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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

In response to my recent comments about the postural cause of lower left sided chest pains L.Sam Lewis provided a link to a research paper by Leon G. Robb et al about the slipping rib syndrome.

They stated that although the cause was obscure and unknown it was sometimes preceded by trauma to the chest which may have produced damage to the fibrous attachments of the ribs and made them loose and liable to slip and impinge on the intercostal nerves to cause the pain.

I can therefore give an example of a possible cause . . .

When I was about fourteen years old I attended a scout camp where we set up our tents and laid canvas ground sheets on hard ground inside.

Later that night I got into my sleeping bag and went to sleep.

I awoke in the middle of the night with my closed fist between my lower left ribs and the hard ground.

The left side of my chest and abdomen and my left arm and leg were numb.

I rolled onto my back and went to sleep again, and when I awoke in the morning everything had returned to normal.

A few months later, for no apparent reason, I felt a sharp stabbing pain in the same area, as if a sewing needle had pierced my chest to a depth of about five centimetres and came out again within a fraction of a second.

The same pain occurred in the same part of my chest at various times, many months apart, until I was about 20, and hasn’t happened since.

Discussion: The biomechanics of that pain . . .

When I began studying the cause of other health problems at the age of 25 I had already noticed that they were related to repetitively leaning toward a desk, and eventually that I had a forward curvature of my upper spine and a vertical sternum which disposed to pressure on my ribs and the intercostal nerves,

I also noticed that I had sideways curvature of the spine to the right which meant that the pressure would be compressing the ribs on the right, and slightly stretching those on the left, so that stretching of the ribs attachments would have had some influence, and the scoliosis would have been responsible for the unilateral nature of that pain.

Therefore when I recently read about the slipping rib syndrome I concluded that when I was asleep at the scout camp with my closed fist between the ground and my lower left ribs, that it was pushing one or more of them inwards and impinging the intercostal nerves for several minutes to produce the numbness which eventually made me wake up in the middle of the night.

Consequently when I rolled onto my back the pressure on the nerve was relieved, which is why the numbness was gone the next morning.

The pressure on the ribs may have also stretched or torn the fibrous attachments so that one of them was loose and prone to slipping.

The ribs would have returned to their normal position which is why I didn’t have any other symptoms for several months.

However, I did get the sharp stabbing pains occasionally after that, and although I was not aware of any specific reason at the time it was probably due to moving, bending, or twisting at an unusual angle which cause the loose rib to slip and impinge an intercostal nerve.

Furthermore the forward curvature of my upper spine would have placed my head and shoulders forward where their weight produced repetitive downward pressure on my lower ribs and may have prevented the damaged fibrous attachments from healing.

Nevertheless, I went through a rapid growth period in my late teens and that may have relieved or changed the dynamics of some of the pressure and allowed those attachments to heal, and that would explain why that particular symptom stopped.

Conclusion . . .
Trauma to the chest and, or kyphosis, scoliosis, and a long, narrow, or flat chest, which have a biomechanical effect on the lower ribs, can cause damage to their fibrous attachments and dispose to slippage, and consequent impingement of the intercostal nerves, and individually, or in combination account for the previously obscure and unexplainable symptoms.

References: related to these conclusions can be seen at the end of my recent comments here . . .
Banfield M.A., 2014 (May 6th), The postural and biomechanical causes of nerve pain in previously unexplainable chest pains, (Online rapid response) BMJ 2008;336:1124.

See also: A method of diagnosing the slipping rib syndrome with sonography . . .
Jean-Yves Meuwly et al, 2002 (March 1st), Slipping Rib Syndrome, A Place for Sonography in the Diagnosis of a Frequently Overlooked Cause of Abdominal or Low Thoracic Pain, Journal of Ultrasound in Medicine, vol.21 no.3, 339-343.

Competing interests: No competing interests

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