What is Slipping Rib Syndrome?

Many patients have rib pain, but this often goes undiagnosed. Today we’ll explore why and get into “Slipping Rib Syndrome” as well as the concept of rib instability. Let’s dig in.

The Typical Patient

Credit: Author and Shutterstock

While many different patients can have pain in the upper back or chest due to a wide variety of things, slipping rib syndrome patients are different. They tend to have pain that travels from their upper back that wraps around the chest to the front. This pain also tends to be modified by taking a deep breath. Despite reporting these symptoms to many physicians and providers, physicians usually want to look at their neck and low back as possible causes. So it’s not uncommon for these confused patients to get several neck or low back injections that do nothing for this pain. Or there is a recognition of a thoracic problem, but then steroid injections are performed locally which almost always fail.

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A Brief Summary of Slipping Rib Syndrome

While I’ll explain in more detail below, the idea behind slipping rib syndrome is that one or more ribs move too much, or said another way, rib instability (1). While this is described as being more common in patients with hypermobile Ehlers-Danlos syndrome (EDS), we also see it because of direct trauma to the ribs or scoliosis.

Anatomy and Biomechanics of the Ribs

Credit: Shutterstock

Your rib cage begins in the thoracic spine and is attached to each thoracic vertebra and then makes it’s way around to the front where it’s attached to the sternum or other ribs that then attach to the sternum.

Credit: Author and Shutterstock

Your ribs have two main motions when you inhale and exhale:

  • Bucket handle
  • Pump handle

The bucket handle motion occurs out to the side as shown above. Pump handle motions occur in the front-back plane. This is important as these ribs have controlled and precise motion in relationship to each other. How does that work?

Credit: Author and Elsevier Complete Anatomy

First, your ribs have lots of ligaments that attach them to the thoracic spine. These include attachments between the rib and transverse processes (lateral and superior costotransverse ligaments as shown here in yellow). There is also a capsule around the two joints between the rib and the vertebra (costotransverse and costovertebral). This also acts to help control motion.

Credit: Author and Elsevier Complete Anatomy

However, while these ligaments in the thoracic spine between the vertebrae and ribs are often important in slipping rib syndrome, it’s the rib fascia that controls local movement along with the intercostal muscles.

If you’ve ever bought ribs from the grocery store, you’ll notice a tough covering on the inside and outside. That’s called the rib fascia.

Credit: Author

Credit: Author

As you can see above, the fascia around the ribs controls the motion between each rib. Hence, for slipping rib syndrome or rib instability to happen, it’s often damage to this fascia that causes the issue of one or more ribs moving too much.

How Can this Problem Be Diagnosed?

This is one of the big problems with slipping rib syndrome. There is no imaging study that can easily identify 95% of the patients with this issue. In about 5% of the patients, the extra motion is so severe that it can be seen on a chest x-ray as a misaligned rib. However, that’s usually normal in the vast majority of patients who have this problem. MRI is also not helpful.

Regrettably, it’s often a good hands-on physical exam combined with a history that usually makes the diagnosis, but most physicians are not trained on how to examine and detect abnormal rib movement. In fact, this diagnosis is much more likely to come from a chiropractor or manually trained physical therapist due to their additional training in this area.

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How Can this Problem Be Treated?

While the traditional medical care system likes to try to inject steroids that can harm the local tissue, in my experience in treating hundreds of patients with slipping rib syndrome, that rarely works. In addition, surgery is almost always a really bad idea here. However, many patients find relief by getting manual chiropractic, osteopathic, or physical therapy manipulation of the wayward rib.

When manual adjustment or physical therapy doesn’t work long-term, what’s next? What is effective based on my clinical experience is injecting prolotherapy solution or platelet-rich plasma directly into the above-described ligaments and the rib facia using very precise ultrasound guidance. This can help heal and tighten these damaged structures. In addition, oftentimes there is irritation of the local spinal nerve that requires adding a transforaminal epidural performed under x-ray guidance with contrast confirmation.


To learn more, see my video and Q&A on the topic:

The upshot? Slipping rib syndrome is a real problem that’s caused by rib instability. It’s not hard to diagnose and treat if you know what to look for and use image-guided orthobiologics, but regrettably, patients, rarely get diagnosed and treated.


(1) Foley Davelaar CM. A Clinical Review of Slipping Rib Syndrome. Curr Sports Med Rep. 2021 Mar 1;20(3):164-168. doi: 10.1249/JSR.0000000000000821. PMID: 33655998.

Chris Centeno, MD is a specialist in regenerative medicine and the new field of Interventional Orthopedics. Centeno pioneered orthopedic stem cell procedures in 2005 and is responsible for a large amount of the published research on stem cell use for orthopedic applications. View Profile

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NOTE: This blog post provides general information to help the reader better understand regenerative medicine, musculoskeletal health, and related subjects. All content provided in this blog, website, or any linked materials, including text, graphics, images, patient profiles, outcomes, and information, are not intended and should not be considered or used as a substitute for medical advice, diagnosis, or treatment. Please always consult with a professional and certified healthcare provider to discuss if a treatment is right for you.

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