Slipping Rib Syndrome (SRS)

Slipping Rib Syndrome (SRS) is a treatable cause of lower chest or upper abdominal pain. It happens when one of the lower ribs (usually the 8th, 9th or 10th) becomes unusually mobile at its cartilage attachments and rubs or “slips” against the rib above. This can irritate the nearby intercostal nerve and cause sharp, catching pain — often for months — and is commonly missed or mistaken for stomach, gallbladder or heart problems.

What are “true”, “false” and “floating” ribs — and why it matters

• True ribs (1–7) attach directly to the breastbone (sternum).
• False ribs (8–10) attach indirectly via cartilage that joins the cartilage above to form the costal margin.
• Floating ribs (11–12) do not attach anteriorly.

SRS involves the false ribs (8–10) because their cartilage and the associated joints (interchondral joints) may become loose. The 10th rib is most commonly affected.

What patients usually experience (Symptoms)

Generally, the patients experience

• Sharp, stabbing or aching pain at the lower chest or upper abdomen.
• A clicking, popping or slipping sensation near the rib margin — sometimes reproducible
• Pain worse with bending, twisting, coughing, deep breathing, or certain sports movements.
• Local tenderness on pressure at the rib tip.
• Pain may radiate to the back or flank.
• Sometimes associated with nausea and vomiting in some people.

Because the pain often mimics biliary (gallbladder), gastric or cardiac pain, many patients undergo multiple tests before the right diagnosis is made.

Who gets Slipped Rib Syndrome? (Causes & risk factors)

Slipped Rib Syndrome can occur in both young and older individuals. It is seen in children, adolescents, and adults with the mean age at diagnosis is 19 years with most patients less than 40 years old. There is a predilection for females with female athletes being more commonly affected, possibly related partly to hormonal influences on ligaments. SRS arises when the costal cartilage attachments weaken or break down such as with:

• Trauma — direct blows or indirect forces (e.g., a sudden twist or extreme respiratory effort). Even minor trauma can be responsible.
• Repetitive strain — sports involving twisting (swimming, gymnastics, throwing) or repetitive one-sided movement.
• Hypermobility or connective tissue weakness — conditions like Ehlers-Danlos or general ligament laxity.
• Degenerative changes or prior chest surgery.

Often the cause is multifactorial — a combination of minor trauma, repetitive strain, and ligament laxity.

Why SRS is commonly missed (diagnostic delay & consequences)

SRS frequently mirrors other problems. Patients commonly see several specialists and undergo many tests before diagnosis:

• In published series, 19% of patients with SRS had previously undergone laparoscopic cholecystectomy (gallbladder removal) for pain — without benefit.
• Median time from symptom onset to surgery has been reported as up to 18 months in adults and 2.5 years in children.
• Delayed diagnosis has serious effects on wellbeing: in one adult cohort one third had suicidal thoughts because of uncontrolled pain.

These figures show how important correct early diagnosis is — it prevents unnecessary operations, long waits, and mental health harm.

How SRS is diagnosed

SRS is primarily a clinical diagnosis — a careful history and physical exam are essential. Common diagnostic steps:

• History — ask specifically about clicking, movement-related pain, and prior trauma or sports activity.
• Physical exam — look for a tender point at the costal margin and try the hooking manoeuvre (Doctor hooks fingers under the lower rib margin and pulls upward). Reproduction of pain or a click supports SRS.

Studies show exam variations exist; gentle palpation to reproduce pain is often most helpful. One study suggested objective examination criteria for aiding diagnosis including  at least 1 cm separation at the anterior insertion of the 10th rib, unusual mobility of the 10th rib, and reproduction of the patient’s pain with local pressure.

• Dynamic ultrasound — increasingly used and useful as ultrasound can show one rib cartilage moving under or over the adjacent rib during maneuvers (e.g., crunch).
• Other imaging (CT/MRI/X-ray) — often normal for SRS but useful to exclude other causes and for surgical planning if needed.
• Diagnostic intercostal nerve block — injecting local anaesthetic under ultrasound can confirm the painful nerve and predict response to further nerve-targeted treatments.

Other research findings: Romano et al. showed thinning of rectus abdominis near the xiphoid in SRS patients, possibly from chronic nerve irritation; this may contribute to instability.

Treatment — stepwise and evidence-based

Treatment should be progressive: start simple and move to minimally invasive or surgical options only if needed.

Conservative measures (first line)

• Reassurance and activity modification — avoid triggers (twisting, heavy lifting, certain sports).
• Anti-inflammatory painkillers for short periods.
• Heat/cold packs, posture correction, physiotherapy — breathing mechanics and core strengthening help rib stability.
• Taping or compression may provide temporary support.

Most patients improve with 2-6 weeks of these measures, but many do not — and that’s where targeted interventions help.

Diagnostic and therapeutic intercostal nerve block

This is an important minimally invasive option for those not improving with conservative measures and for those not keen on surgical options.

• Ultrasound-guided intercostal nerve block is commonly used. Typical injectate includes local anaesthetic ± steroid. This can confirm the pain source (diagnostic) and provide meaningful short-term relief. A ≥50% reduction in pain predicts a good chance of success with neuroablative procedures discussed below.
• Repeated blocks are often used as a bridge or when patients prefer to avoid surgery.

Cryoablation / cryoneurolysis

• This involves freezing the intercostal nerve, causing interruption of the pain signals being transmitted through these nerves. It does not destroy the nerves completely and the sensation gradually returns with time without the risk of any neuroma ( nerve swelling) formation.

Case series and newer reports show good medium-term relief (months to years) with low complication rates. It is an attractive option for patients who want to avoid surgery.

Radiofrequency ablation (RFA) — alternative option

and commonly reported specifically for SRS but used in intercostal neuralgia. It is considered where cryoablation is not available or based on clinician experience. Evidence is weaker than for cryoablation for this condition.

Surgery — for persistent structural hypermobility

Surgery is reserved for patients with clear structural problems failing other measures.

• Cartilage resection (CRE) — excision of the slipping costal cartilage; commonly used and often relieves pain. However, because hypermobility may persist, recurrence rates can be significant.
• Costal margin reconstruction / suture repair — stabilises the rib without removing cartilage.
• Vertical rib plating (VRP) / rib fixation — newer approach to stabilize the rib; recent series show lower recurrence. Bioabsorbable plates are also used in some centres.
• Laparoscopic or minimally invasive approaches — allow smaller incisions and faster recovery in select patients.

When to see a specialist

See a pain specialist or thoracic surgeon if:

• Pain is severe, recurrent, or long-standing despite basic measures.
• You have a clear clicking/rib-tip sensation and localised tenderness.
• Prior tests (heart, stomach, gallbladder) are normal but pain persists.
• Pain affects sleep, work or mental health.

Early referral can avoid unnecessary tests and procedures.

Final note

Slipped Rib Syndrome can be disabling and is often missed, but it is treatable. Many people improve with a combination of conservative care and targeted procedures. For others, surgery yields excellent long-term relief. Honest discussion about realistic outcomes, stepwise care, and mental health support is important.

For help, diagnosis, or a second opinion, contact International Pain Centre:
+91-9993336525
internationalpaincentre.com