Marco Scarci - Expert Thoracic Surgeon in London
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Slipping Rib Syndrome · Cyriax Syndrome · Chest Wall Specialist · London

Years of pain. Normal test results. Being told nothing is wrong.

If this sounds like your story, you may have slipping rib syndrome — one of the most consistently misdiagnosed conditions in medicine. It is real, it has a name, and there is a treatment path. You just need a specialist who knows what they're looking for.

Book a Specialist Consultation → ic baseline phone 020 8090 5119
Mr Marco Scarci — Consultant Thoracic Surgeon London
Mr Marco Scarci FRCS · FCCP · FACS · FEBTS
2–5 yrs Avg delay to correct diagnosis
5+ Specialists seen before diagnosis
Surgery <7 days from Diagnosis to Treatment
20+ Years' chest wall experience
Sharp pain under lower ribs Clicking or popping sensation Normal X-rays, CT, MRI Dismissed or told "it's stress" Pain that moves and shifts Worse with bending or twisting
FRCS(Eng) · FCCP · FACS · FEBTS
Slipping rib syndrome specialist, London
Costal cartilage resection surgery available
All major insurers accepted
For patients who have been told nothing is wrong

You are not imagining it. And you are not alone.

The most common thing patients with slipping rib syndrome say at their first appointment is: "I thought I was going mad."

Years of sharp, unpredictable pain under the lower ribs. Dozens of appointments. Blood tests, X-rays, CT scans, MRI scans — all reported as normal. Referrals to cardiologists, gastroenterologists, physiotherapists, pain clinics. Perhaps, at some point, a gentle suggestion that anxiety might be a factor.

And through all of it, the pain continued. Because slipping rib syndrome does not show up on standard imaging. It is diagnosed clinically — by a physical examination performed by a clinician who knows exactly what to look for. When someone who knows finally examines you, the diagnosis is usually made in under five minutes.

"The tragedy of slipping rib syndrome is not the condition itself — it is the years patients spend being investigated for everything else before someone finally performs a proper rib examination. A single clinical test, the Hooking Maneuver, often makes the diagnosis that five years of imaging could not."

This guide explains what slipping rib syndrome actually is, why it is so frequently missed, how the diagnosis is made, and what the treatment options are — from physiotherapy and nerve blocks to costal cartilage resection surgery.

This guide covers: Slipping rib syndrome diagnosis London Cyriax syndrome treatment Hooking maneuver / hooking test Costal cartilage resection surgery Clicking rib / popping rib pain Rib subluxation treatment Slipped rib surgery UK Intercostal nerve block rib pain Hypermobility slipping rib Lower rib pain misdiagnosed

Book a Specialist Consultation

Seen within days. No referral needed. Mr Scarci specialises in slipping rib syndrome and can perform the Hooking Maneuver at your first appointment.

ic baseline phone Call 020 8090 5119
Seen within one week
All major insurers accepted
Hooking Maneuver at first appointment
No GP referral required
→ Book online ✉ [email protected]

Why slipping rib is missed

2–5 yrs Average delay from first symptoms to correct diagnosis
5+ Specialists typically seen before diagnosis is reached
<5 min Time to diagnose with Hooking Maneuver by experienced clinician
Normal X-ray, CT, MRI — standard imaging misses this diagnosis
From patients who've been exactly where you are
★★★★★

"I had seen five specialists over three years. Every scan was normal. I'd been told it was stress, then a pulled muscle, then 'unexplained chest wall pain.' Mr Scarci did the hooking test in the first five minutes and said 'I know exactly what this is.' I cried with relief."

Patient with 3-year diagnostic delay — private consultation, London
★★★★★

"I'd stopped going to yoga, avoided hugging my children, and couldn't sleep on my left side. Every time it slipped, I felt sick with the pain. After surgery I could take a full breath without bracing for something to go wrong. It changed everything."

Post-costal cartilage resection patient — verified review
Who develops slipping rib syndrome

Risk groups — and who benefits most from specialist care

Anyone can develop SRS, but certain people are significantly more prone — and for all of them, early specialist diagnosis dramatically shortens the journey.

🏊

Athletes in rotational sports

Swimmers, rowers, golfers, tennis and racket sport players, gymnasts — sports with repetitive trunk rotation are consistently associated with SRS through cumulative microtrauma to the interchondral ligaments.

🧬

Hypermobility & Ehlers-Danlos Syndrome

Generalised ligamentous laxity from connective tissue disorders dramatically increases rib instability. SRS in hypermobile patients may affect multiple ribs and often requires more complex repair techniques to prevent recurrence.

🤱

Postpartum patients

Pregnancy-related changes in relaxin hormone and connective tissue mechanics — combined with the physical demands of carrying and lifting a baby — can precipitate or worsen rib instability, sometimes for months after delivery.

🚗

Trauma survivors

Road accidents, falls, direct blows to the lower chest, or even vigorous coughing can tear the interchondral ligaments that keep the false ribs stable. SRS may develop weeks or months after the original injury.

🏗️

Manual workers

Jobs requiring repetitive lifting, twisting, or overhead reaching place sustained mechanical stress on the lower costal margin, gradually loosening the interchondral attachments over time.

🔄

Post-surgical patients

Some patients develop SRS immediately following abdominal laparoscopic surgery — including cholecystectomy, appendicectomy, or gynaecological procedures. The mechanism may relate to port placement, retraction, or post-operative positioning.

Understanding the condition

What is slipping rib syndrome?

The anatomy in plain English

Also called Cyriax syndrome, clicking rib syndrome, rib tip syndrome, or painful rib syndrome. The name changes but the anatomy is the same.

Your upper ribs are securely attached to the breastbone. But your lower ribs — the 8th, 9th, and 10th — are "false ribs" that connect through softer cartilage and interchondral ligaments rather than directly to the sternum. In most people, these ligaments are strong enough to keep the ribs stable.

In slipping rib syndrome, those ligaments have become lax — through injury, repetitive strain, hypermobility, or sometimes with no obvious cause. The loose rib tip moves abnormally, hooking over the rib above it and irritating the intercostal nerve that runs between them.

The result is a sharp, stabbing pain — sometimes with a perceptible click or pop — that happens when the rib slips and the nerve is compressed. Because the rib returns to position, standard imaging shows nothing abnormal. The problem is dynamic: it only appears when you move.

The 10th rib (most commonly affected) hooks over the rib above, compressing the intercostal nerve
Slipping rib syndrome anatomy — lower rib hypermobility
2–5 yrs Median time from symptom onset to correct diagnosis. This delay is not inevitable with the right specialist.
~86% Of slipping rib syndrome patients in one study were women. Many had been told their pain was stress-related before the correct diagnosis.
100% Clinical examination findings correlated with operative findings in one published series. The diagnosis can be made with history and physical exam alone.
The typical patient journey — before the correct diagnosis

Why doctors keep missing it — and why that isn't your fault

The journey most SRS patients describe before finding a correct diagnosis follows a painfully familiar pattern.

First presentation

A&E or GP — chest pain, all tests normal

Sharp chest pain triggers urgent investigation. ECG, blood tests, chest X-ray — all normal. Discharged with analgesia and reassurance that the heart is fine.

Months later

Gastroenterology — suspected gallbladder, IBS, or GORD

Upper abdominal pain is investigated. Endoscopy, ultrasound, breath tests. Some patients undergo cholecystectomy — and are surprised when their pain continues or worsens after surgery.

Year 1–2

Musculoskeletal — costochondritis, muscle strain, "nothing wrong"

Physiotherapy, osteopathy, chiropractic. Some provide temporary relief; none address the underlying instability. The pain keeps returning unpredictably.

Year 2–4

Pain clinic — referred pain, neuralgia, "functional pain"

Nerve pain medications, injections with partial relief, psychological assessment. Some patients are given a functional pain diagnosis. Many begin to doubt themselves.

Finally

Chest wall specialist — Hooking Maneuver positive. Diagnosis made.

A clinical examination by someone who knows what to look for. The test takes minutes. Patients typically describe the moment of diagnosis as the greatest relief of the entire ordeal.

⚠ The cholecystectomy problem

In one published series, 19% of slipping rib syndrome patients had already undergone laparoscopic cholecystectomy (gallbladder removal) for their pain — and experienced persistent or worsened symptoms afterwards. SRS is regularly mistaken for gallbladder disease, and surgery for the wrong diagnosis solves nothing.

💡 Why imaging misses it every time

X-rays, CT scans, MRI, and standard ultrasound cannot visualise the subtle cartilage laxity of slipping rib syndrome. In one major study, 76% of patients had prior imaging — none confirmed the diagnosis. The rib looks normal at rest. The problem only appears when it moves.

🩺 Who actually knows to look for it

Slipping rib syndrome is not covered in most medical school curricula. Chest wall specialists and experienced thoracic surgeons who routinely see lower chest pain are the clinicians most likely to consider it.

Recognising the condition

Symptoms of slipping rib syndrome

The symptoms are distinctive once you know what to look for — but they overlap significantly with many other conditions, which is why diagnosis is so often delayed.

  • ⚡
    Sharp, stabbing pain under the lower ribsTypically one-sided, along the lower costal margin. Often described as a knife or stabbing sensation.
  • 🔊
    Clicking, popping, or slipping sensationA palpable or audible click when the rib moves. Many patients describe actually feeling the rib "move" under their hand.
  • 🔄
    Pain triggered by twisting, bending, or reachingSpecific movements provoke the rib to slip. Reaching overhead, rolling over in bed, getting in and out of a car.
  • 🌊
    Radiating pain to the back, flank, or upper abdomenIntercostal nerve irritation refers pain along the nerve's distribution — into the back, side, or upper abdomen.
  • 😓
    Unpredictable, fear-inducing episodesMany patients develop anxiety about movement, avoiding activities, positions, and even clothing that might trigger an episode.
  • 😮‍💨
    Pain with deep breathing, coughing, or sneezingActivities that expand the lower chest and move the ribs can trigger slipping and acute pain.

🔀 What it gets mistaken for

  • Gallbladder disease — pain location and trigger pattern is almost identical
  • Costochondritis — rib cartilage inflammation also causes chest wall tenderness
  • Gastro-oesophageal reflux (GORD) / IBS — abdominal referral misleads gastroenterologists
  • Intercostal neuralgia or nerve entrapment — nerve irritation is real, but the cause is mechanical
  • Muscle strain or thoracic facet joint pain — normal after exercise or trauma
  • Cardiac chest pain — triggers urgent cardiac investigation that returns normal
  • Functional/psychosomatic pain — when everything else is excluded, some clinicians wrongly attribute it to anxiety

Note: SRS can coexist with some of these — particularly costochondritis and hypermobility conditions. A full chest wall assessment is essential.

Does this sound like what you've been experiencing? A single consultation with a specialist who knows this condition can provide the diagnosis that years of investigation have not.
Book a Consultation →
The test that makes the diagnosis

The Hooking Maneuver — the most important test you've probably never had

This simple clinical examination test, performed correctly, diagnoses slipping rib syndrome with high sensitivity. If no one has ever done this to you, the diagnosis has never been properly assessed.

What the Hooking Maneuver is and how it works

The Hooking Maneuver physically reproduces the slipping movement that causes the patient's pain — confirming both the diagnosis and exactly which rib is affected. A positive test (pain or a click) is diagnostic of slipping rib syndrome. Clinical examination findings correlate with surgical findings in 100% of cases in published series.

If your GP, physiotherapist, gastroenterologist, or emergency doctor has never performed this test on you, they have not assessed you for slipping rib syndrome.
Request a clinical examination →

How the test is performed

1

You lie on your back or sit comfortably. The examiner palpates along your lower costal margin to identify the area of maximum tenderness.

2

The examiner curls their fingers beneath the costal margin (the lower rib edge) and applies gentle upward and outward traction.

3

If the rib is hypermobile, this movement reproduces the characteristic slip — and your familiar pain or a click is felt by both you and the examiner.

4

The test is repeated on the opposite side to assess for bilateral involvement. The specific rib(s) that test positive guide treatment planning.

A positive Hooking Maneuver — pain or click reproduced — is diagnostic of slipping rib syndrome. No additional imaging is required to confirm the diagnosis.
Beyond the Hooking Maneuver

Diagnostic tools — what works, and what doesn't

Understanding why your previous investigations came back normal — and what actually confirms the diagnosis.

Most effective 🤲

Clinical Examination — Hooking Maneuver

The gold standard. History of characteristic pain plus a positive Hooking Maneuver is sufficient to diagnose SRS. Correlates with operative findings in 100% of cases in published series. No imaging can substitute for a skilled physical examination.

Best imaging 🔊

Dynamic Ultrasound

Standard ultrasound is unhelpful — but dynamic ultrasound, performed during active movement of the rib, can directly visualise the abnormal rib motion and confirm the diagnosis. Requires an experienced sonographer familiar with this specific application.

Supportive 💉

Intercostal Nerve Block (Diagnostic)

A local anaesthetic injection alongside the affected intercostal nerve(s) can confirm the diagnosis by temporarily abolishing the pain. It also identifies precisely which nerve(s) and rib(s) are responsible — essential information for surgical planning.

Limited value 📷

X-Ray, CT Scan, Standard MRI

These do not show the cartilage laxity or dynamic rib movement responsible for SRS. They are useful only to exclude other diagnoses — not to confirm SRS. A normal CT does not mean there is nothing wrong.

A structured path to relief

Treatment — from conservative care to definitive surgery

Treatment is not one-size-fits-all. Most patients begin with conservative approaches, with surgery reserved for those whose quality of life remains severely affected despite other management.

1
First line

Activity modification, physiotherapy & pain management

Once the diagnosis is confirmed, targeted physiotherapy addresses the muscle imbalances and postural compensation that allow the rib to slip. Breathing mechanics, core stability, and neuromuscular control are all addressed. Oral analgesia, topical lidocaine patches, and anti-inflammatory medications support this phase.

2
If symptoms persist

Intercostal nerve block — targeted relief and diagnostic confirmation

A local anaesthetic injection alongside the affected intercostal nerve(s) can provide days to weeks of significant pain relief — and simultaneously confirms which nerve is responsible. Corticosteroid added to the injection reduces local inflammation and can extend the relief period for several months in some patients.

3
Emerging option

Prolotherapy — regenerative ligament injection

Prolotherapy involves injecting a dextrose-based solution into the affected ligaments and cartilage attachment points to stimulate the body's own repair response. Evidence is limited but some patients report sustained improvement. Appropriate for patients who are keen to avoid surgery and have responded partially to nerve blocks.

4
Definitive

Costal cartilage resection surgery — when quality of life demands a permanent solution

Surgery is recommended for patients whose quality of life remains severely affected despite adequate conservative management. Costal cartilage resection removes the structural source of the slipping, eliminating the mechanical stimulus for nerve irritation. For appropriately selected patients, the improvement in pain and function can be transformative.

Costal cartilage resection — what the surgery involves

Surgery for slipping rib syndrome involves removing the abnormally mobile cartilage tip that is causing the rib to slip and irritating the nerve. Performed under general anaesthetic through a small incision (typically 4–6 cm) at the lower costal margin. The affected cartilage is resected to the costochondral junction. Intercostal nerve ablation may be performed simultaneously if chronic nerve sensitisation is a significant component of the pain.

Standard

Costal Cartilage Excision (CCE)

The established technique: the affected cartilage tip(s) — most commonly ribs 8, 9, or 10 — are resected to the costochondral junction. Highly effective for pain relief, with most patients reporting significant improvement.

Modern

CCE + Vertical Rib Plating

Addition of bioabsorbable vertical rib plates provides costal margin stability during healing, addressing the recurrence weakness of isolated cartilage excision and lowering reoperation rates.

Rib-preserving

Minimally Invasive Sutured Repair

A rib-preserving technique that stabilises the slipped rib tip by suturing it back to the costal margin without excising the cartilage. Suitable for carefully selected patients where the cartilage is anatomically normal but simply detached.

For nerve pain

Intercostal Nerve Cryoablation

Freezing of the affected intercostal nerve under direct vision during the operation, providing prolonged post-operative pain relief and addressing the chronic nerve sensitisation that may have developed over years of mechanical irritation.

4–6 cmIncision size for cartilage resection
1–3Days typical hospital stay
2–4 wksReturn to light activity
HighPatient satisfaction in published series
Worried about surgery after years of being let down by treatment? Surgery is never the first recommendation. Mr Scarci will assess your full history, confirm the diagnosis, and discuss all options honestly.
Discuss your options →
While you await treatment

Living with slipping rib syndrome — what actually helps

These are practical, evidence-informed strategies that reduce the frequency and severity of episodes — not a substitute for treatment, but meaningful tools for daily life.

🛏️

Sleep positioning

Lie on your unaffected side with a pillow between your knees. Avoid deep trunk rotation during rolling over. A body pillow can support the lower ribs through the night.

🧘

Movement awareness

Identify your specific triggers — reaching overhead, twisting to the affected side, getting in and out of cars. Modify these movements consciously until core stability improves.

🧊

Ice during flares

Apply ice wrapped in a cloth to the lower costal margin for 15–20 minutes during acute episodes. Ice reduces local inflammation and nerve irritation more effectively than heat in the acute phase.

💪

Core stabilisation

Targeted exercises strengthening the obliques, transversus abdominis, and paraspinal muscles provide a muscular splint for the unstable rib. Avoid high-rotation exercises until stable.

🧥

Compression support

Some patients find a light rib brace or compressive garment worn during activity reduces the amplitude of rib movement and lowers episode frequency.

📓

Pain diary

Logging what triggers episodes, what positions relieve them, and how pain changes with time helps your clinician refine diagnosis, assess treatment response, and plan intervention precisely.

🧠

Mental health support

Chronic pain — especially chronic pain that was dismissed for years — causes real psychological damage. Anxiety, depression, and social withdrawal are common. Addressing these alongside the physical condition improves overall outcomes.

⚠️

Chiropractic — use caution

Some patients find temporary relief; others report significant worsening after spinal manipulation in the thoracic area. Proceed cautiously and only with a practitioner aware of your SRS diagnosis.

Questions patients ask

Slipping rib syndrome — everything you need to know

  • How do I know if I have slipping rib syndrome?
    The classic presentation is sharp, lower rib pain that is reproducible — triggered by specific movements like twisting, bending, reaching, or deep breathing — and often accompanied by a clicking or popping sensation. Normal imaging results despite real, persistent pain are a strong indicator. The definitive test is the Hooking Maneuver, performed by a clinician who is familiar with the condition. If no one has ever performed this test on you, the diagnosis has never been properly assessed.
  • Why have all my tests come back normal if I'm in this much pain?
    Because standard imaging — X-ray, CT, MRI, standard ultrasound — cannot show the cartilage laxity or dynamic rib movement responsible for slipping rib syndrome. The problem is mechanical and movement-dependent: the rib looks entirely normal when you're lying still in a scanner. In one major published series, 76% of confirmed SRS patients had prior imaging — and none of those images confirmed the diagnosis. A normal scan does not mean nothing is wrong. It means the problem isn't visible at rest.
  • Is costal cartilage resection surgery effective for slipping rib syndrome?
    For appropriately selected patients — those who have confirmed SRS by clinical examination, have failed conservative management including nerve blocks, and have significant functional limitation — costal cartilage resection provides meaningful long-term pain relief with high patient satisfaction rates in published series. Recurrence is a known risk, which is why modern surgeons increasingly combine cartilage excision with rib stabilisation techniques to reduce reoperation rates.
  • Can slipping rib syndrome be cured without surgery?
    For mild cases or patients with specific identifiable triggers, a combination of physiotherapy, activity modification, and nerve blocks can achieve sufficient symptom control that surgery is not needed. However, slipping rib syndrome is caused by structural ligamentous laxity — and conservative measures address the consequences rather than the cause. For patients with severe, frequent episodes that significantly limit daily activities, surgery is the only intervention that addresses the underlying mechanical problem directly.
  • I have Ehlers-Danlos Syndrome (EDS) / hypermobility. Does that change my treatment?
    Yes, significantly. Generalised ligamentous hypermobility means the costal margin ligaments are more prone to laxity — and that surgery, if needed, needs to be planned differently. Standard costal cartilage excision alone has higher recurrence rates in hypermobile patients. Rib stabilisation techniques (vertical plating or sutured repair) become more important, and rehabilitation must be carefully managed. A specialist who understands the interaction between hypermobility disorders and chest wall mechanics is essential.
  • Will my insurance cover diagnosis and treatment for slipping rib syndrome?
    Consultations, diagnostic nerve blocks, and surgical treatment for slipping rib syndrome are covered by most major UK private health insurers as a chest wall condition. Mr Scarci's team will verify your specific policy and manage pre-authorisation. Self-funding is also available with transparent pricing. If your pain developed following a road accident or workplace injury, costs may be recoverable through personal injury proceedings.
  • How quickly can I be seen?
    Most patients are seen within one week of contact. Given the years many SRS patients have spent waiting for a correct diagnosis, we make every effort not to add further delay once you reach us. Online consultations are also available if you are not local to London.

You've been looking for this diagnosis for long enough.

A single consultation with a specialist who understands chest wall mechanics can provide the clarity that years of normal scans could not. You will leave knowing whether this is what you have — and what can be done about it.

Book a Consultation → ic baseline phone 020 7459 4367
All major insurers accepted
Typically seen within one week
Costal cartilage resection surgery available
Online consultations available
Clinical References
PubMed / PMC Costal cartilage resection for SRS in adults Annals of Thoracic Surgery Minimally invasive repair without cartilage excision Journal of Clinical Medicine Diagnostic and treatment updates — SRS review 2023 PubMed Why slipping rib syndrome is frequently missed

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