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11 Articles in Volume 13, Issue #7
Ask the Expert: Which NSAIDs are Most Selective for COX-1 and COX-2?
Chronic Pain and Depression: Sorting Out Types of Mood Disorders
Chronic Pain and Depression—Why Antidepressants Treat Both
Editor's Memo: Fibromyalgia: Time To Be a Secondary Diagnosis?
Evaluation and Comparison of Online Equianalgesic Opioid Dose Conversion Calculators
History of Pain: A Brief Overview of the 19th and 20th Centuries
Letters To the Editor
Obesity and Pain Management
Pharmaceutical Treatment of Insomnia In Intractable Pain Patients
The Slipping Rib Syndrome: An Overlooked Cause of Abdominal Pain
You Ordered the Urine Drug Test: Now What?

The Slipping Rib Syndrome: An Overlooked Cause of Abdominal Pain

This series of cases illustrates the authors’ experiences of using intercostal nerve blocks and local infiltration of anesthetics to diagnose and treat this obscure syndrome.
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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.

Second Case Example

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.

Figure 3. Costal margin hooking recreates the abdominal pain.

Figure 4. Costal margin hooking recreates the abdominal pain.

Third Case Example

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.

Fourth Case Example

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.

Last Case Example

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

Last updated on: October 28, 2014