The cause of abdominal pain can be hard to figure out, with so many key organs, muscles and skeletal parts located between the shoulders and hips. But if your belly, back or chest hurts when you move certain ways—and other conditions have been ruled out—you might have slipping rib syndrome. Here’s what happens…and what to do about it.

You probably think that your ribs expand enough to allow breathing, but they basically stay in place. And that’s mostly true. However, your eighth, ninth and 10th ribs are not attached directly to your sternum (the flat bone at the center front of the chest, aka the breastbone). Instead, they are attached to cartilage that attaches to the sternum. 

The cartilage itself can weaken because of trauma from activities that involve major movement of the rib cage. Or the cartilage attachments can weaken from unknown causes. The weakening allows one of the ribs to slip from its proper position during normal movements of the abdominal muscles.  

Most often, the slipping rib is the 10th one…and 90% of the time it occurs on just one side of the body. The slippage compresses and irritates the intercostal nerve that runs through the tissue between the ribs. This causes pain that comes and goes, often worsening with exercise or certain movements. (More on that below.) 

Who’s at Risk?

Slipping rib syndrome first came to medical attention about 60 years ago. While the condition is not considered common, it is so often missed or mistaken for other conditions—such as an ulcer, gallbladder disease, kidney stones or appendicitis—that it’s hard to know exactly how common it really is. For instance, 54 cases were found at one sports medicine clinic between 1999 and 2014. And a recent study published in Clinical Journal of Sports Medicine found that the average person with this condition sees more than two specialists and takes more than 15 months to get a correct diagnosis. 

Slipping rib can happen at any age and afflicts more women than men, particularly during reproductive years. (In the sports medicine clinic study mentioned above, 70% of cases were in women.) Certain sports, such as running, rowing, swimming and weight lifting…and conditions that cause chronic coughing, such as asthma or bronchitis, can make slipping rib syndrome more likely. Being hypermobile (the medical term for “double-jointed”) also increases risk. About 20% of patients with slipping rib syndrome are hypermobile.    

Symptoms and Diagnosis

Upper-abdominal pain unrelated to an obvious injury is the most common symptom of slipping rib. The pain usually starts gradually and is described as sharp, severe or cramping…although over time it may fade to a dull ache. The pain usually is triggered by activities that involve upper-arm movement. However, coughing, getting up from a chair or just rolling over in bed also may cause pain. 

Once other conditions have been ruled out and slipping rib is suspected, it’s actually not hard to diagnose. This is often done with a simple test performed in the doctor’s office called a “hooking maneuver.” The doctor hooks his/her fingers under the edge of the lower rib cage and pulls upward and outward to see if that triggers pain. Ultrasound also can confirm the diagnosis. 

Treatment Options

Depending on the patient’s age, activity level and disability from the condition, treatment usually starts with less invasive treatments—nonsteroidal anti-inflammatory drugs (NSAIDs), Lidoderm patches, chiropractic treatment and acupuncture. Generally, noninvasive treatments are about 30% effective at relieving pain, although some work better than others. Diclofenac gel was found to be 60% effective, and osteopathic manipulative treatment (OMT) was 71% effective at relieving pain.

If these methods aren’t effective or don’t help enough, physical therapy and special home exercises can be beneficial for roughly half the patients who try these therapies.

For patients who still aren’t getting adequate pain relief, an ultrasound guided nerve block can be tried. Injections of numbing medication and/or steroids can provide full relief for several months…and may resolve the pain permanently.

For severe cases of slipping rib, surgery to remove the affected cartilage attached to the problematic rib can relieve the pain. Once healed, pain usually goes away permanently—and the patient can return to normal activities, including sports.