[size=20px]A 17-year-old girl complains of 6 months of pain at her left costal margin when playing gymnastics. She notes that she feels a "click" with sudden shooting pain with certain movements. On physical exam, you can recreate a “click” sound and pain by hooking the lower rib cartilages with your finger as you feel it move. The best next step in management for this patient is

 

A NSAIDS and activity restriction

 

B Lower rib excision

 

C Intercostal nerve block

 

D Steroid injection

 

E Lower disconnected rib chondrectomy[/size]

A

A

A

Correct answer

A NSAIDS and activity restriction

 

This patient is most likely suffering from slipped rib syndrome. The syndrome is caused by a hypermobility of the anterior false ribs. In these patients, the 8th–10th ribs (which are not directly attached to the sternum but are normally attached to each other by cartilage), lose their cartilagenous attachments to each other and become mobile thus allowing them to slip or click as the cartilaginous rib tip slips under the rib above. Pain occurs from impingement of the intercostal nerve.

 

Diagnosis can be made by feeling the disconnected cartilages or even recreating the slip with the "hook maneuver", where the examiner hooks the fingers under the inferior margin of the ribs (ribs 8-10) and pulls straight up, reproducing the pain of rib movement. The change in rib location may also be documented on dynamic ultrasound with provocative maneuvers.

 

Treatment can begin with non-steroidal anti-inflammatory drugs (NSAIDS), activity restriction, and local anesthetic injections, but definitive treatment is excision of the disconnected cartilages.