In February 2025 I figured it out and it has since been verified by a radiologist with the only scan that is capable of detecting my condition – a dynamic ultrasound. What is my condition? What is it that turned my life upside down 15 years ago? It’s Slipping Rib Syndrome. The medical term is interchondral subluxation. It is associated with Ehlers Daniels Syndrome (EDS) and it involves laxity in the costal cartilage that connects your false ribs (8-10) to the sternum. It is somewhat rare and underdiagnosed however there’s a test that confirms it called the “Hooking Maneuver”. That’s how I diagnosed myself.
Using the Hooking Maneuver, I can easily pop at least two of my left ribs out of place or actually, back into place.
So why the back pain?
My first suspect is the left 10th costotransverse joint. It is extremely sensitive to palpation about 1/2″ left of the spinous process and it is one of the two joints that the rib uses to articulate into the spine. Mid-back pain is a very common symptom of Slipping Rib Syndrome and I need to find out why. I suspect the subluxed 10th rib tip has pushed the rib out of alignment or is putting pressure on the rib which irritates the costotransverse joint. The costovertebral joint is probably involved too. A PET scan shows excess uptake at both joints from T4 to T12.
My second suspect is the intercostal nerve. Actually that may be my first suspect. It is the the most common nerve irritated by SRS. However, it’s the “knife in my back” that has shut me down and that seems to be the location of the costotransverse joint.
Here is a a good article on how SRS causes back pain.
Check this out!
Evidence
Hooking Maneuver: Positive
When performing the hooking maneuver, the 10th rib appears to be folded under the ninth rib. Pulling downward and outward (feels like unfolding), the 10th rib can be pulled back into place with an audible thud that can be heard across the room as well as felt by the practitioner as well as the patient. This triggers a familiar pain in the flank that radiates to the two primary pain locations in the front and back (i.e. it recreates “the Pain”). When the hook is released the rib immediately subluxates (i.e. folds back under the ninth rib). I believe my 9th rib is subluxed as well. I may even have a broken cartilage fragment floating around. I expect Dr. Hansen will find multiple problems when I see him August 12th.
MO
- Easily and definitively diagnosed with hooking maneuver (patient tested strong positive)
- Most commonly affects the 10th rib (the knife in my back is left of my 10th vertebrae)
- Would explain why it has remained undiagnosed for 15 years (this is a rare/underdiagnosed condition)
- Cannot be seen with x-rays, CT, MRI or standard ultrasound. Requires dynamic ultrasound
- Refers pain to the intercostal nerve root between the 9th and 10th vertebrae, exacerbated by pushing on the end of the left transverse process (easily located with Nerve Finder (patent pending))
- The condition often accompanies a history of physical trauma.2 (my ribs have been a piñata, slamming into windsurfing booms for decades, not to mention many other traumatic injuries to my ribcage including mountain biking, snowboarding and numerous watersports). It is a common injury for windsurfers and big-wave surfers.
- The condition is known to accompany hypermobility (the patient is hypermobile)
- It refers to both the mid-back and the chest (same for patient)
- It comes and goes but comes on sharp and stabbing and fades to aching (same for patient)
My Story
I have been in severe, chronic pain for 14 years. Prior to 2010 when it began, I lived with pain as an extreme sports athlete, constantly injured from surfing, windsurfing, snowboarding, mountain biking, motocross and other sports. However the pain that I’ve been battling for over a decade is on a whole other level, more severe than anything I could have imagined before. The pain is constant and wavers between level 3 and level 10. Trying to get help from the US medical system has been a nightmare. I am a disabled engineer. I had to stop working in 2011 because the pain was so severe I couldn’t think straight. It hurt too much to eat. I lost so much weight people were concerned I was dying. In truth I was. I was screaming inside, but nobody was listening. This was before the DEA’s war on pain patients so I was able to get opiates, but even fentanyl patches didn’t relieve the pain. Thankfully I’ve learned to manage it with the help of a doctor who puts her patients first, who still has some empathy and is willing to prescribe methadone, a drug known to be very effective for nerve pain at a low dose. Most doctors won’t do this for their patients and many patients are suffering needlessly and even committing suicide. I do plan to battle this politically once I get my own case under control.
Every day for 14 years, I have been trying to figure out what is hurting me; what is causing the knife in my back just left of my 10th vertebrae? Or the spear that goes all the way through to my xiphoid process. What is the unknown thing inside me that has ruined my life, that is so painful you can see the inflammation all over my left mid-back with the naked eye?
Mystery Solved?!
I think I finally figured it out on my own. I believe my 9th intercostal nerve (left) is being irritated by a subluxated 10th rib, much like in the photo above (actually the photo shows the 7th intercostal nerve being irritated by the 8th subluxated rib). SRS affects the “false ribs”, 8, 9 and 10. But if the 8th rib subluxates, it can irritate the 7th intercostal nerve. My pain near the spine seems closer to T10 so I am trying to find a doctor to give me intercostal nerve blocks on nerves 9 and 10, or preferably, 8, 9 and 10, although any injection above 9 has always felt too high.
I may not have Slipping Rib Syndrome but the “hooking maneuver” produces an unmistakable positive result. I can pull my 10th rib out from under my 9th rib (i.e. back into place), and when I let go, it falls back out of place with a thud, into my ninth rib. This is supposed to be a definitive test and I pass it with flying colors. I think my costal cartilage is probably a wreck. My ribs have been a piñata over the years with all my sports, including windsurfing, surfing, snowboarding and mountain biking where I had numerous crashes. This condition is especially common among windsurfers because at extreme speeds, you are often catapulted by a 15′ mast with extreme force. Stuck in the harness, your ribs crash onto the exposed boom. The prime suspect however is the extreme force that a windsurfing harness puts on the floating (11,12) and false (8-10) ribs. I don’t know if it’s responsible for the breaking of my costal cartilage, but once, subluxated, it was really irritating my intercostal nerves (I suspect 9th and 10th). The biggest mistake I made was not stopping when it started to hurt. My life was so wrapped up in extreme sports, I couldn’t stop. I kept going until I was in so much pain I couldn’t move.
More than one practitioner has commented that my ribs seem out of alignment. I am now almost certain that the intercostal nerves are involved. An intercostal nerve block is the one injection I’ve always wanted but for a variety of reasons, have yet to get. Everyone says it is the next step, so this new theory fits right in with what they were going to do anyway. Now, all my crazy symptoms make sense. This can be a debilitating condition and mine is a severe case. In addition to all the damage done to my costal cartilage over the years, I am hypermobile. This is often associated with Slipping Rib Syndrome. I try not to blame doctors for not diagnosing my problem. What shocked me was their unwillingness to even try.
Here, is a list of websites and YouTubes that I’ve found informative. There is a lot of information out there about this underdiagnosed condition. As they say, getting a diagnosis is half the battle. I’m doing this in hopes of helping others, with this same condition or similar undiagnosed pain. A guy named Matt has a website, much better than this one, at SlippingRibSyndrome.org and his story is very similar to mine.
Slipping rib syndrome (SRS) is a condition in which the interchondral ligaments are weakened or disrupted and have increased laxity, causing the costal cartilage tips to subluxate (partially dislocate). This results in pain or discomfort due to pinched or irritated intercostal nerves, straining of the intercostal muscles, and inflammation. The condition affects the 8th, 9th, and 10th ribs, referred to as the false ribs, with the 10th rib most commonly affected.
Wikipedia
Thankfully I can keep a very long and complicated story, relatively simple. For now I’ll leave a 18-year rectus abdominis hernia, requiring two surgeries, out of it and concentrate on my newest discovery – interchondral subluxation, or Slipping Rib Syndrome.
From Cleveland Clinic….
“A slipping rib can irritate the intercostal nerve that runs between your ribs. This probably triggers the sharp, localized pain you feel at first. Eventually, it may also inflame the soft tissues around your rib. This may cause a more diffuse type of pain that’s harder to locate in one place. It might feel like lower chest pain or upper abdominal pain. Sometimes, it radiates to your upper back or one of your flanks.
How do you fix a slipping rib?
Sometimes, a slipping rib heals on its own. If it’s not bothering you too much, your provider might suggest waiting and watching to see if it does. They’ll suggest conservative treatments to ease your pain, like:
- Hot/cold therapy
- Over-the-counter pain medications, like NSAIDs
- A period of rest, followed by physical therapy
If this approach isn’t working, they might suggest an intercostal nerve block — an injection of medication to calm your irritated nerve. This provides temporary relief, and sometimes it helps the healing process.
Surgery
If your symptoms don’t improve over the long term, you might need surgery to fix slipping rib syndrome. Surgeons use minimally invasive methods, like video-assisted thoracic surgery (VATS), whenever possible.
Surgery to fix a slipping rib might mean:
- Tightening or repairing loose ligaments or cartilage with stitches (stabilization)
- Removing the damaged or detached cartilage tip (partial rib resection)
- Using metal plates to separate ribs that are sliding together (rib plating)
Outlook / Prognosis
What can I expect if I have this condition?
Getting a diagnosis for slipping rib syndrome is half the battle. Once your healthcare provider recognizes the condition, healing can begin. Many people find relief over time through conservative treatments.
Not everyone will need surgery for slipping rib syndrome, but surgery is usually successful if you do. Occasionally, there’s an unrecognized cause that leads to symptoms returning later in another rib.
A note from Cleveland Clinic
Slipping rib pain can be intense, confusing and frightening, especially when your healthcare provider can’t explain it. It’s incredibly frustrating to have chronic pain with no diagnosis or treatment plan.
Fortunately, awareness of slipping rib syndrome is gradually increasing. And for all its mystery, it’s not an incurable or life-threatening disease — just an anatomical issue that surgery can fix.
Snippets above from https://my.clevelandclinic.org/health/diseases/slipping-rib-syndrome
Diagnosis
Diagnosing slipping rib syndrome is predominantly clinical,[10][11] with a physical examination of the affected rib being the most commonly utilized. A technique known as the “hooking maneuver” is commonly used amongst medical professionals to diagnose slipping rib syndrome. The examiner will hook their fingers under the costal margin, then pull in an anterior (outward) and superior (upward) direction, with a positive result when movement or pain is replicated during this action.[7]
Plain radiographs, CT scans, MRI, and standard ultrasound, are all unable to visualize the cartilage affected by SRS; however, they are often used to exclude other conditions.[3] Dynamic ultrasound is occasionally used to evaluate the dynamic laxity or displacement of the cartilage;[10] however, it has been said to be not much superior to that of a physical examination from an experienced physician, as a diagnosis is dependent on the technician’s expertise and knowledge of the condition.[9] A positive result of a dynamic ultrasound for slipping rib syndrome requires an observed subluxation of the cartilage, which may be elicited with the Valsalva, crunch, or other maneuvers.[12][13] Nerve blocking injections have also been utilized as a diagnostic method by noting the absence of pain following an injection to the intercostal nerves of the affected ribs.[14][11]
Note: I passed the “hooking maneuver” test with flying colors. I can pull at least one of my false ribs (I suspect 10), in and out of the joint with an audible thud. A positive result of this test is considered definitive but I need to find a practitioner to confirm my result.
Slipping Rib Syndrome in a Collegiate Swimmer: A Case Report is an interesting case and a theory as to why this condition causes back pain (the ribcage is a “closed system”)
Rib hypermobility caused by weakness of the rib-sternum (sternocostal), rib-cartilage (costochondral), and/or rib-vertebral (costovertebral/costotransverse) ligaments, allowing rib hypermobility, is thought to be the primary cause of slipping rib syndrome.36 Ribs 8 through 10 (false ribs), which are not connected to the sternum but are connected to each other via a cartilaginous cap or fibrous band, tend to be the most mobile and susceptible to trauma. Because of this, slipping rib syndrome is usually caused by hypermobility of rib 8, 9, or 10. Anterior rib hypermobility is also likely to cause problems in the posterior thoracic area as well because in a closed system (in this case, the rib cage) it is difficult for motion to occur at 1 site (the anterior portion of the rib) without causing motion to occur elsewhere (the posterior portion of the rib).36 So, as was the case with our athlete, the condition often results in back pain.