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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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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.

Last updated on: October 28, 2014