Twelfth rib syndrome

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Twelfth rib syndrome
Other namesRib tip syndrome
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Side view of the rib cage
Symptoms Flank, groin, or loin pain
Diagnostic method Physical examination
Differential diagnosis Slipping rib syndrome, irritable bowel syndrome, peptic ulcers, renal pathology, aortic aneurysm, sciatica, arachnoiditis, postoperative pain, biliary tract pathology, pleurisy, pneumonia, shingles
TreatmentRest, analgesics, NSAIDs, therapeutic techniques, nerve block injections, surgery

Twelfth rib syndrome, also known as rib tip syndrome, is a painful condition that occurs as a result of highly mobile floating ribs. It commonly presents as pain that may be felt in the lower back or lower abdominal region as a result of the 11th or 12th mobile rib irritating the surrounding tissues and nervous systems. Diagnosis is often made by a physical examination after other conditions are ruled out. The condition is often labelled as slipping rib syndrome due to the unclear definitions of the conditions, with twelfth rib syndrome sometimes being referred to as a subtype of slipping rib syndrome.

Contents

Presentation

The presentation of twelfth rib syndrome varies between individuals. The predominant symptom experienced by individuals with this condition is abdominal, back, groin, loin, or flank pain, and pain that is typically localized to the 11th and 12th rib tips. [1] [2] The pain is often worse with movement, such as sitting, leaning forward, rotating of the trunk, lifting objects, or bending over. It may be continuous or intermittent, and has been described as dull, achy, or sharp. The pain can typically be reproduced by point tenderness on physical examination. [2] The length of symptomatology of the condition can last weeks or years. [1]

Pathogenesis

The exact cause of the condition is not understood, however the pathogenesis of the condition is likely to involve hypermobility of the floating ribs. These hypermobile 11th and 12th ribs subsequently result in irritation of the intercostal nerves, leading to neuropathic pain. [2]

Mechanism

The rib cage consists of 12 pairs of ribs including the true ribs (1st to 7th), false ribs (8th to 10th), and the floating ribs (11th and 12th). The true ribs are directly connected to the sternum by the costal cartilage. Similarly, the false ribs also connect to the sternum through costal cartilages, however indirectly through a connection to the costal cartilage of the rib above it. Unlike the true and false ribs, the floating 11th and 12th ribs do not connect to the sternum. [3]

Muscles of the thoracic cage 1112 Muscles of the Abdomen Anterolateral.png
Muscles of the thoracic cage

There is an extensive number of muscle groups that surround the floating ribs such as the external oblique, quadratus lumborum, latissimus dorsi, levator costarum, external intercostals, serratus posterior inferior, lumbocostal ligament, iliocostalis, longissimus thoracis, and the costodiaphragmatic pleural recess. A hypermobile floating rib can cause irritation to these muscles, which as a result can cause variation in the location and intensity of pain felt with twelfth rib syndrome. [2]

Additionally, there is a complex nervous system surrounding the floating ribs. The 12th intercostal nerve communicates with the first lumbar nerve, closely travels next to the subcostal artery, travels behind the kidney, through the aponeurosis of the transversus abdominis, communicates with the iliohypogastric nerve, and gives a branch to the pyramidalis. [4] Irritation of the lower intercostal nerves and surrounding tissues can cause neuropathic pain that may travel or radiate to other parts of the body, [2] such as in the groin or the suprapubic area. [1]

Diagnosis

The diagnosis of twelfth rib syndrome is clinical, often through a diagnosis of exclusion. After excluding other causes for the back, flank, groin, or loin pain, the clinician can confirm the diagnosis by a physical examination of the 11th and 12th ribs. The examiner will palpate the ribs to identify point tenderness locations, often trying to replicate the pain the individual experiences. [2]

Differential diagnosis

Some individuals with twelfth rib syndrome may be misdiagnosed and undergo investigations or surgical procedures that are unnecessary. [4] Due to the wide range in presentation of the condition, differential diagnoses of conditions that may produce abdominal, back, groin, loin, or flank pain are considered. Many individuals with twelfth rib syndrome often meet with a variety of specialists prior to their diagnosis, commonly within gastroenterology clinics. Conditions that may present similar to twelfth rib syndrome include irritable bowel syndrome, peptic ulcers, renal pathology, aortic aneurysm, sciatica, arachnoiditis, postoperative pain, biliary tract pathology, pleurisy, pneumonia, and shingles. [2] Additionally, twelfth rib syndrome should be differentiated from iliocostal friction syndrome, which involves the lower ribs coming in contact with the iliac crest. [5]

Twelfth rib syndrome is similar to slipping rib syndrome, to which some researchers consider twelfth rib to be a subtype of slipping rib syndrome. The two are commonly confused as a result of unclear definitions of the ribs involved with slipping rib syndrome, however they have different presentation and diagnostic criteria. [2] Slipping rib syndrome predominantly presents as upper abdominal, chest, and back pain, [6] whereas twelfth rib syndrome predominantly affects the lower abdomen, groin, and back. Diagnosis of slipping rib syndrome is also clinical, however utilizes the hooking maneuver, which twelfth rib syndrome does not. [2]

Treatment

The first line of method to treat twelfth rib syndrome is conservative measures. Usually individuals will be advised to reduce their physical activity or movements that exacerbate their symptoms. Individuals will be suggested to use ice packs, heat packs, analgesic medications or nonsteroidal anti-inflammatory drugs to manage the pain. Other conservative therapeutic measures such as physiotherapy, ultrasound therapy, transcutaneous electrical nerve stimulation (TENS), or cryotherapy may be used. In some cases intermittent relief is reported from chiropractic manipulations and electric stimulation. [1] [2]

If conservative measures do not provide relief, intercostal or costovertebral nerve blocks may be used. Repeated injections may be necessary as these injections may not provide long-term relief. [1] Surgical management is a permanent solution for cases in which do not resolve with repeated nerve blocks. Surgical excision or resection of the affected rib provides immediate relief of symptoms without recurrence. [2]

Related Research Articles

<span class="mw-page-title-main">Rib cage</span> Bone structure that protects the vital organs and major blood vessels

The rib cage is an endoskeletal enclosure in the thorax of most vertebrate animals that comprises the ribs, vertebral column and sternum, which protects vital organs such as the heart, lungs and great vessels. The circumferential enclosure formed by left and right rib cages, together known as the thoracic cage, is a semi-rigid bony and cartilaginous structure which surrounds the thoracic cavity and supports the shoulder girdles to form the core part of the axial skeleton.

<span class="mw-page-title-main">Thorax</span> Frontal part of an animals body, between its head and abdomen

The thorax or chest is a part of the anatomy of humans, mammals, and other tetrapod animals located between the neck and the abdomen. In insects, crustaceans, and the extinct trilobites, the thorax is one of the three main divisions of the creature's body, each of which is in turn composed of multiple segments.

<span class="mw-page-title-main">Tietze syndrome</span> Inflammation, tenderness, and pain of the chest wall with swelling present

Tietze syndrome is a benign inflammation of one or more of the costal cartilages. It was first described in 1921 by German surgeon Alexander Tietze and was subsequently named after him. The condition is characterized by tenderness and painful swelling of the anterior (front) chest wall at the costochondral, sternocostal, or sternoclavicular junctions. Tietze syndrome affects the true ribs and has a predilection for the 2nd and 3rd ribs, commonly affecting only a single joint.

<span class="mw-page-title-main">Peripheral neuropathy</span> Nervous system disease affecting nerves beyond the brain and spinal cord

Peripheral neuropathy, often shortened to neuropathy, is a general term describing damage or disease affecting the nerves. Damage to nerves may impair sensation, movement, gland, or organ function depending on which nerves are affected; in other words, neuropathy affecting motor, sensory, or autonomic nerves result in different symptoms. More than one type of nerve may be affected simultaneously. Peripheral neuropathy may be acute or chronic, and may be reversible or permanent.

<span class="mw-page-title-main">Pectoralis major</span> Main human chest muscle

The pectoralis major is a thick, fan-shaped or triangular convergent muscle of the human chest. It makes up the bulk of the chest muscles and lies under the breast. Beneath the pectoralis major is the pectoralis minor muscle.

<span class="mw-page-title-main">Thoracic outlet syndrome</span> Medical condition

Thoracic outlet syndrome (TOS) is a condition in which there is compression of the nerves, arteries, or veins in the superior thoracic aperture, the passageway from the lower neck to the armpit, also known as the thoracic outlet. There are three main types: neurogenic, venous, and arterial. The neurogenic type is the most common and presents with pain, weakness, paraesthesia, and occasionally loss of muscle at the base of the thumb. The venous type results in swelling, pain, and possibly a bluish coloration of the arm. The arterial type results in pain, coldness, and pallor of the arm.

<span class="mw-page-title-main">Costochondritis</span> Human disease

Costochondritis, also known as chest wall pain syndrome or costosternal syndrome, is a benign inflammation of the upper costochondral and sternocostal joints. 90% of patients are affected in multiple ribs on a single side, typically at the 2nd to 5th ribs. Chest pain, the primary symptom of costochondritis, is considered a symptom of a medical emergency, making costochondritis a common presentation in the emergency department. One study found costochondritis was responsible for 30% of patients with chest pain in an emergency department setting.

Meralgia paresthetica or meralgia paraesthetica is numbness or pain in the outer thigh not caused by injury to the thigh, but by injury to a nerve that extends from the spinal column to the thigh.

<span class="mw-page-title-main">Intercostal nerves</span>

The intercostal nerves are part of the somatic nervous system, and arise from the anterior rami of the thoracic spinal nerves from T1 to T11. The intercostal nerves are distributed chiefly to the thoracic pleura and abdominal peritoneum, and differ from the anterior rami of the other spinal nerves in that each pursues an independent course without plexus formation.

Athletic pubalgia, also called sports hernia, core injury, hockey hernia, hockey groin, Gilmore's groin, or groin disruption, is a medical condition of the pubic joint affecting athletes.

<span class="mw-page-title-main">Costal cartilage</span> Resilient, smooth, glass-like tissue at the front ends of ribs in verterbrates

The costal cartilages are bars of hyaline cartilage that serve to prolong the ribs forward and contribute to the elasticity of the walls of the thorax. Costal cartilage is only found at the anterior ends of the ribs, providing medial extension.

<span class="mw-page-title-main">Precordial catch syndrome</span> Medical condition

Precordial catch syndrome (PCS) is a non-serious condition in which there are sharp stabbing pains in the chest. These typically get worse with inhaling and occur within a small area. Spells of pain usually last less than a few minutes. Typically it begins at rest and other symptoms are absent. Concerns about the condition may result in anxiety.

<span class="mw-page-title-main">Spinal disc herniation</span> Injury to the connective tissue between spinal vertebrae

A spinal disc herniation is an injury to the cushioning and connective tissue between vertebrae, usually caused by excessive strain or trauma to the spine. It may result in back pain, pain or sensation in different parts of the body, and physical disability. The most conclusive diagnostic tool for disc herniation is MRI, and treatment may range from painkillers to surgery. Protection from disc herniation is best provided by core strength and an awareness of body mechanics including posture.

<span class="mw-page-title-main">Loin pain hematuria syndrome</span> Medical condition

Loin pain hematuria syndrome (LPHS) is the combination of debilitating unilateral or bilateral flank pain and microscopic or macroscopic amounts of blood in the urine that is otherwise unexplained.

In medicine, Carnett's sign is a finding on clinical examination in which (acute) abdominal pain remains unchanged or increases when the muscles of the abdominal wall are tensed. For this part of the abdominal examination, the patient can be asked to lift the head and shoulders from the examination table to tense the abdominal muscles. An alternative is to ask the patient to raise both legs with straight knees.

<span class="mw-page-title-main">Sacroiliac joint dysfunction</span> Medical condition

The term sacroiliac joint dysfunction refers to abnormal motion in the sacroiliac joint, either too much motion or too little motion, that causes pain in this region.

Cancer pain can be caused by pressure on, or chemical stimulation of, specialised pain-signalling nerve endings called nociceptors, or by damage or illness affecting nerve fibers themselves.

Anterior cutaneous nerve entrapment syndrome (ACNES) is a nerve entrapment condition that causes chronic pain of the abdominal wall. It occurs when nerve endings of the lower thoracic intercostal nerves (7–12) are 'entrapped' in abdominal muscles, causing a severe localized nerve (neuropathic) pain that is usually experienced at the front of the abdomen.

<span class="mw-page-title-main">Slipping rib syndrome</span> Pain in the false ribs due to the partial dislocation of the costal cartilage

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. 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.

<span class="mw-page-title-main">Iliocostal friction syndrome</span> Medical condition

Iliocostal friction syndrome, also known as costoiliac impingement syndrome, is a condition in which the costal margin comes in contact with the iliac crest. The condition presents as low back pain which may radiate to other surrounding areas as a result of irritated nerve, tendon, and muscle structures. It may occur unilaterally due to conditions such as scoliosis, or bilaterally due to conditions such as osteoporosis and hyperkyphosis.

References

  1. 1 2 3 4 5 Jung J, Lee M, Choi D (September 2020). "Twelfth rib syndrome: a case report". The Journal of International Medical Research. 48 (9): 300060520952651. doi:10.1177/0300060520952651. PMC   7479855 . PMID   32883133.
  2. 1 2 3 4 5 6 7 8 9 10 11 Urits I, Noor N, Fackler N, Fortier L, Berger AA, Kassem H, et al. (January 2021). "Treatment and Management of Twelfth Rib Syndrome: A Best Practices Comprehensive Review". Pain Physician. 24 (1): E45–E50. PMID   33400437.
  3. ↑ Gundersen A, Borgstrom H, McInnis KC (March 2021). "Trunk Injuries in Athletes". Current Sports Medicine Reports. 20 (3): 150–156. doi: 10.1249/JSR.0000000000000819 . PMID   33655996. S2CID   232102047.
  4. 1 2 Cranfield KA, Buist RJ, Nandi PR, Baranowski AP (March 1997). "The twelfth rib syndrome". Journal of Pain and Symptom Management. 13 (3): 172–175. doi: 10.1016/S0885-3924(96)00271-0 . PMID   9114637.
  5. ↑ Wynne AT, Nelson MA, Nordin BE (1985). "Costo-iliac impingement syndrome". The Journal of Bone and Joint Surgery. British Volume. 67 (1): 124–125. doi:10.1302/0301-620X.67B1.3155743. ISSN   0301-620X. PMID   3155743.
  6. ↑ McMahon LE (June 2018). "Slipping Rib Syndrome: A review of evaluation, diagnosis and treatment". Seminars in Pediatric Surgery. 27 (3): 183–188. doi:10.1053/j.sempedsurg.2018.05.009. PMID   30078490.
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