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Assessment and management of medically unexplained symptoms

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

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In previous discussions in BMJ I have presented evidence that kyphosis and scoliosis contributes to lower left sided chest pains and L. Sam Lewis responded by recommending a research paper by Leon G. Robb et al about the Slipping rib syndrome.

Robb mentioned that in 1941 J.F.Holmes, and later in 1975 A.A.McBeath and J.S.Keene studied the problem and found that in some cases the eighth to 10th ribs, which are not directly attached to the sternum, had their ends curled up, and if they were fragile and their attachments were incised they became locked one behind the other.

Holme’s concluded that the cause was recurrent irritation of the intercostal nerves which may be direct or indirect and sometimes completely covert.

I subsequently found an SRS sonography study by Jean-Ives Meuwly et al, in 2002, who concluded that it is related to minor trauma, constrained posture, or prior abdominal surgery, but added that the cause remains unclear because many patients could not recall any preceding event.

Some time after reading those reports I was standing up and placed my hand on the left side of my chest and moved it down from the clavicle along the slight undulations created by the ribs and intercostal spaces until I came to an obstruction.

On closer observation it was the eighth rib which was projected in the anterior direction to the extent of almost it’s entire diameter, creating an L-shaped bend between the anterior surface of the seventh rib, and the upper surface of the eighth rib.

I then moved my hand over that rib and the next was projected slightly more forward, and then I moved it over and around and to the left, and the tenth rib continued slightly further forward, and the 11th and 12th were then roughly vertically aligned, and then my hand moved over, around, and back toward the abdominal wall.

The same feature was evident as I ran my hand down the right ribcage.

Later that day I was laying on my back and I tried the same process where the eighth ribs onwards were projected upwards in a similar manner.

By way of explanation I could describe my rib cage, when upright, as having the structure of a vertical seven ribbed wall with a narrow downward 5 ribbed verandah below, which extends immediately forward and then somewhat slightly follows the forward curvature of the muscular abdominal wall, which is all hidden behind a layer of skin.

I.e. the eighth ribs jut out about 1cm, and then the 9th to12th proceed out for a total of another 2cm as they taper to the side of the lower chest.

I then considered how and why that structural feature developed.

In that regard I have previously explained how kyphosis projects the weight of the head and shoulders forward and down over the chest wall, and that the normal chest and sternum are angled forward, and that mine is vertical, and that when I lean forward my sternum tilts slightly backwards.

Consequently any kyphotic pressure down the top ribs is likely to displace one of the next ribs forwards, and in my case it was the eighth rib, and any more downward pressure is likely to make the seventh rib slip slightly behind the eighth, and impinge the intercostal nerves, which would explain the occasional sharp stabbing pains I had as a teenager.

Repeated kyphotic strain and slippage of that sort would also be the likely cause of inflammation and tenderness in that region and eventually stretch the intercostal attachments and leave the eighth rib permanently displaced.

During that process the eighth rib would also push the ninth to twelfth ribs downwards and they would tend to follow the forward curve of the abdominal wall, and that would explain the structural change.

I have also previously explained that my kyphosis occurred as the result of an illness at the age of six which involved nausea, vomiting, poor appetite and poor nutrition resulting in a temporary softening of bones, and the rib feature may have also occurred then, or developed later as the result of long term or repetitive kyphotic pressure on the rib cage.

I also explained that the occasionally sharp stabbing pains which I had in the left side of my chest as a teenager, had stopped when I was about 20.

That may have been due to the fact that teenage ribs are pliable and prone to slippage whereas they harden toward adulthood and therefore become more fixed in their position.

However, similar pains could also occur in adulthood where an injurious incident forced one rib over the other in a similar manner such as being hit in the chest by a solid object, or when the ribs are severely stretched at an awkward angle.

Those conclusions are consistent with Robb’s observation that the hooking manoeuvre which places the fingers down, under, and behind the lower ribs, and then pushes them forward, can reproduce the pain.

I applied it and felt various areas of tenderness, and when my fingers moved up and behind the lower ribs I felt a spot pain, which didn’t radiate, but it was in the same location where I had the radiating pains as a teenager.

i.e. Kyphotic and downward pressure on the seventh rib, and the hooking manoeuvre, both displace the lower ribs forward to produce a similar effect, which explains the cause that has previously been described as being unknown in most cases.


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

2. 2014, March 30th, Banfield M.A. The Posture Theory as an explanation for many previously unexplainable symptoms, (Online rapid response) BMJ 2008:336:1124.

3. 2014, April 27th, Banfield M.A. Posture as a cause of previously unexplainable left sided chest pain, The British Medical Journal (Online Rapid Response), BMJ 2008; 336:1124.

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

5. 2013, Rajender Kumar et al,, The painful rib syndrome, Indian Journal of Anaesthesia, Vol. 57, Issue 3, p.311-313.

6. Jean-Yves Meuwly et al 2002 (March 1st), Slipping Rib Syndrome, A Place for Sonongraphy in the Diagnosis of a Frequently Overlooked Cause of Abdominal or Low Thoracic Pain, Journal of Ultrasound in Medicine, Vol 23, no.3, p.339-343.

Competing interests: No competing interests

13 July 2014
Max Allan Max Allan Banfield
Unit 6, 6-8 Hartman Ave., Modbury, South Australia