Dynamic ultrasound in the evaluation of patients with suspected slipping rib syndrome

  • Dane Van Tassel
  • Lisa E. McMahon
  • Monique Riemann
  • Kevin Wong
  • Craig E. Barnes
Scientific Article



Slipping rib syndrome (SRS) affects adolescents and young adults. Dynamic ultrasound plays a potential and likely significant role; however, limited data exist describing the protocol and techniques available. It is our intent to describe the development of a reproducible protocol for imaging in patients with SRS.

Materials and Methods

Retrospective review of suspected SRS patients from March 2017 to April 2018. A total of 46 patients were evaluated. Focused history and imaging was performed at the site of pain. Images of the ribs were obtained in the parasagittal plane at rest and with dynamic maneuvers. Dynamic maneuvers included Valsalva, crunch, rib push maneuver, and any provocative movement that elicited pain. Imaging was compared with records from the pediatric surgeon specializing in slipping ribs. Statistical analysis was performed.


Thirty-six of the 46 patients had a diagnosis of SRS, and had an average age of 17 years. Thirty-one patients were female, 15 were male. Thirty-one out of 46 (67%) were athletes. Average BMI was 22.6. Dynamic ultrasound correctly detected SRS in 89% of patients (32 out of 36) and correctly detected the absence in 100% (10 out of 10). Push maneuver had the highest sensitivity (87%; 0.70, 0.96) followed by morphology (68%; 0.51, 0.81) and crunch maneuver (54%; 0.37, 0.71). Valsalva was the least sensitive (13%; 0.04, 0.29).


Dynamic ultrasound of the ribs, particularly with crunch and push maneuvers, is an effective and reproducible tool for diagnosing SRS. Valsalva plays a limited role. In addition to diagnosing SRS, ultrasound can give the surgeon morphological data and information on additional ribs at risk, thereby assisting in surgical planning.


Slipping rib syndrome Chest pain Rib pain Abdominal pain Dynamic ultrasound 


Compliance with ethical standards


This article is currently solely submitted for review as original research to Skeletal Radiology. This material is IRB approved and is the result of work supported with resources and the use of facilities at the Phoenix Children’s Hospital.

Conflicts of interest

The authors declare that they have no conflicts of interest.

Supplementary material

256_2018_3133_MOESM1_ESM.mp4 (863 kb)
Video 1. Scanning of normal cartilage morphology with the normal course and contour of the 7th and 8th ribs. (MP4 863 kb)
256_2018_3133_MOESM2_ESM.mp4 (439 kb)
Video 2. Scanning of abnormal cartilage morphology with an abnormal course of the 8th rib, which hooks deep to and underneath the 7th rib at rest. (MP4 439 kb)
256_2018_3133_MOESM3_ESM.mp4 (1006 kb)
Video 3. Scanning of the normal motion of the 10th and 11th ribs during Valsalva maneuver. Note the normal mild contraction of the intercostal musculature and the maintenence of the normal position and relative relationship to the adjacent ribs. (MP4 1006 kb)
256_2018_3133_MOESM4_ESM.mp4 (749 kb)
Video 4. Scanning of an abnormal Valsalva of the 9th and 10th ribs. Note the abnormal hooked morphology of the 10th rib, which closely abuts the 9th rib on Valsalva. (MP4 749 kb)
256_2018_3133_MOESM5_ESM.mp4 (983 kb)
Video 5. Scanning of the normal motion of the 8th and 9th ribs during the crunch maneuver. Note the normal mild contraction of the intercostal musculature and maintenence of the normal position and relative relationship to the adjacent ribs. (MP4 982 kb)
256_2018_3133_MOESM6_ESM.mp4 (916 kb)
Video 6. Scanning of an abnormal crunch maneuver of the 8th and 9th ribs. Note the abnormal motion of the 9th rib, which moves deep to and underneath the adjacent 8th rib, contacting the rib and resulting in a palpable “click.” (MP4 916 kb)
256_2018_3133_MOESM7_ESM.mp4 (1.1 mb)
Video 7. Scanning of the normal motion of the 8th and 9th ribs during a rib push maneuver. Note the normal mild deep motion of the pushed rib, with maintenence of the normal position and relative relationship to the adjacent ribs. (MP4 1159 kb)
256_2018_3133_MOESM8_ESM.mp4 (1.2 mb)
Video 8. Scanning of an abnormal rib push maneuver of the 10th and 11th ribs. Note the abnormal at-rest position of the 11th rib. The rib push maneuver results in abnormal motion of the 11th rib, which moves deep to and underneath the adjacent 10th rib, contacting the rib and resulting in a palpable “click/pop.” (MP4 1200 kb)


  1. 1.
    Saltzman DA, Schmidt ML, Smith SD, Jackson RJ. The slipping rib syndrome in children. Paediatr Anaesthesiol. 2001;11:740–3.CrossRefGoogle Scholar
  2. 2.
    Arroyo JF, Vine R, Reynaud C, et al. Slipping rib syndrome: don’t be fooled. Geriatrics. 1995;50:46–9.PubMedGoogle Scholar
  3. 3.
    Guttentag AR, Salwen JK. Keep your eyes on the ribs: the spectrum of normal variants and diseases that involve the ribs. Radiographics. 1999;19(5):1125–42.CrossRefGoogle Scholar
  4. 4.
    Udermann BE, Cavanaugh DG, Gibson MH, Doberstein ST, Mayer JM, Murray SR. Slipping rib syndrome in a collegiate swimmer: a case report. J Athl Train. 2005;40(2):120–2.PubMedPubMedCentralGoogle Scholar
  5. 5.
    Cyriax EF. On various conditions that may simulate the referred pains of visceral disease, and a consideration of these from the point of view of cause and effect. Practitioner. 1919;102:314–22.Google Scholar
  6. 6.
    Davies-Colley R. Slipping rib. Br Med J. 1922;1:432.CrossRefGoogle Scholar
  7. 7.
    Bass J, Pan HC, Fegelman RH. Slipping rib syndrome. J Natl Med Assoc. 1979;71(9):863–5.PubMedPubMedCentralGoogle Scholar
  8. 8.
    Heinz GJ, Zavala DC. Slipping rib syndrome. JAMA. 1977;237:794–5.CrossRefGoogle Scholar
  9. 9.
    Spense EK, Rosaro EF. The slipping rib syndrome. Arch Surg. 1985;118:1330–2.CrossRefGoogle Scholar
  10. 10.
    Telford KM. The slipping rib syndrome. Can Med Assoc J. 1950;62:463–5.PubMedPubMedCentralGoogle Scholar
  11. 11.
    Porter GE. Slipping rib syndrome: an infrequently recognized entity in children: a report of three cases and review of the literature. Pediatrics. 1985;76:810–3.PubMedGoogle Scholar
  12. 12.
    Bolanos-Vergaray JJ, Garcia FG, Obaya Rebollar JC, Albarez MB. Slipping rib syndrome as persistent abdominal and chest pain. A A Case Reports. 2015;5:167–8.CrossRefGoogle Scholar
  13. 13.
    Mooney DP, Shorter NA. Slipping rib syndrome in childhood. J Pediatr Surg. 1997;32:1081–2.CrossRefGoogle Scholar
  14. 14.
    Taubman B, Vetter VL. Slipping rib syndrome as a cause of chest pain in children. Clin Pediatr. 1996;8:403–5.CrossRefGoogle Scholar
  15. 15.
    Wright JT. Slipping rib syndrome. Lancet. 1980;20:632–4.CrossRefGoogle Scholar
  16. 16.
    Copeland GP, Machi DG, Sheehan TM. Surgical treatment of the slipping rib syndrome. Br J Surg. 1984;71:522–3.CrossRefGoogle Scholar
  17. 17.
    Zbojniewicz AM. US for diagnosis of musculoskeletal conditions in the young athlete: emphasis on dynamic assessment. Radiographics. 2014;34(5):1145–62.CrossRefGoogle Scholar
  18. 18.
    Meuwly JF. Slipping rib syndrome, a place for sonography in the diagnosis of a frequently overlooked cause of abdominal pain or low thoracic pain. J Ultrasound Med. 2003;21:339–43.CrossRefGoogle Scholar
  19. 19.
    Scott EM, Scott BB. Painful rib syndrome, a review of 76 cases. Gut. 1993;34:1006–8.CrossRefGoogle Scholar
  20. 20.
    Foley CM, Sugimoto D, Mooney DP, Meehan WP, Stracciolini A. Diagnosis and treatment of slipping rib syndrome. Clin J Sport Med. 2019;29(1):18–23.CrossRefGoogle Scholar
  21. 21.
    Russek LN, Errico DM. Prevalence, injury rate and symptom frequency in generalized joint laxity and joint hypermobility in “healthy” college population. Clin Rheumatol. 2016;35:1029–39.CrossRefGoogle Scholar
  22. 22.
    Peterson LL, Cavanaugh DG. Two years of debilitating pain in a football spearing victim: slipping rib syndrome. Med Sci Sports Exerc. 2003;35:1634–7.CrossRefGoogle Scholar
  23. 23.
    Goffin J, van Loon J, Van Calenbergh F, Plets C. Long-term results after anterior cervical fusion and osteosynthetic stabilization for fractures and/or dislocations of the cervical spine. J Spinal Disord. 1995;8:500–8.CrossRefGoogle Scholar
  24. 24.
    Chau CL, Griffith JF. Musculoskeletal infections: ultrasound appearances. Clin Radiol. 2005;60:149–59.CrossRefGoogle Scholar

Copyright information

© ISS 2019

Authors and Affiliations

  • Dane Van Tassel
    • 1
  • Lisa E. McMahon
    • 1
  • Monique Riemann
    • 1
  • Kevin Wong
    • 1
  • Craig E. Barnes
    • 1
  1. 1.Phoenix Children’s HospitalPhoenixUSA

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