The same pain beneath your ribs returns when you turn over in bed, bend forward, or take a deep breath. Sometimes it is accompanied by a clicking or slipping sensation. Tests may have been performed and different causes investigated, yet the source of the pain may still remain unexplained.
Slipping rib syndrome, or SRS, is one possible cause of these symptoms. The problem is not always an abnormality that can be seen on a static image. In some patients, pain occurs when the rib cartilage shifts relative to neighbouring structures during movement. Assessment therefore needs to consider not only where the pain occurs, but also which movements trigger it.
My approach is first to establish the relationship between the pain the patient describes and rib movement, and then, for patients who need surgery, to plan a reconstruction that addresses the mechanical problem causing the pain.
What is slipping rib syndrome?
The cartilage connections at the front of the lower ribs form part of the costal margin, the lower border of the rib cage. In slipping rib syndrome, weakness of these connections, most often around ribs 8, 9, and 10, can lead to abnormal mobility. This movement can irritate the nerve running between the ribs and cause pain. [5]
Patients may experience this as a stabbing sensation at the rib tip, sharp upper abdominal pain, an ache in the side, or discomfort extending to the back. Not every patient has a noticeable click, and a clicking sensation alone does not establish the diagnosis.
Which symptoms warrant assessment?
The following symptoms, particularly when recurrent and associated with movement, may warrant investigation of rib-related causes during the clinical examination:
- Pain localised to a specific point along the lower rib margin or in the upper abdomen.
- Discomfort that increases with twisting the torso, bending, coughing, or certain exercises.
- A slipping, catching, or clicking sensation beneath the ribs.
- Changing sleeping positions and avoiding everyday movements because of pain.
These symptoms can also have other causes. Conditions involving the heart, lungs, digestive system, spine, and muscles are considered according to the patient’s history. A normal test result does not mean the pain is not real; nor does it, on its own, establish a diagnosis of slipping rib syndrome.
Why can diagnosis be delayed for years?
The absence of pain during examination, symptoms felt in different areas, and the inability of routine imaging to show movement can prolong the diagnostic journey. Over time, recurring pain affects not only the body, but also sleep, working life, and a person’s confidence in their own body.
Some patients who consult me describe symptoms that have lasted for 10–12 years and numerous consultations across different specialties. The need they share is for their pain to be taken seriously and its cause understood.
This long search is also reflected in the scientific literature. In a study of 435 patients by Hansen and colleagues, the reported median time spent seeking a diagnosis or relief was 36 months, and the number of physicians consulted was six. These findings illustrate the burden that diagnostic delays place on patients. [2]
What do dynamic ultrasound and clinical examination offer?
Assessment begins with a discussion of the location and onset of the pain and the movements that trigger it. Examination findings are then considered alongside the symptoms the patient describes. When needed, dynamic ultrasound helps show how the ribs move in relation to one another during selected movements.
Simply observing movement is not enough. It is also necessary to assess whether the observed movement corresponds to the patient’s familiar pain at the same location and at the same time. Studies have shown the diagnostic value of dynamic ultrasound; its findings are interpreted in conjunction with the examination technique and clinical assessment. [3, 6]
MRI, CT scans, or standard ultrasound may be valuable for investigating other conditions. However, when a problem is related to movement, normal findings on previous imaging do not, on their own, bring the assessment to an end. Likewise, observing movement on dynamic ultrasound does not automatically mean that surgery is needed.
How is slipping rib syndrome treated?
Treatment decisions depend on the severity of symptoms, their impact on daily life, examination findings, and rib anatomy. Not every patient needs surgery. Activity modification, appropriate pain management, individually tailored rehabilitation, and injections in selected cases may be considered. [4]
If a particular movement consistently increases pain during exercise, the programme should be reassessed. Rather than asking the patient to push through the pain, it is necessary to understand the movement and mechanical cause responsible for it.
Surgical options include cartilage excision, suture stabilisation, and costal margin reconstruction. The choice of technique depends on the patient’s anatomy. Removing a rib or cartilage may benefit some patients, but removal does not always resolve the remaining abnormal mobility. Some patients require reassessment because of persistent instability or pain. [2, 4]
What does costal margin reconstruction aim to achieve?
Costal margin reconstruction is a surgical approach that aims to restore the relationship between the ribs along the lower border of the rib cage. Planning takes into account the spacing between the ribs, abnormal movement, and contact that causes nerve irritation. [5]
When explaining this to patients, I emphasise one point in particular: the ribs need to move with breathing. The aim of the surgical plan is to control painful slipping while preserving chest wall function. Which structures are preserved, which are repositioned, and what type of support is used are determined individually.
My approach using vertical autologous cartilage support
The distinguishing feature of the reconstruction I perform is the combined use of spacers prepared from the patient’s own cartilage and a vertical cartilage support. “Autologous” means using the patient’s own tissue.
The pieces of cartilage placed between the ribs act as spacers and are secured with permanent tape suture. A vertical piece of cartilage is added to this arrangement and fixed to the ribs with permanent sutures. The aim is not only to adjust the spacing between the ribs, but also to provide additional support to the reconstructed structure.
In this procedure, the patient’s own cartilage was used for vertical support. The choice of support material does not mean that one material is superior in every situation. What matters is developing a plan suited to the patient’s anatomy and evaluating the outcome during follow-up.
The long-term outcomes of this procedure incorporating vertical autologous cartilage support must be assessed through follow-up of the patients who undergo it. A published success rate for another reconstruction technique cannot be applied directly to this procedure.
Treatment outcomes are reflected in changes to the patient’s life
For someone living with rib pain, success may mean being able to turn over more comfortably in bed at night, pick up their child, or no longer have to plan their day around pain. Assessment therefore considers sleep, movement, working life, and the need for pain medication alongside the pain score.
A 2024 study by Hansen and colleagues included 247 patients who underwent costal margin reconstruction. Among patients with available follow-up data, the mean pain score was reported as 7.5 out of 10 before surgery and 0.9 at 24 months. Although the study showed promising results, it was not a randomised comparison. These figures relate to the patients in that study, not to my own patients. [1]
For me, understanding patient satisfaction involves more than asking “How would you rate your pain?” at a follow-up appointment. Questions such as “Are you sleeping more comfortably?”, “Which movements can you do again?”, and “What has changed in your daily life?” are equally valuable. These are the improvements treatment aims to achieve; they do not mean that every patient will obtain the same outcome.
Recovery and follow-up after surgery
Pain related to the procedure may occur in the early period after surgery. How this differs from the patient’s preoperative pain should be discussed during follow-up. The return to work, exercise, and daily activities is planned according to the extent of the procedure, any coexisting conditions, and the course of recovery.
A single follow-up appointment is not enough to establish the long-term outcome. The course of pain, mobility, medication needs, and possible complications are assessed over time. If pain persists or returns, mechanical causes and other coexisting sources of pain are investigated again.
Assessment for patients from Turkey and abroad
Before an assessment in Izmir, it may be helpful to note how long the pain has been present and which movements bring it on. Previous test results, treatments, and any available surgical reports also contribute to clinical planning.
For patients travelling from abroad, travel arrangements, possible treatment, and follow-up should be discussed in advance. An initial remote consultation can help clarify the medical history; the in-person assessment needed for a definitive diagnosis and surgical decision is arranged separately. Information about the consultation and assessment process is available on the Dr. Pectus contact page.
Frequently asked questions about slipping rib syndrome
Which doctor should I see for slipping rib syndrome?
A thoracic surgeon with experience in chest wall conditions and slipping rib syndrome can carry out an assessment. Depending on the nature of the symptoms, input from other specialties may also be needed.
Can I have this syndrome even if my CT scan or MRI is normal?
Yes. Problems related to movement may not always be visible on routine imaging. Diagnosis is based on the combined assessment of the medical history, clinical examination, and, when needed, dynamic ultrasound findings. A normal imaging result alone neither confirms nor rules out the diagnosis. [3]
Does every patient need surgery?
No. The decision to operate takes into account how much the pain affects daily life, the treatments already tried, and the structural problem identified. [4]
Can I be reassessed if I have already had rib cartilage removed?
Yes. The possible cause of pain can be investigated by reviewing the previous surgical report and the current anatomy. Whether revision surgery is appropriate is determined individually; another operation is not necessary or beneficial for everyone.
Is vertical cartilage support suitable for every patient?
The same reconstruction plan is not used for every patient. Rib anatomy, available cartilage, previous procedures, and the need for support are considered together. The suitability of the technique is determined during the examination and surgical planning.
Will the pain disappear completely immediately after surgery?
Immediate and complete freedom from pain cannot be promised. The early effects of surgery and the course of the original symptoms are assessed separately during follow-up. Recovery time and the degree of relief vary from patient to patient.
Persistent rib pain deserves an explanation
When pain has persisted for years, the first need is for the patient’s experience to be heard carefully and assessed systematically. When slipping rib syndrome is suspected, investigating the relationship between pain and movement can be an important starting point for treatment planning.
This article discusses persistent and recurring symptoms. New-onset severe chest pain, shortness of breath, or fainting requires urgent assessment.
