How is costochondritis differentiated from slipping rib syndrome?

Updated: Feb 19, 2020
  • Author: Lynn K Flowers, MD, MHA, ABAARM, FACEP; Chief Editor: Barry E Brenner, MD, PhD, FACEP  more...
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Physical examination can help differentiate costochondritis from Tietze syndrome and from slipping rib syndrome. Although Tietze syndrome also produces costochondral tenderness, it is acute rather than chronic and it is additionally characterized by nonsuppurative edema (usually of the second and third costochondral junctions), heat, and erythema, all of which are absent in costochondritis. [4, 5]

Slipping rib syndrome involves the anterior portions of ribs 8-10—the vertebrochondral false ribs, which unlike the first 7 ribs (the true ribs) are connected not to the sternum directly but to each other by fibrocartilaginous bands (it does not involve ribs 11 and 12, the floating false ribs, whose ventral ends are free). Slipping rib syndrome is caused by laxity of the intercostal attachments of the false ribs, which allows the costal cartilage tips to subluxate and impinge on the intercostal nerves. [6, 7]

Patients with slipping rib syndrome may or may not report a history of trauma. They may describe insidious onset of dull, chronic pain or sudden onset of sharp, stabbing pain, which may be preceded by a slipping, clicking, or popping sensation. The pain may be precipitated by breathing or by certain movements. It may be thoracic or abdominal.   

The classic diagnostic test for slipping rib syndrome is the hooking maneuver: with the patient supine, the examiner hooks the fingers under the inferior margin of the ribs (ribs 8-10) and pulls straight up. The maneuver is positive if it reproduces the pain or rib movement. Relief of the pain with an intercostal nerve block strongly supports the diagnosis. Treatments include osteopathic manipulation, surgical resection, and diclofenac gel. [6, 7]

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