Costal cartilage excision for the treatment of pediatric
slipping rib syndrome
, Corey W. Iqbal
, Dawn E. Jaroszewski
, Shawn D. St. Peter
Department of Surgery, Mayo Clinic Scottsdale, Scottsdale, AZ 85054, USA
Department of Surgery, Children's Mercy Hospitals and Clinics, Kansas City, MO 64108, USA
Received 23 April 2012; revised 1 June 2012; accepted 3 June 2012
Slipping rib syndrome;
Background: Costal cartilage excision is an effective treatment of slipping rib syndrome (SRS), although
the diagnosis of SRS may be elusive. We review our experience with SRS in the pediatric patient.
Methods: This is a retrospective review from 2000 to 2011 of patients presenting with symptoms of SRS
before 18 years of age.
Results: Seven patients were identified who were diagnosed with SRS and underwent costal cartilage
excision. All patients presented with unilateral chest pain that was exacerbated by activity. Five patients
reported a popping or clicking sensation with activity that was associated with pain. On physical
examination, all patients had reproducible pain with palpation over the affected cartilage. Four patients had
a mobile or popping rib with palpation, and 4 also had chest wall asymmetry. Five patients underwent
imaging, and 4 patients were referred to specialists. It was a median of 2 years (0-5 years) from onset of
symptoms to resection. At resection, all cartilages were grossly abnormal. There were no postoperative
complications. Follow-up was complete for all patients over a median 0.9 years (0.2-2.0 years). One patient
had recurrence of pain in a different location; another had persistent pain, which was less severe.
Conclusions: Slipping rib syndrome presents with costal cartilage pain that is reproducible on physical
examination and commonly associated with a mobile rib. Excision of the affected cartilage(s) is an effective
treatment and should be considered early to avoid unnecessary diagnostic tests and evaluation, which delay
© 2012 Elsevier Inc. All rights reserved.
Pain in the region of the costal cartilages that is owing to
an abnormality in the cartilages themselves can be difﬁcult to
diagnose because cardiac and gastroenterological etiologies
are oftentimes considered ﬁrst. Furthermore, multiple
diagnoses encompass a clinical picture of costal cartilage
pain including costochondritis, Tietze syndrome, and
slipping rib syndrome (SRS). Similar conditions such as
costochondritis and Tietze are primarily inﬂammatory
processes, whereas SRS is not . Slipping rib syndrome
is related to abnormal mobility of the lower costal cartilages
leading to subluxation and pain.
Cyriax  ﬁrst described SRS in 1919. Patients present
with unilateral chest pain overlying the affected costal
Presented in part at the 7th Annual Academic Surgical Congress,
February 14 to 16, 2012, Las Vegas, NV.
Corresponding author. Center for Prospective Clinical Trials,
Children's Mercy Hospitals and Clinics, Kansas City, MO 64108, USA.
Tel.: + 1 816 234 300; fax: + 1 816 983 6885.
E-mail address: firstname.lastname@example.org (S.D. St. Peter).
0022-3468/$ – see front matter © 2012 Elsevier Inc. All rights reserved.
Journal of Pediatric Surgery (2012) 47, 1825–1827