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Clinical Review

Assessment and management of medically unexplained symptoms

BMJ 2008; 336 doi: (Published 15 May 2008) Cite this as: BMJ 2008;336:1124

Rapid Response:

Re: Assessment and management of medically unexplained symptoms

I would like to thank L. Sam Lewis for his response to my previous comments about postural factors being the cause of lower left sided chest pains.

He provided a link to a research paper by Leon G. Robb et al about the Slipping rib syndrome which is also called Tietze syndrome.

That syndrome involves upper abdominal pains in various locations behind the lower ribs on one side of the chest which were obscure in nature and of uncertain cause where they are often confused with conditions such as cholecystitis or pleurisy, and it may include referred pain to other areas to be confused with appendicitis etc, and sometimes causes epigastric pain.

However there is no evidence of disease to account for the pain.

The hooking manoeuvre involves hooking the fingers under and behind the lower ribs and pulling them forwards, and when it is applied a clicking or slipping sensation can be felt and it “often aggravates or recreates the typical pain sensation, but often cannot be done because of severe sensitivity of the subcostal margins”.

That maneuver does not have any effect when applied to the ribs on the other side of the chest.

Robb also refers to previous anatomical studies by J.F. Holmes in 1941, and McBeath and Keene in 1975 which “identified recurring subluxation (dislocation) of the costal margins of the eighth, ninth and tenth ribs due to hypermobility of their anterior edges”, and that “the cartilage ends curl upward inside the ribs so that they come into close relationship to the intercostal nerves” and they concluded that recurrent and repetitive irritation of them caused the pain.

The diagnosis can be confirmed “by intercostal local anaesthesia nerve blockade of the eighth, ninth, and tenth ribs as well as subcostal infiltration” which abolishes the pain.

Those aspects have some overlap with Paul Wood’s report of 1956 that the injection of novocaine between the ribs relieved left inframammary pain.

They are also consistent with my conclusions that five aspects of postural physique contribute the the cause of unilateral or bilateral chest pains as follows . . .

Forward curvature of the upper spine places the head and shoulders forward and over the chest where the weight would be directed downwards and applies pressure on the sternum and ribcage.

Sideways curvature of the spine to the right would compress the right side of the rib cage excessively, and probably slightly stretch the left side upwards, and vice versa, which would explain the unilateral nature of the symptoms.

The scoliosis would probably also result in a sideways tilt in the sternum which would affect its attachments, and the xyphoid process.

A vertical sternum, or pectus excavatum would change the effect of forward bending because the sternum would move backwards instead of forwards to produce excessive pressures on the ribs.

The backward movement of the sternum, in combination with the forward protrusion of the abdomen produces a crease line in the upper abdomen which acts in the manner of a hinge when the person bends forward, and applies additional strain on the lower ribs.

Activities which involve repetitively bending forwards and backwards toward desks or benches, such as reading and writing, would produce repetitive strain on the hinge area between the lower ribs.

I therefore suggest that it may be useful to examine patients with non-cardiac chest pains to determine if they have any one or more of those aspects of physique which could account for the previously unexplainable symptoms and their location where Tietze Syndrome is a relevant example, and the hooker manoeuvre, and nerve blocks can be used as part of the differential diagnosis and treatment.

1. Banfield M.A. 1980, (June), The Matter of Framework, Australasian Nurses Journal, p.27-28.

2. Paul Wood, 1956, Diseases of the heart and circulation, 2nd, revised edition, Eyre and Spottiswoode, London, p.937-947.

3. Banfield M.A. 2014 (March 30th), The Posture Theory as an explanation for many previously unexplainable symptoms, (Online rapid response) BMJ 2008:336:1124.

4. Banfield M.A. 2014 (April 6th), The biomechanics of writing, typing, and computing, and it’s relation to recurring abdominal pain, The British Medical Journal (Online Rapid Responses), BMJ 2008; 336:1124.

5. Banfield M.A. 2014 (April 27th), Posture as a cause of previously unexplainable left sided chest pain, The British Medical Journal (Online Rapid Response), BMJ 2008; 336:1124.

6. Leon G. Robb et al, (August 3rd. 2013), The Slipping Rib Syndrome: An Overlooked Cause of Abdominal Pain, Practical Pain

7. Rajender Kumar et al, (2013), The painful rib syndrome, Indian Journal of Anaesthesia, Vol. 57, Issue 3, p.311-313.

Competing interests: No competing interests

06 May 2014
Max Allan Banfield
Unit 6, No.6 Hartman Ave., Modbury, South Australia 5092