Question
Hey, I came off my push-bike in november. The handlebars speared me in the lower right ribs where they meet the stomach below the sternum. I could not train for two months, with general pain around my chest and into my sternum. I also had really bad pain in the area of impact and around the right side of ribs. it was difficult to put my arm over my head, especially when doing the front crawl.
In March I went back surfing and when I got out of the water I had acute pain/stiffness in my mid back. This got worse and has been there since march. Then in June I over-exercised in the pool and after that the pain became really bad in my right ribs again. Lying on the surfboard became painful, as did the paddling movement. Mid-back MRI and x-rays show nothing unremarkable. When I put my hand around my side and pull forward I hear/feel a click at the end of my ribs where they meet the stomach. This does not cause pain but it clicks in one of the area's where I have constant pain. Doctor and physio say the ribs feel secure and they dont pop out or anything like that. I am getting deep tissue massage on mid back and intercostal muscles from a sports therapist. Pain has been there for a long time now with no real relief. Training tends to make it worse not better. It is a constant pain as opposed to a really sharp pain. Could I have unhealed cartilage or hypermobile ligaments after injury. What is slipping rib syndrome and do I have symptoms? I'm going for CT in october on my chest. I am 26 years old and mobile and athletic. The physio said I had a lot of movement in my mid spine but the joints feel real sore.

Answer
Dear Jack,

If the doctor and the physiotherapist both agree that the ribs are stable/secure, I doubt that you have slipping rib syndrome.  However, Slipping Rib Syndrome may be caused by hypermobility of the anterior end of the costal cartilage, located at the rib-cartilage interface called the costochondral junction(your question about hypermobile ligament structures). Most often, the tenth rib is the source because, unlike ribs one through seven which attach to the sternum, the eighth, ninth, and tenth ribs are attached anteriorly to each other by loose, fibrous tissue. This provides increased mobility, but a greater susceptibility to trauma. Slipping rib cartilage may cause no pain or only intermittent pain.

Slipping Rib Syndrome is also more likely to occur in the lower ribs because of the poor blood supply to the cartilaginous tissue and ligaments. Injury (like a blunt trauma) to the cartilage tissue in the lower ribs or the sternocostal ligaments in the upper ribs seldom completely heal naturally. The sternocostal(rib-sternum), and costochondral joints undergo stress when the rib cage expands or contracts abnormally or when excessive pressure is applied on the ribs themselves, therefore, these issues can easily become chronic.

What I would recommend is that you look into a specific therapy called Prolotherapy which is administered by an MD.  Prolotherapy is a simple technique that stimulates the body to repair the painful area when the natural healing process needs assistance. In most cases, commonly prescribed anti-inflammatory medications and more drastic measures like surgery and joint replacement may not help, and often hinder or even prevent the healing process.

mechanism:  A substance (often a dextrose solution) is injected into the affected cartilage, ligaments or tendons, which leads to local inflammation. The localized inflammation triggers a wound healing cascade, resulting in the deposition of new collagen, the material that ligaments and tendons are made of. New collagen shrinks as it matures. The shrinking collagen tightens the ligament that was injected and makes it stronger. Prolotherapy has the potential of being 100 percent effective at eliminating chronic pain due to ligament and tendon weakness, but depends upon the technique of the individual doctor.

Bottom Line is that it is a technique that I would recommend that you research further, and look for qualified physicians in your area to  treatment options.

Respectfully,
Dr. J. Shawn leatherman
www.suncoasthealthcare.net