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

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Abstract

Objective

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.

Results

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).

Conclusion

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.

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Authors and Affiliations

  1. Phoenix Children’s Hospital, 1919 E. Thomas Road, Phoenix, AZ, 85016, USA

    Dane Van Tassel, Lisa E. McMahon, Monique Riemann, Kevin Wong & Craig E. Barnes

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  1. Dane Van Tassel
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  2. Lisa E. McMahon
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  3. Monique Riemann
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  4. Kevin Wong
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Corresponding author

Correspondence to Dane Van Tassel.

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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.

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The authors declare that they have no conflicts of interest.

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Electronic supplementary material

Video 1.

Scanning of normal cartilage morphology with the normal course and contour of the 7th and 8th ribs. (MP4 863 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)

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)

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)

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)

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)

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)

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)

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Van Tassel, D., McMahon, L.E., Riemann, M. et al. Dynamic ultrasound in the evaluation of patients with suspected slipping rib syndrome. Skeletal Radiol 48, 741–751 (2019). https://doi.org/10.1007/s00256-018-3133-z

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  • DOI: https://doi.org/10.1007/s00256-018-3133-z

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