Abstract
Background
Diagnostic, therapeutic and surgical techniques for slipping rib syndrome (SRS) are evolving to improve clinical outcomes and recurrence. Our objective was to evaluate current practice patterns in SRS diagnosis and treatment among surgeons nationally.
Methods
An electronic survey was nationally distributed to surgeons who were identified as slipped rib repair providers to assess trends in diagnosis and treatment. Descriptive analyses were performed.
Results
Twenty-four surgeons responded to the survey (45.3%). Almost half identified as thoracic surgeons (47.6%, n=10); 23.8% identified as pediatric surgeons (n=5), 23.8% as trauma/acute care surgeons (n=5), and 4.8% as general surgeons (n=1). Patient history (54.2%, n=13) and physical exam (70.8%, n=17) were reported as most important diagnostic factors. Of surgeons who utilized preoperative and intraoperative pain regimens, rib blocks with lidocaine were the most common (92.9%, n=13). Suturing of ribs/cartilage was identified as the most integral step in the slipped rib repair operation (70.8%, n=17), followed by excision of rib cartilage (66.7%, n=16), use of a biodegradable plate (54.2%, n=13) and utilizing excised rib cartilage as a spacer (29.2%, n=7). Trauma or inciting event was reported as a positive prognostic factor for post-operative pain relief (82.6%, n=19). Connective tissue disorder (58.3%, n=14) and hypermobility disorder (45.8%, n=11) were identified as the two most common factors associated with recurrence.
Conclusions
This national survey of surgeons demonstrates high variability in management and expected outcomes related to diagnosis and treatment for SRS. Further research is needed to identify optimal patient selection and operative approach and long-term clinical outcomes.
Keywords: Slipping rib syndrome (SRS), costal cartilage excision (CCE), sutured repair (SR), slipped rib repair, survey
Highlight box.
Key findings
• We conducted a national survey to assess trends in management of slipping rib syndrome (SRS).
• There was high variability in management and expected outcomes related to diagnosis and treatment of SRS.
What is known and what is new?
• Diagnostic, therapeutic and surgical techniques for SRS are evolving to improve clinical outcomes and recurrence. However, there is limited knowledge on current practice patterns among surgeons who offer slipped rib repair.
• This national survey of surgeons demonstrates significant heterogeneity in self-reported practices of surgeons who manage SRS, filling an important void in current literature.
What is the implication, and what should change now?
• Further research is needed to identify optimal patient selection and operative approach and long-term clinical outcomes.
Introduction
Slipping rib syndrome (SRS) occurs when one or more eighth through tenth ribs become abnormally mobile. SRS presents in both adults and children, often as a sharp, radiating costal margin pain. Although its awareness is growing, it has been a poorly understood disorder that can lead to excessive, invasive testing and late diagnosis and treatment (1,2). Diagnosis can usually be made with history and physical examination; imaging modalities can be used to confirm the diagnosis or assist with operative planning (3). Treatment begins with conservative management with decreased activity, oral and/or topical non-steroidal anti-inflammatory drugs (NSAIDs), ice and/or heat, physical therapy, as well as intercostal nerve blocks and/or steroid injections. Use of osteopathic manipulative treatment and Botox injections have also been reported for symptom relief (4,5). If patients continue to have significant symptoms, surgical intervention is recommended (6).
The slipped rib repair operation has evolved overtime. Historically, costal cartilage excision (CCE) was offered to patients who failed medical therapy. Since then, vertical rib plating (VRP), minimally invasive sutured repair (SR) and costal margin reconstruction (CMR) techniques have been introduced (1,6,7). Although there have been multiple slipped rib repair techniques proposed, there is limited long-term outcome data. Moreover, no technique has been deemed as guideline-directed surgical therapy. Pre-operative, intra-operative and post-operative pain control and follow-up regimens are not well characterized.
Diagnostic, therapeutic and surgical techniques are continuously progressing to improve long-term clinical outcomes and minimize recurrence. To our knowledge, there is no data illustrating the current practice patterns in SRS management. We aim to evaluate trends in SRS diagnosis and treatment among surgeons in the United States. We present this article in accordance with the SURGE reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-568/rc).
Methods
We utilized the online Research Electronic Data Capture (REDCap) platform to create and distribute a 17-question, multiple-choice, anonymous survey. Invitations for participation were sent to surgeons in the United States who were identified as providing slipped rib repair for SRS via patient-centered online resources. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was deemed exempt by the Institutional Review Board at Thomas Jefferson University (iRISID-2024-3185) and informed consent was obtained from all individual participants.
Our group recently published a review of SRS discussing updates in diagnosis and treatments for SRS (8). This comprehensive review of current literature allowed us to build a survey that encompassed the continuum of care for patients with SRS. Five domains were addressed: (I) diagnosis; (II) pre-operative evaluation; (III) surgical technique; (IV) post-operative management; (V) follow-up. The survey questions are included in Appendix 1. We incorporated feedback from experts in the field to ensure relevance, clarity, validity and comprehensiveness and revised the survey instrument accordingly. An individual survey link was emailed to the 53 potential respondents via REDCap. The first author and last author were identified in the correspondence (I.M. and O.T.O.). Each invitation utilized a unique link that could only be used once. This was preceded by a confidentiality statement ensuring anonymity; respondents names or emails were not linked with survey responses. Survey completion was voluntary. A monetary incentive was offered to participants who completed the survey. Reminder emails were sent at the 2-week and 3-week mark to non-responders. The survey was closed at 4 weeks.
Statistical analysis
Descriptive statistical analyses were performed using REDCap, a secure, web-based platform for managing data collection and performing basic data analysis for research purposes. Descriptive statistics were used to summarize respondent characteristics and survey question responses, including frequencies and for categorical variables.
Results
A total of 24 surgeons responded to the survey (45.3%) with 29 non-respondents. Almost half identified as thoracic surgeons (n=10, 47.6%); 23.8% (n=5) identified as pediatric surgeons, 23.8% (n=5) as trauma/acute care surgeons, and 4.8% (n=1) as general surgeons (Figure 1).
Figure 1.
Distribution of survey respondents. †, 21 of 24 respondents answered the survey question.
Diagnosis
Surgeons were asked to rate patient history, physical examination, dynamic ultrasound, intercostal nerve block and computed tomography (CT) imaging from most important to least important when making a diagnosis for SRS. Patient history (n=13, 54.2%) and physical exam (n=17, 70.8%) were reported as the most important diagnostic factors. In comparison, CT imaging was identified as the least important diagnostic factor among 54.2% of surgeons (n=13). There was high variability in utilization of dynamic ultrasound and intercostal nerve block for diagnosis (Figure 2). Most surgeons reported 0–25% of patients with SRS have other rib and/or chest wall pathologies (e.g., 11th and 12th rib tip syndrome, L1 syndrome, pectus excavatum) (n=20, 83.3%).
Figure 2.
Modalities used for diagnosis of slipping rib syndrome. CT, computed tomography; SBS, slipping rib syndrome; US, ultrasound.
Pre-operative management
Most surgeons offer conservative treatment options prior to surgical intervention, with rib block with lidocaine (n=15, 62.5%) and rest, ice, heat (n=12, 50.0%) being the most common, followed by rib block with steroids (n=9, 37.5%), topical analgesics (n=9, 37.5%), core stabilization physical therapy (n=9, 37.5%), pain anesthesia intervention (including radiofrequency ablation) (n=7, 29.2%), pain psychology consultation (n=7, 29.2%), TENS unit pads (n=4, 16.7%), kinesiology tape (n=3, 12.5%), and stretching maneuvers (n=2, 8.3%). Four surgeons did not offer any treatment options prior to surgery (16.7%) (Figure 3).
Figure 3.
Conservative management offered prior to surgical intervention. TENS, transcutaneous electrical nerve stimulation.
Almost all surgeons reported failure of medical management as an indication to undergo slipped rib repair (n=22, 91.7%), followed by severity of pain (n=16, 66.7%), length of time of pain (n=15, 62.5%), and ‘other’ factors (n=5, 20.8%). Among surgeons who described other factors, 40% use physical examination to determine if patient should undergo operation (n=2), 20% use patients’ inability to perform activities of daily living or inability to be an active member of society (n=1), 20% use location of rib pain (n=1), and 20% use a positive response to rib blocks with recurrent symptoms afterwards (n=1). More than half of surveyed surgeons do not obtain additional pre-operative imaging prior to surgery (n=13, 54.2%). Among surgeons who obtain additional imaging (n=11, 45.8%), 45.5% obtain CT imaging (n=5), 27% obtain ultrasound imaging (n=3), and 27% obtain both CT and ultrasound imaging (n=3).
Three-quarters of surgeons do not utilize preoperative pain medication regimens (n=18, 75%). Among surgeons who do utilize preoperative pain medication regimens (n=6, 25%), all prescribed neuropathic medications (e.g., gabapentin, Lyrica) (n=6, 100%), 83.3% NSAIDs (n=5), 66.7% acetaminophen (n=4), and 16.7% opioids (n=1). A majority of surgeons utilize preoperative and intraoperative modalities to optimize pain control (n=14, 58.3%). Among these surgeons, rib blocks with lidocaine were the most common (n=13, 92.9%), followed by cryotherapy (n=4, 28.6%), paravertebral blocks (n=2, 14.3%), paravertebral catheters (n=1, 17.1%). No one reported use of epidural catheters. Almost all surgeons did not use a specific anesthetic regimen to optimize pain control intraoperatively and post-operatively (n=20, 90.9%). The two surgeons who utilize anesthetic regimens reported “total intravenous anesthesia (TIVA), methadone, and lidocaine” and “McLott mixture given by anesthesia intraoperatively”. Of note, the opioid-free, maintenance anesthetic combination of dexmedetomidine, lidocaine, ketamine and magnesium is colloquially known as the McLott Mix (9).
Intraoperative and post-operative management
Surgeons were asked to identify integral steps in the slipped rib repair operation. A majority of surgeons identified suturing of ribs/cartilage as an integral step in the slipped rib repair operation (n=17, 70.8%), followed by excision of rib cartilage (n=16, 66.7%), use of a biodegradable plate (n=13, 54.2%), and utilizing excised rib cartilage as a spacer (n=7, 29.2%) (Figure 4).
Figure 4.
Most integral step in slipped rib repair operation.
Most surgeons discharge patients same-day (n=19, 79.2%), with 20.8% discharging patients within 1 to 2 days postoperatively (n=5). The most common post-operative pain medication prescribed was NSAIDs (n=24, 100%), followed by acetaminophen (n=22, 91.7%), opioids (n=19, 79.2%), neuropathic pain medications (e.g., gabapentin, Lyrica) (n=16, 66.7%), and antispasmodics (e.g., valium) (n=14, 58.3%) (Figure 5). Three quarters of surgeons report patients experience a majority of pain relief between 1 and 3 months postoperatively (n=18, 75%); 16.7% reported in 2 weeks (n=4), 4.2% in 6 months (n=1), and 4.2% in 1 year (n=1). Trauma or inciting event was reported as a positive factor for post-operative pain relief by most surgeons (n=19, 82.6%). In contrast, connective tissue disorder (n=16, 69.6%) and hypermobility disorder (n=14, 60.9%) were reported as negative prognostic factors by a majority of surgeons (Figure 6).
Figure 5.
Post-operative pain management. NSAID, non-steroidal anti-inflammatory drug.
Figure 6.
Prognostic factors for post-operative symptom relief.
Optimal length of follow-up after slipped rib repair was variable: 8.3% reported 1 month (n=2), 25% reported 3 months (n=6), 20.8% reported 6 months (n=5), 20.8% report 1-year (n=5), and 25% reported greater than 1-year (n=6). Connective tissue disorder (n=14, 58.3%) and hypermobility disorder (n=11, 45.8%) were identified as the two most common factors associated with recurrence, followed by trauma (n=9, 37.5%) (Figure 7). Additionally, “too much activity too soon” (n=1, 4.2%), “technical [factors]” (n=1, 4.2%), and “not removing enough levels” (n=1, 4.2%) were other factors reported as associated with recurrence.
Figure 7.
Common factors associated with recurrence.
Discussion
In this survey, we aim to assess current trends in diagnosis and management of slipped rib syndrome among surgeons in the United States. We found high variability in diagnosis, pre-operative treatment and planning, surgical technique, and post-operative care.
A majority of surgeons reported history and physical examination as the most important factors in diagnosis. This is concordant with current literature which supports SRS as a clinical diagnosis (1,6,8). However, there was heterogeneity in the utilization of dynamic ultrasound, intercostal nerve blocks, and CT imaging. Van Tassel et al. retrospectively studied the use of dynamic ultrasound as a diagnostic tool. The authors found it correctly detected SRS in 89%, and its absence in 100% of cases (3). Current literature supports dynamic ultrasound as a useful adjunct or confirmatory tool in the diagnosis of SRS. However, with the exception of Van Tassel et al., recent data is largely limited to case series and case reports (10-12). Further high-quality research in prospective cohorts is necessary to determine if it should remain as a confirmatory test, or if it should be used as a primary modality in diagnosis. Similarly, intercostal nerve blocks have been reported as a diagnostic tool in addition to providing symptomatic relief; however, further studies are necessary to determine its sensitivity and specificity for diagnosis of SRS (6). There is also debate as to the utility of a posterior versus anterior block. In contrast, CT imaging is mostly unhelpful in diagnosis for SRS; however, it may aid surgeons in pre-operative planning by identifying aberrant anatomy and ruling out concomitant chest wall pathologies that could affect surgical technique (8). Anecdotally, occult rib fractures are much more easily detected on CT compared to other imaging modalities. Our survey showed there is high variability among surgeons who recommend preoperative imaging (i.e., CT and/or ultrasound) prior to surgical treatment. Additional research is needed to determine which patients would benefit from pre-operative imaging to optimize clinical outcomes.
Our survey showed most surgeons offer preoperative medical treatments prior to offering surgical intervention; however, there is high variability between the various modalities used. McMahon established a treatment algorithm for pediatric patients that suggests rest, reassurance, NSAIDs, ice followed by rib blocks with local anesthesia with or without corticosteroids; if there is limited or no relief, the authors recommend proceeding with surgery when this was published in 2018 (6). Of note, the authors practice patterns have evolved since 2018 to focus on core stabilization and pain control in a multidisciplinary setting prior to offering surgical intervention. Our survey demonstrates much broader categories of non-surgical therapies are utilized by practicing surgeons including, but not limited to pain anesthesia intervention (including radiofrequency ablation), pain psychology consultation, and core stabilization physical therapy.
Failure of medical therapy was almost universally reported as an indication for slipped rib repair in our survey, which is concordant with current literature (2,6,8). In contrast, Hansen et al. recently proposed CCE with rib stabilization should be offered as first-line therapy for all patients with SRS (7).
Pre-operatively, most surgeons do not utilize medication regimens to assist with post-operative pain relief. However, they do offer preoperative and intraoperative adjuncts; we identified lidocaine rib blocks are used by almost all practicing surgeons, followed by cryotherapy, paravertebral blocks, and paravertebral catheters. Lai et al. retrospectively studied the effectiveness of cryoablation in pediatric patients that underwent cartilaginous rib excision (CRE) with CCE and VRP with and without cryoablation; they found a significant decrease in in-hospital opioid use and length of stay in pediatric patients who underwent CRE with CCE and VRP with cryoablation (13). There is limited literature that shows its effectiveness in adult patients; further research is needed to understand its long-term outcomes in this patient population. This heterogeneity among medical therapies as well as pre-operative, intraoperative and post-operative pain control demonstrate the importance of multidisciplinary management (i.e., pain management, psychology, physical therapy) to allow providers to create a more individualized plan for symptom relief, with or without surgical intervention.
With regard to surgical technique, there was high variability in which steps surgeons identified as integral within the slipped rib repair operation. A majority of surgeons identified SR, CCE, and VRP with a biodegradable plate as an integral step. In contrast, only one-third of surgeons identified utilizing excised rib cartilage as a spacer as an integral step. Initially, CCE was the standard of care operation for SRS. Although this operation resulted in short-term symptom resolution, it offered no costal margin stability restoration and had high rates of symptom recurrence in the long run (14,15). McMahon et al. introduced VRP with a bioabsorbable plate as an adjunct to CCE. This technique showed an improved rate of recurrence and reoperation compared to patients who underwent isolated CCE (16). Later, Hansen et al. proposed an alternative minimally invasive suture repair (SR) technique which is a rib-preserving operation without CCE that stabilizes the slipped rib by fixing it superiorly and inferiorly. Short-term outcomes were promising with significant increase in function and disability; however, long-term durability was limited (1). Most recently, Hansen et al. introduced the CMR technique, which includes CCE and uses the excised cartilage as an autograft spacer to permanently fixate and restore costal margin stability. An overlay bioabsorbable plate is utilized to provide a temporary reinforcement while the reconstructed costal margin components integrate and fuse. CMR was associated with long-term improvement in symptoms and quality of life, as well as 1% rate of revisional surgery in the largest cohort of SRS patients studied to date (7). There are multiple surgical techniques in current literature, many of which are utilized in combination to improve symptom relief and minimize recurrence. Due to a lack of randomized control trials and sufficient long-term outcome data, current surgical practice trends are variable. Current literature largely comprised short-term outcomes coupled with surgeon technical experience and patient-reported outcomes.
Due to the lack of large cohort randomized controlled data with long-term follow-up, there is wide variation in practice. Ultimately, the goal of SRS research is to better predict who will benefit from surgical therapy and what optimal surgical therapy is. This study highlights the significant need for collaborative research into patient selection and optimal procedure selection.
Our study has inherent limitations. First, we identified potential respondents utilizing patient-identified surgeons who offered slipped rib repair. This list may not have been comprehensive, and surgeons who offer slipped rib repair may not have been invited to participate in our survey. This may affect the external validity of our study. Second, the survey is subject to recall bias, as it requires respondents to report current practice trends based on memory. Third, our survey response rate was 45.3%; to our knowledge, this is the first study to survey surgeons’ management of SRS. However, our study may be subject to non-response bias. Although we do not have practice information on non-respondents, there may be more or less variable practice patterns than was observed in our survey data. Future studies may benefit from further multi-center collaboration that include building national databases. Supplementing survey data with provider outcomes for a larger sample size would help identify standardized protocols for current management of SRS.
Conclusions
Although awareness of SRS is growing, it remains a complex disorder to diagnose and manage. There is limited knowledge on current practice patterns among surgeons who offer slipped rib repair. This national survey of surgeons demonstrates significant heterogeneity in self-reported practices of surgeons who manage SRS, filling an important void in current literature. The high variability found in our study supports the need for national collaboration to identify standardized protocols for appropriate management for SRS. Further research with larger sample sizes is needed to evaluate long-term clinical outcomes in patients with SRS to optimize diagnosis, preoperative, intraoperative and postoperative management, minimize recurrence and move towards clinical guidelines based on high-quality evidence.
Supplementary
The article’s supplementary files as
Acknowledgments
None.
Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was deemed exempt by the Institutional Review Board at Thomas Jefferson University (iRISID-2024-3185) and informed consent was obtained from all individual participants.
Footnotes
Reporting Checklist: The authors have completed the SURGE reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-568/rc
Funding: This work has been supported by the Thomas Jefferson University Department of Surgery Saligman Family Pilot Grant (to I.M. and O.T.O.).
Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-568/coif). O.T.O. has received research funding from the Bristol Myers Squibb Foundation, paid to his institution. O.T.O. has also received speaker honoraria from Intuitive Surgical, AstraZeneca, Johnson & Johnson, and Medtronic. S.M.P. received educational grants for his role as a CME course director from Mertz Pharmaceuticals, LLC and Ipsen Biopharmaceuticals with payments directly made to his institution. S.M.P. also received payment from Gordon, Gordon, & Centracchio for expert testimony, and food from Abvie Inc. and Mertz Pharmaceuticals, LLC without direct payment. L.M. received payments for consulting fees and presentations from Atricure paid to her. L.M. also received consulting fees from Zimmer/Biomet paid to her. L.M. has no relevant disclosures for this particular work. The other authors have no conflicts of interest to declare.
Data Sharing Statement
Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-568/dss
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