In 1921, Alexander Tietze first described a syndrome characterized by a painful affliction of the costochondral cartilages (area between the ribs and costal cartilages).1 He described a benign, painful, nonsuppurative swelling involving one or more of the costochondral or sternoclavicular junctions. The following year, Davies-Colley described two women in whom severe abdominal pain was caused by atraumatic, spontaneous overriding of the ninth and tenth ribs.2 This syndrome has been dubbed Tietze syndrome, costal margin syndrome, clicking rib, rib tip syndrome, and now commonly slipping rib syndrome.3-5 Even though this disorder was described more than 60 years ago, it is often overlooked in the differential diagnosis of abdominal or chest pain.6,7 This article will review the diagnosis and treatment of the syndrome and present case examples.
The pathophysiology of the syndrome was further clarified by Holmes in 1941, and later by McBeath and Keene in 1975.3,4 They examined the gross and microscopic anatomy of the costochondral, sternal, and subcostal regions in normal individuals and identified recurring subluxation (dislocation) of the costal margins of the eighth, ninth, and tenth ribs due to hypermobility of their anterior edges. Actually, the rib tips do not sublux unless the fragile, fibrous articulations are disrupted. Unlike ribs one to seven, which are attached to the sternum, the eighth, ninth, and tenth ribs are attached only to each other by loose fibrous tissue. Paradoxically, when the fibrous tissue between the ribs is incised, they come in contact with each other and become locked behind the adjoining rib.
Holmes’ anatomic studies revealed that the cartilage ends curl upward inside the ribs so that they come in close relationship to the intercostal nerves.8 The fibrous hammocks surrounding the synovial membranes of the interchondral cartilages of the eighth, ninth, and tenth ribs also involve the terminal branches of the intercostal nerves. These nerves are particularly vulnerable to even trivial trauma. On careful examination, Holmes did not find the synovial membranes to be pathologic; thus, he concluded that the cause of the pain was recurrent, repetitive irritation of the intercostal nerves, not a synovitis of the interchondral cartilages. These factors support the hypothesis that direct or indirect trauma is the cause of the syndrome. The trauma may, at times, be completely covert and not directly implicated.4,9
Upon physical examination, the pain is clinically recreated when the rib margins are displaced upwards and anteriorly; thus, the “hooking maneuver” can be used to corroborate the diagnosis (Figures 1 and 2). In all our cases, local anesthesia intercostal blockade relieves the pain. We have found that the relief could be prolonged by infiltration of the subcostal rib margins. In several cases, this has completely relieved the pain permanently.
The slipping rib syndrome should be considered whenever a patient is referred with a complaint of upper quadrant abdominal pain of obscure and uncertain etiology, especially if it involves the subcostal upper quadrants of the abdomen. Most often all diagnostic studies had ruled out underlying visceral pathology. In many cases, the patients had already undergone abdominal explorations with negative findings. The pain is often confused with cholecystitis, subphrenic abscess, pleurisy, or hepatic pathology. As in many cases, the pain may radiate to the right lower quadrant mimicking appendicitis or renal lithiasis. In some cases, it may create epigastric symptoms of such proportion that myocardial infarction is suspected.
The diagnosis often can be made by physical examination. Palpation of the tips of the eighth, ninth, and tenth ribs or of the posterior intercostal margins often reproduces the pain. A sensation of clicking or slipping is felt beneath the examining hand when the hooking maneuver is applied. The hooking maneuver often aggravates or recreates the typical pain sensation, but often cannot be done due to severe sensitivity of the subcostal margins. If the pain is absent, the maneuver may reproduce it. The condition is most often unilateral10 and performing the maneuver on the contralateral side will not evoke a pain response. The diagnosis is further confirmed by intercostal local anesthesia nerve blockade of the eighth, ninth, and tenth ribs as well as subcostal infiltration. After the block has taken effect, the hooking maneuver will not evoke pain.
If a conduction block is used for diagnostic purposes only, then another block may be performed using the combination of local anesthesia 0.5% bupivacaine and 40 mg triamcinolone. This has been found to relieve the problem unless further trauma recreates the pathology. If residual pain persists, or should reoccur, then follow-up with another local anesthesia steroid blockade may be performed.
Prolotherapy also has been used with great success and prolonged amelioration of the syndrome.11 A more profound blockade may be obtained by the use of the extract of the pitcher plant (Sarapin). The duration of the anesthesia may be prolonged in difficult cases by use of a neurolytic block with phenol 6%. Alcohol should not be used due to the potential for severe neuritis. Our cases all responded to local anesthesia and steroids. Surgery and further injections were unnecessary.
A 34-year-old woman was referred to our pain clinic complaining of right upper quadrant pain of 4 months duration. The pain prevented her from teaching school and performing her activities of daily living. She rated her pain as 10 out of 10 on visual analog scale (VAS).
There was no history of trauma. The subcostal abdominal pain was aggravated by distention of the abdominal wall and there was associated nausea without vomiting. There were no other gastrointestinal (GI) symptoms. The pain was not affected by eating or taking antacids, belladonna, cimetidine, or other GI medication.
All laboratory and radiological studies, including abdominal computed tomography scan, were negative. A short trial of non-steroidal anti-inflammatory indomethacin 50 mg 3 times daily and supplemental hydrocodone 10 mg every 4 hours, did not alter the symptom complex. Deep palpation produced pain in the right upper quadrant, with pain radiating posteriorly to the upper dorsal back. Palpation of the margins of the eighth, ninth, and tenth ribs and anterior displacing of the rib margins enhanced the pain. Characteristic snapping or clicking was not induced when performing the hooking maneuver.
Based on the history, clinical, and laboratory findings, the patient was diagnosed with slipping rib syndrome and treated with intercostal blockade of the eighth, ninth, and tenth ribs in conjunction with subcostal local anesthetic and steroid infiltration.
The patient’s pain was reduced from a 10 to 2 on VAS. The patient returned 1 week later and described only residual soreness, which was completely eliminated by treatment with percutaneous electrical nerve stimulation (electroacupuncture). She has been pain free ever since.
A 23-year-old Hispanic male was evaluated in the hospital for severe, intractable right flank and lower quadrant pain. He had been hospitalized 8 months earlier, and had been seen in the emergency room on 5 occasions for the same complaint. Each time he was sent home on several analgesics after a thorough workup proved to be negative.
On initial physical examination, there were no GI findings. There were abdominal scars indicative of 2 previous laparotomies, which were reported to be negative for intra-abdominal pathology. The patient initially indicated that he had no history of trauma, but upon further careful questioning he revealed that prior to all of the previous incidents—including this hospital admission—he had undergone some trauma to his chest wall. This information had been withheld since there was involvement of gang activity. He was an orderly in the hospital, and was concerned about losing his employment.
On this hospital admission, further evaluation revealed a healthy but somewhat pale man with acute right upper quadrant pain. Cardiac and pulmonary examinations were negative. Electrocardiogram and chest x-ray did not reveal pathology, but careful physical examination revealed bruises over the center of the sternum and on his face. There was tenderness to deep palpation of the right upper quadrant, with some radiation to the right lower quadrant. There was no rebound but some right flank costovertebral angle tenderness. Bowel sounds were active and the abdominal scars were well healed and nontender.
Right subcostal displacement using the hooking maneuver (Figures 3 and 4) produced severe right upper quadrant pain. A diagnostic blockade of the eighth, ninth, and tenth intercostal nerves was performed at the level of the xiphoid process at the anterior axillary line. This completely relieved the pain, which then could not be reproduced by the subcostal hooking maneuver. Following this, 0.5% bupivacaine 10 mL containing 40 mg of triamcinolone was infiltrated along the subcostal margin. The pain was totally relieved and had not reoccurred. He was subsequently instructed to avoid any further altercations.
An obese 41-year-old woman was referred to our clinic with a complaint of recurrent right upper quadrant pain, which had been present for several months. The most recent episode occurred approximately 1 month prior to the examination. The workup by a gastroenterologist was found to be negative for intra-abdominal pathology. Large doses of propoxyphene (Darvon) were being used for pain relief (prior to the manufacturer’s removal of the drug from the market based on FDA recommendations). She had been beaten by her husband prior to being seen, but she was unable to delineate the exact areas of trauma.
There was marked tenderness in the right upper quadrant, and hooking the margins of the ribs and anterior displacement caused excruciating pain in the abdomen, with radiation to the right dorsal spine—confirming the diagnosis. Subcostal infiltration of the eighth, ninth, and tenth intercostal nerves with local anesthetic and subcostal injection of steroids and local anesthesia completely relieved the pain. It has not reoccurred since she left her husband and no longer is being battered.
A 50-year-old black man was evaluated for a complaint of severe right upper quadrant pain. He was in the care of a neurologist for Parkinson’s disease (paralysis agitans). His pain was exacerbated by deep inspiration, coughing, and straining. The patient had been involved in an automobile accident 3 years previously, at which time he sustained left chest trauma and fractures of several ribs. His pain had been present intermittently for 2 years in varying degrees of intensity and severity. In the week prior to being evaluated, however, the pain became so severe that it was unmanageable at home due to the development of severe rigidity and uncontrolled tremors. The patient was usually able to tolerate his medication for Parkinson’s, but the chest pain precluded him taking his medication.
On examination, his abdomen was mildly tympanitic with a moderate degree of gaseous distention and tenderness in the right upper quadrant. The hooking maneuver was performed on the right costal margins and created severe pain on that side. The procedure was performed on the left and did not cause pain. An intercostal block of the eighth, ninth, and tenth ribs on the right and subcostal infiltration with steroids completely relieved the pain.
The patient was subsequently able to tolerate the Parkinson’s medication and the symptoms resolved. He was re-evaluated 6 months later and there was mild resurgence of the pain. He required one further intercostal nerve block and has been pain free since that time. On further questioning it was determined that, in addition to his car accident, he had fallen several times traumatizing his right chest.
A 50-year-old woman was seen in pain consultation following treatment for postherpetic neuralgia. This problem responded well to sympathetic blocks and a workup for intra-abdominal pathology was negative. The patient described right upper quadrant pain that was deep, aching, and sharp—different than the burning dysesthesias she had experienced with postherpetic neuralgia. She recalls leaning over a trash bin, which caused pressure on her right costal area.
On examination, deep palpation of the abdomen exacerbated the pain and hooking maneuver produced radiating pain posteriorly to the level of the eighth, ninth, and tenth costal vertebral junctions. There was no cutaneous hypersensitivity usually seen with postherpetic neuralgia. Intercostal nerve blocks at the appropriate levels and subcostal infiltration completely relieved her pain. Six months later, she was relatively pain free although she still complained of some subcostal discomfort, which was thought to be related to the postherpetic neuralgia.
The trauma that precipitates this syndrome often goes unnoticed. In our first case and those of Wright,10 no history of trauma could be obtained. In our second case, a history of trauma became evident only after careful questioning. Often the cause may be straining—such as during violent coughing, sneezing, or vomiting. Pressure by the gravid uterus on the costal margins also has been reported to produce this syndrome.9
Although not in our cases, the ribs and adjacent structures can be the source of pain simulating visceral disease. Epigastric tenderness can be caused by a similar mechanism when the xiphoid cartilage is involved. The xiphoid is in close proximity to the articulations of the lower ribs.12,13 It is remarkable that often cardiac, gastric, or gallbladder disease can be diagnosed by the finding of xiphoid tenderness. Pain at the xiphoid cartilage often merely simulates these disease entities. This may be due to the xiphisternal innervations, which are by dorsal intercostal nerves 6 and 8. Local anesthetic infiltrated into the xiphisternal junction may well abolish the pain and make further diagnostic and therapeutic studies unnecessary.14
Prior to the use of nerve blocks for the different diagnosis and treatment of slipping rib syndrome, many patients were treated by rest and, in many cases, surgery. In 1950, Telford reported spontaneous atraumatic episodic pain that was attributed to the slipping rib syndrome.15 Treatment consisted of avoidance of any precipitating physical activities, although surgery was a definite consideration and was discussed. Slipping rib syndrome was reported in a collegiate swimmer.16 This champion female swimmer had 8 months of unresolved pain and disability, which ultimately were treated with resection of the cartilaginous attachments and a portion of the rib. The diagnosis originally was made by the hooking maneuver. No nerve blocks or subcostal infiltration was performed prior to surgery. Many of the cases reported in the literature, which were surgically treated, could have avoided surgery if the blocking procedures were used prior.
Our cases illustrate the use of intercostal nerve blocks and local infiltration of anesthetic in the chest cartilaginous articulations, which can be used to diagnose and treat this overlooked and obscure cause of abdominal pain. In our experience, when used judiciously they may allow patients to avoid surgery.