Slipping Rib Syndrome (SRS)

Slipping rib syndrome is a under-recognized rather than rare  condition where the lower ribs (typically the 8th, 9th, or 10th) become hypermobile or lose stability, causing them to slip or move out of their usual position. This movement can lead to pain or discomfort in the chest or abdomen due to irritation or impingement of surrounding intercostal nerves and soft tissues.

 

Causes of Slipping Rib Syndrome

• direct impact or trauma to the chest
• joint hypermobility such as in Ehlers-Danlos Syndrome
• weak ligamentous support
• congenital factors
• increased joint laxity
• repetitive motion and flexibility
• genetic predisposition

 

Signs and Symptoms of Slipping Rib Syndrome

• Typically insidious onset of pain, though trauma can cause it.
• Unilateral (more often than bilateral) sharp, stabbing or aching pain at the lower anterior rib margin.
• Pain is triggered by upper body activities like coughing, laughing, twisting or side bending
• Patient feels sensation of the rib "slipping," "popping," or "clicking" out of place.
• Localized tenderness over the affected rib or costal cartilage.
• Referred pain to the back, shoulder or upper abdomen.
• Discomfort or shallow breathing is seen.

 

Diagnosing Slipping Rib Syndrome

As a physiotherapist, diagnosing slipping rib syndrome involves a combination of a thorough history, physical examination, and special tests.

 

Differential Diagnosis

• Costochondritis
• Rib Fracture
• Intercostal Muscle Strain
• Thoracic Outlet Syndrome
• Herpes Zoster (Shingles)
• Gallbladder Disease
• Peptic Ulcer Disease
• Pancreatitis
• Pneumothorax
• Abdominal Aortic Aneurysm

 

Physiotherapy Management for Slipping Rib Syndrome

Physiotherapy management for slipping rib syndrome aims to alleviate pain, restore normal rib function, and improve overall movement. Here’s a detailed approach:

Pain Management

• Cryotherapy: Apply ice to the affected area to reduce inflammation and pain, especially in the acute phase.
• Manual Therapy: Use techniques such as soft tissue mobilization, myofascial release, facilitated positional release and muscle energy to reduce pain and improve rib mobility. Nerve blocks may be required to reduce pain for direct OMT techniques.

Strengthening Exercises

Focus on strengthening the abdominal, shoulder girdle and upper back muscles to promote stability. Examples include:

• Planks
• Pelvic tilts
• Rows
• Shoulder blades squeezes

 

Stretching Exercises

Incorporate stretches for the thoracic spine, chest and intercostal muscles to improve flexibility and decrease tension. Examples include:

• Side stretches
• Gentle thoracic rotations

Rigid Taping

Taping the ribs can help reduce pain or discomfort, especially in cases where certain rib or chest wall movements cause symptoms. It includes following steps:

1. First, identify the correct area to apply the tape by using a gentle pushing technique.
2. Apply a slight upward (superior) pressure on the back and side of the rib cage (postero-lateral area).
3. While holding this pressure, ask the patient to perform a movement that typically triggers their symptoms, like taking a deep breath or rotating their torso.
4. If the patient feels a noticeable reduction in pain or discomfort during these movements, it suggests that taping in that specific area might help stabilize and relieve the affected ribs.
5. Using the findings from the test, apply tape to that part of the rib cage to provide support and potentially reduce symptoms.

Postural Education

Educate the patient on proper posture to reduce stress on the ribs. Encourage a neutral spine and ribcage position. Teach the importance of ergonomics in daily activities to minimize exacerbation.

 

Breathing Exercises

Encourage diaphragmatic breathing to improve lung capacity and reduce rib movement during respiration. Use specific breathing exercises to enhance rib cage mobility without pain.

Movement Retraining

Teach the patient to perform activities of daily living (ADLs) with proper biomechanics to avoid aggravating the condition. Gradually introduce functional movements that mimic activities they perform regularly.

Activity Modification

Advise on modifying activities that may exacerbate symptoms, including avoiding heavy lifting or repetitive twisting motions until symptoms improve.

 

Gradual Return to Activity

Create a progressive rehabilitation plan that gradually increases activity levels based on symptom improvement. Monitor progress and adjust the treatment plan as necessary, including re-evaluating pain levels and function.