Slipping rib syndrome
Citation, DOI, disclosures and article data
At the time the article was created Mohammed Sultan had no recorded disclosures.View Mohammed Sultan's current disclosures
Slipping rib syndrome, also known as Cyriax syndrome, occurs when hypermobility of the rib cartilage of the lower ribs slips and moves, leading to pain in the lower chest or upper abdomen 1.
This condition may occur at any age, but is reportedly more common in middle-aged adults, and is a recognized cause of recurrent lower chest and/or upper abdomen pain in adolescents.
This disorder appears to be less common in young children because of the pliability of their rib cage. There is no significant gender difference.
- intermittent sharp stabbing pain in the upper abdomen or back, followed by a dull, aching sensation
- slipping, popping, or clicking sensations in the lower ribs
- worsening of symptoms with certain maneuvers, such as when bending, lifting, twisting or turning in bed
- palpation of the affected rib will reveal a tender spot on the costal margin and reproduce the specific pain
- pain is also reproduced by performing the hooking maneuver, where the clinician places his fingers in the subcostal area and pulls in the anterior cranial direction 7,8
Most cases of slipping rib syndrome occur unilaterally, but the condition has been reported to occur bilaterally.
The exact cause of slipping rib syndrome is not well understood. Slipping rib syndrome might occur after a trauma, injury, or surgery, but cases have been reported without any notable injuries.
It is believed to be a result of hypermobility of the rib cartilage (costochondral) or ligaments, particularly ribs 8, 9, and 10.
This slippage movement irritates the nerves and may strain the intercostal muscles in the area, leading to inflammation and pain.
Cyriax syndrome is usually a clinical diagnosis but the presentation of symptoms overlap with possible intrathoracic or intra-abdominal pathology. Imaging may be necessary to exclude these.
Dynamic ultrasound may demonstrate slipping of the costochondral region of the rib 3.
Treatment and prognosis
- modifying activity
- corticosteroid or local anesthetic intercostal nerve block injections help to relieve pain
- if the condition persists or causes severe pain, surgery (e.g. costal cartilage excision 4,5, minimally invasive repair 12) may be required although costal cartilage excision may not prevent late pain recurrence 11
Pain can become severe enough to cause disability but the condition does not cause any other serious complications.
History and etymology
It was initially described in 1919 by Edgar Ferdinand Cyriax (1874-1955), specialist in mechanotherapeutics, Central Institute for Swedish Gymnastics, London 6.
Other rib, lower chest and upper abdominal pathologies, such as:
- gastric ulcers
- stress fractures
- muscle tears
- pleuritic chest pain
- Tietze syndrome
- bone metastases
- Cyriax syndrome is an often underdiagnosed condition
- knowledge of this syndrome can prevent a delay in diagnosis and prevent unnecessary laboratory and radiological investigations
- 1. Barki J, Blanc P, Michel J, Pageaux GP, Hachemane-Aourag S, Carabalona JP, Larrey D, Michel H. [Painful rib syndrome (or Cyriax syndrome). Study of 100 patients]. Presse Med. 1996 Jun 15;25(21):973-6. French. Pubmed
- 2. Monnin JL, Pierrugues R, Bories P, Michel H. [Cyriax's syndrome. A cause of diagnostic error in abdominal pains]. Presse Med. 1988 Jan 9-16;17(1):25-9. French. Pubmed
- 3. Meuwly JY, Wicky S, Schnyder P, Lepori D. Slipping rib syndrome: a place for sonography in the diagnosis of a frequently overlooked cause of abdominal or low thoracic pain. J Ultrasound Med. 2002 Mar;21(3):339-43. Pubmed
- 4. McMahon LE. Slipping Rib Syndrome: A review of evaluation, diagnosis and treatment. Semin Pediatr Surg. 2018 Jun;27(3):183-188. doi: 10.1053/j.sempedsurg.2018.05.009. Epub 2018 May 27. Review. Pubmed
- 5. Alshammari DM, Talon I, Rod J, Schneider A, Lavrand F, Piolat C, Gelas T, Hameury F, Sica M, Gicquel P, Flaum V, Becmeur F. Thoracoscopic Rib Resection in Children. J Laparoendosc Adv Surg Tech A. 2018 Jan;28(1):106-110. doi: 10.1089/lap.2017.0131. Epub 2017 Oct 26. Pubmed
- 6. Cyriax EF.On various conditions that may simulate the referred pains of visceral disease, and a consideration of these from the point of view of cause and effect. Practitioner, London, 1919, 102: 314-322.
- 7. Heinz GJ, Zavala DC. Slipping rib syndrome, Diagnosis Using the "Hooking Maneuver". JAMA. 1977 Feb 21;237(8):794-5. Pubmed
- 8. Khan NAJ, Waseem S, Ullah S, Mehmood H. Slipping Rib Syndrome in a Female Adult with Longstanding Intractable Upper Abdominal Pain. Case Rep Med. 2018 Jul 2;2018:7484560. doi: 10.1155/2018/7484560. eCollection 2018. Pubmed
- 9. Van Tassel D, McMahon LE, Riemann M, Wong K, Barnes CE. Dynamic ultrasound in the evaluation of patients with suspected slipping rib syndrome. (2019) Skeletal radiology. 48 (5): 741-751. doi:10.1007/s00256-018-3133-z - Pubmed
- 10. Fares MY, Dimassi Z, Baydoun H, Musharrafieh U. Slipping Rib Syndrome: Solving the Mystery of the Shooting Pain. (2019) The American journal of the medical sciences. 357 (2): 168-173. doi:10.1016/j.amjms.2018.10.007 - Pubmed
- 11. Mazzella A, Fournel L, Bobbio A, Janet-Vendroux A, Lococo F, Hamelin EC, Icard P, Alifano M. Costal cartilage resection for the treatment of slipping rib syndrome (Cyriax syndrome) in adults. (2020) Journal of thoracic disease. 12 (1): 10-16. doi:10.21037/jtd.2019.07.83 - Pubmed
- 12. Hansen AJ, Toker A, Hayanga J, Buenaventura P, Spear C, Abbas G. Minimally Invasive Repair of Adult Slipped Rib Syndrome Without Costal Cartilage Excision. (2020) The Annals of thoracic surgery. 110 (3): 1030-1035. doi:10.1016/j.athoracsur.2020.02.081 - Pubmed
- 13. Gress K, Charipova K, Kassem H et al. A Comprehensive Review of Slipping Rib Syndrome: Treatment and Management. Psychopharmacol Bull. 2020;50(4 Suppl 1):189-96. PMC7901126 - Pubmed