Slipping Rib Syndrome: Why Dynamic Ultrasound Matters

Slipping rib syndrome occurs when a lower false rib becomes abnormally mobile and irritates adjacent tissue or the intercostal nerve. Patients may describe sharp lower chest or upper-abdominal pain with clicking, popping or movement-related symptoms. Because the abnormality appears with movement, a static scan can look normal, which is why dynamic ultrasound has become an important part of the evaluation.

What slipping rib syndrome is

Ribs 1 to 7 attach directly to the breastbone through their own cartilage. Ribs 8 to 10, the false ribs, connect indirectly: their cartilage tips join the cartilage of the rib above. A 2023 review defines slipping rib syndrome as a disorder in which one or more of the eighth through tenth ribs become abnormally mobile (Madeka, 2023). A pediatric surgical review explains the mechanism: hypermobility of the anterior false ribs lets the cartilaginous rib tip slip or click under the rib above, and pain arises from impingement of the intercostal nerve running along the underside of the adjacent rib (McMahon, 2018).

Symptoms can include:

• Sharp or stabbing lower chest pain
• Upper abdominal pain
• Clicking or popping
• Pain with bending, twisting, reaching or specific positions
• Intermittent symptoms that can be debilitating when they flare

Who gets it

The 2019 ultrasound study described slipping rib syndrome as affecting adolescents and young adults, and both ultrasound cohorts were drawn largely from teenagers, many of them athletes (Van Tassel, 2019; Schultz, 2025). The 2023 review discussed treatment in both adult and pediatric populations (Madeka, 2023). Because the best imaging data come from young patients, findings in older adults are interpreted with that limitation in mind.

Why it is often missed

Slipping rib syndrome is frequently overlooked because standard static imaging may be normal and symptoms overlap with abdominal, thoracic and musculoskeletal conditions.

The 2018 review described patients consistently reporting months to years of typical symptoms, unnecessary tests and procedures before diagnosis (McMahon, 2018). The 2023 review called it poorly understood, leading to significant delays in diagnosis and treatment (Madeka, 2023). Upper abdominal pain often prompts gastrointestinal investigations first, and lower chest pain can be labeled as muscle strain.

How it is diagnosed

Both reviews describe slipping rib syndrome as primarily a clinical diagnosis. The 2023 review states that history and physical examination are usually sufficient, with dynamic ultrasound studied as a useful diagnostic tool, and the 2018 review describes dynamic ultrasound as helpful for confirmation or for difficult cases (Madeka, 2023; McMahon, 2018).

The examination looks for focal tenderness along the lower costal margin, clicking, reproduction of the pain with movement, a sense of rib hypermobility and reproduction with provocative rib maneuvers. The hooking maneuver, in which the examiner pulls the lower rib margin forward, is commonly described, but no single office maneuver is perfectly sensitive or specific, and a click by itself does not confirm the diagnosis.

Why dynamic imaging is different

Dynamic ultrasound is particularly valuable for slipping rib because the abnormality is movement-dependent. The examination can reproduce the symptomatic motion rather than relying on a static image.

A 2023 review of dynamic musculoskeletal ultrasound described the technique as a way to observe soft tissue through a range of motion and identify pathology not diagnosed on other modalities, with slipping rib among its main indications (Caldwell, 2023). During the examination, the ribs are imaged at rest and during maneuvers such as a crunch, a rib push and whatever movement provokes the patient's pain, and the examiner watches for one rib tip moving abnormally relative to its neighbor.

What the 2019 study showed

In a 46-patient study, dynamic ultrasound detected slipping rib syndrome in 89% of confirmed cases and correctly identified all 10 patients without the condition. The rib-push maneuver was the most sensitive provocative maneuver at 87%.

The study was a retrospective review of 46 patients seen between 2017 and 2018. Thirty-six had slipping rib syndrome confirmed by a specialist pediatric surgeon, with an average age of 17 years, and 31 of the 46 (67%) were athletes. Dynamic ultrasound correctly detected the syndrome in 32 of 36 patients and correctly found it absent in 10 of 10. By maneuver, sensitivity was 87% for the push maneuver, 68% for rib morphology, 54% for the crunch maneuver and 13% for Valsalva (Van Tassel, 2019).

This was a small, predominantly young cohort at a specialty center, so the figures describe that setting rather than every patient with lower rib pain.

What the 2025 cohort showed

A 2025 cohort of 227 patients found that a complete dynamic-ultrasound protocol detected slipping rib in 97.4% of positive examinations and correctly excluded it in 88.7% of negative examinations. Individual maneuvers were less sensitive, reinforcing that the full dynamic assessment matters more than one provocative test.

This retrospective review from a children's hospital covered patients evaluated between 2017 and 2022, giving 301 ultrasound evaluations; 78% of patients had one evaluation and 22% had more than one. The average age was 17.4 years and 70% were female. Dynamic ultrasound accurately detected slipping rib in 220 of 226 positive studies and correctly found no evidence in 63 of 71 negative studies. Combining right and left sides, sensitivity and specificity were 55.1% and 88.0% for rib morphology, 54.1% and 92.6% for the crunch maneuver, and 54.8% and 90.7% for the push maneuver (Schultz, 2025).

The cohort was predominantly pediatric and adolescent, evaluated by an experienced specialty team. Those exact performance values should not be assumed to apply identically to older adults or to other settings.

The whole protocol matters more than one maneuver

The two studies agree on the main point even though individual maneuver figures differ. In the smaller study, the push maneuver stood out; in the larger cohort, morphology, crunch and push each had sensitivity in the mid-50% range when analyzed side by side, yet the complete examination detected nearly all positive cases. Combining rest images, several maneuvers and whatever movement reproduces the patient's symptoms is what makes the examination useful. Valsalva added little in the 2019 study.

Twelfth rib syndrome

A related problem can involve the twelfth rib. A small case series described dynamic high-frequency ultrasound reproducing pain in patients with long-standing loin pain from twelfth rib syndrome, and slipping of the eighth rib over the seventh in a cricketer with lower chest and upper abdominal pain, after earlier tests had been unrevealing (Patel, 2021). This is case-level evidence, but it reinforces the value of dynamic imaging when routine investigations are negative.

Treatment

Persistent symptomatic rib hypermobility is structurally different from an intercostal muscle strain. When dynamic instability is the primary problem, treatment may require specialist evaluation rather than repeated soft-tissue treatment.

Initial care often involves activity modification, symptom control and selected rehabilitation, and some patients are treated with intercostal nerve blocks. The 2018 review described resection of the slipping rib cartilages as the mainstay of surgical treatment, with good pain relief, and rib stabilization as an emerging option for recurrent symptoms (McMahon, 2018). The 2023 review noted that costal cartilage excision has been the most common technique but has a high reported recurrence rate and associated risks, and that minimally invasive rib fixation and cartilage excision with vertical rib plating have been reported as safe and successful alternatives (Madeka, 2023). Whether surgery is appropriate is a specialist decision.

Where manual therapy and shockwave fit

Manual treatment may help surrounding muscular restriction, but it does not mechanically reconstruct an unstable costal cartilage attachment.

Shockwave does not correct pathological rib hypermobility and should not be used as a substitute for dynamic diagnosis. Supportive care for nearby muscle tension or deconditioning may still have a role once the diagnosis is clear.

Living with suspected slipping rib

While the diagnosis is being confirmed, many people find that certain positions and movements reliably provoke symptoms, such as deep forward bending, twisting while flexed, sit-ups or sleeping on the affected side. Temporarily modifying those positions, adjusting training that loads the lower ribs and keeping a simple record of what provokes the pain can make the dynamic examination more productive, because the examiner can reproduce the exact movement that hurts.

Slipping rib vs. intercostal strain

An intercostal strain usually follows a clear mechanical event, sits between two ribs and settles with graded loading. Slipping rib pain sits at the lower costal margin, often clicks, recurs with particular positions and may persist for months. See intercostal strain vs. rib and chest-wall pain.

When to seek medical evaluation

Lower chest and upper abdominal pain have many causes. Fever, vomiting, jaundice, blood in the stool or vomit, unexplained weight loss, severe or worsening abdominal pain, chest pressure or shortness of breath need medical evaluation rather than a musculoskeletal workup.

How Novo approaches suspected slipping rib

We screen for medical causes, localize the pain along the lower ribs, test the movements and positions that reproduce it, check for clicking and hypermobility, and look for muscular, joint and nerve contributors. When slipping rib syndrome is suspected, we coordinate dynamic ultrasound and specialist evaluation rather than treating it as a strain. See how we approach rib, thoracic and intercostal pain.

References

• Schultz N, Qubain L, Riemann M, Temkit M, McMahon LE, Van Tassel D. Dynamic ultrasound evaluation of patients with suspected slipping rib syndrome: five years in. Skeletal Radiology. 2025;54(12):2777-2786. PMID 40613897. (link)
• Van Tassel D, McMahon LE, Riemann M, Wong K, Barnes CE. Dynamic ultrasound in the evaluation of patients with suspected slipping rib syndrome. Skeletal Radiology. 2019;48(5):741-751. PMID 30612161. (link)
• Madeka I, Alaparthi S, Moreta M, et al. A review of slipping rib syndrome: diagnostic and treatment updates to a rare and challenging problem. Journal of Clinical Medicine. 2023;12(24):7671. PMID 38137739. (link)
• McMahon LE. Slipping rib syndrome: a review of evaluation, diagnosis and treatment. Seminars in Pediatric Surgery. 2018;27(3):183-188. PMID 30078490. (link)
• Caldwell AS, Elangovan SM, Jacobson JA. Dynamic musculoskeletal ultrasound: slipping rib, muscle hernia, snapping hip, and peroneal tendon pathology. Pediatric Radiology. 2023;53(8):1553-1561. PMID 37286853. (link)
• Patel NG, Patel DM, Patel MV, et al. Diagnostic value of dynamic high-frequency ultrasound for the slipping rib and twelfth rib syndrome: a case series with review. Current Medical Imaging. 2021;17(4):459-463. PMID 33019936. (link)