatment procedure, an injury could cause a pneumothorax. This term refers to a partially or completely collapsed lung. This can result from an air leakage into the space between the lung and chest wall.

Major Complications Are Uncommon

Salman Zaheer, MBBS, a cardiothoracic surgeon at Loma Linda University Health, states that slipping rib syndrome alone does not produce major complications. In addition, the condition does not cause damage to internal organs.

When to See Your Doctor

Slipping rib syndrome symptoms can be uncomfortable and painful. They can also be life threatening.

If you have difficulty breathing, or you are experiencing chest pain, this may indicate a serious medical emergency. Seek immediate medical care, including emergency room treatment if necessary.

If your pain shows no signs of subsiding, and/or if symptoms are interfering with your ability to perform daily tasks, see your doctor as soon as possible. By getting a proper diagnosis and treatment, you’ll be on the path to pain relief.

Slipping rib syndrome’s symptoms mimic those of many other medical conditions. This makes it difficult to make an accurate diagnosis. To begin the process, your doctor or spine specialist will carefully review your medical history.

Next, the physician will ask you to describe your symptoms and note their severity and duration. Your doctor will also want to know what worsens or eases these symptoms.

Diagnostic Tests

Because so many other conditions have similar symptoms, the doctor may order tests that will help to eliminate potentially serious causes. These tests may include:

• Blood tests (to detect signs of a heart attack or other conditions)

• Bone scan (to check your bone health and for the presence of osteoporosis or osteopenia)

• Chest MRI (to more closely review cartilage abnormalities)

• Chest X-ray (to rule out broke ribs or other fractures)

• Electrocardiogram (or EKG) (to evaluate heart function)

• Ultrasound imaging (to look for rib cartilage inflammation)

Physical Examination

Your doctor will conduct a targeted physical examination, which will reveal whether a rib is not properly positioned compared to your other ribs. If your doctor finds a rib out of alignment, he or she may perform the “hooking” or “hook” maneuver. Here, the doctor gently moves the misaligned rib to determine if the movement causes pain. They will also listen for a clicking sound.

Next, your doctor may order imaging tests. The test results may enable the physician to rule out other conditions. In certain cases, the hooking maneuver may be sufficient to confirm a slipping rib syndrome diagnosis.

Slipped Rib Syndrome Differential Diagnosis

Varied medical conditions have similar signs or symptoms. Making a differential diagnosis refers to the process of differentiating between multiple conditions that feel largely the same to the patient. Slipping rib syndrome’s differential diagnosis includes these medical conditions:

• Appendicitis

• Asthma

• Bone metastases

• Bronchitis

• Cholecystitis

• Esophagitis

• Gastric ulcer disease

• Heart conditions

• Muscle tears

• Myocardial infarction (heart attack)

• Pancreatitis

• Pleuritic chest pain

• Pulmonary embolism

• Stress fractures

A Thoracic Surgeon’s Perspective

Dr. Zaheer states that slipping rib syndrome presents with lower chest and/or upper abdominal pain. The differential diagnosis for this symptom is extensive. Potential cardiovascular system causes are of major significance.

Your doctor will go down a list much like the one above (which is non-exhaustive), checking off what conditions aren’t causing your symptoms, one by one. Then, slipping rib syndrome is usually a diagnosis of exclusion—the last condition standing.

To resolve your slipping rib syndrome symptoms, your physician may use a combination of treatments. Each therapy is designed to address a different component of the condition.

Nonsurgical Treatments for Slipping Rib Syndrome

If your slipping rib syndrome is considered mild or moderate, conservative treatment may be sufficient to relieve pain. Your doctor may recommend one or more of these nonsurgical treatments:

• Rest

• Cold and heat therapy

• Avoidance of strenuous activities

• Gentle stretches and rotation exercises

• Rib stabilization with a chest binder

To complement the above therapies, your physician may prescribe the following pain relief measures:

• Epidural corticosteroid injection or intercostal nerve block (to relieve inflammation and pain)

• Botulinum toxin therapy (or Botox) (to relieve muscle pain)

• Prolotherapy (to strengthen weak ligaments)

• Ultrasound therapy (to reduce muscle inflammation)

• Massage (to work out any muscle spasms)

Medication Management

Your physician may recommend medication that will help to relieve pain and inflammation. If you are experiencing mild pain, over-the-counter non-steroidal anti-inflammatory drugs (NSAIDs) may provide relief. Commonly used NSAIDs include:

• Aspirin

• Ibuprofen (Advil or Motrin)

• Naproxen (Aleve or Naprosyn)

Physical Therapy and Exercise

Maybe you currently have slipping rib syndrome, and you want to exercise to maintain your fitness level. Know that many types of exercises can worsen your symptoms and sabotage the healing process. If you overdo your workouts, you may develop a chronic problem that requires pain injections or surgery to resolve.

Exercises to Avoid

Avoid exercises that place direct pressure on your chest. In addition, avoid exercises that involve throwing or pitching motions (such as pushups or throwing a baseball or softball). Until you are completely healed, stay away from sports in which you are likely to contact other athletes (such as basketball or football).

Suggested Exercises

During your recovery, your physician may recommend specific types of gentle exercise. Obtain his or her approval before engaging in any exercise program. Working with a physical therapist may also be beneficial.

Early-Stage Exercises

At the beginning, you’ll need to take it slow—very slow. Your physical therapist or recovery specialist can show you some breathing exercises, which is about as vigorous as you’ll want to go at first. Focus on segmental breathing, which will help to provide you with more rib mobility.

Expansion Exercises

To further improve your rib joint mobility, engage in thoracic extension and flexion exercises. Seated rotation exercises may also be useful. A physical therapist can also guide you through these exercises.

Surgery for Slipping Rib Syndrome

If you are experiencing severe chest wall and mid-back pain, and it has not responded to nonsurgical treatments, slipping rib syndrome surgery may help. The medical name for this procedure is costal cartilage resection or excision, which Dr. Zaheer says can be very effective.

During the procedure, the surgeon will remove the slipped rib and the connecting costal cartilage. Afterward, the surgeon will advise you if follow-up treatment is necessary.

Slipping rib syndrome patients’ outlooks can vary. In some cases, the condition may gradually resolve on its own without any treatment. Other patients achieve complete pain relief with one or more therapies. For certain patients, slipping rib syndrome discomfort can evolve into chronic pain.

In especially severe cases, patients may achieve permanent relief with a single intercostal nerve block. Surgery may be an option for debilitating or persistent pain.

Fortunately, slipping rib syndrome does not lead to long-term damage. In addition, the condition does not appear to negatively affect internal organs.

Slipping rib syndrome affects each patient differently. Some people may be impacted more than others, and each person will experience their own healing journey.

One subgroup may be especially prone to slipping rib syndrome and its varying levels of severity. In Dr. Zaheer’s experience, slipping rib syndrome mostly occurs in athletes and people involved in vigorous physical activity.

“This condition results in significant pain and sometimes the sensation of ‘clicking’ at the injury site. This can make the person unable to perform at the same level as before. In the worst cases, the person is not able to perform at all,” he explains.

Minimizing Slipping Rib Syndrome Pain

Dr. Zaheer recommends several strategies that will help to minimize slipping rib syndrome pain. Because healing may take time, the patient should implement this approach under the direction of their physician.

• Physical therapy

• Reduction of the displaced rib (via at-home maneuvers)

• Avoidance of rigorous activity (can take up to three months)

• Analgesics (particularly NSAIDs)

A Timely Diagnosis is Important

As with other medical conditions, quickly getting an accurate diagnosis plays a key role in your treatment program’s success. If you are experiencing severe middle back or chest pain, see your personal physician or spine specialist without delay. Varied treatments and therapies can help with pain relief, enabling you to enjoy a better quality of life.