Intended for healthcare professionals

Rapid response to:

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:

I would like to thank the editors of BMJ for publishing my comments of 11-5-14 in which I described an incident where pressure from my fist on my chest was followed several months later by a chest pain.

I would now like to describe some comparable injuries which involved delayed reactions to clarify that particular link between cause and effect.

Firstly, in 1975 A.A.McBeath & J.S.Keene described a case where . . . “A nineteen-year old woman was kicked in the anterior part of the right side of the thorax during a soccer game.”

“She stated that the right second and third ribs had been fractured”, and that her chest had been taped, and that “the pain soon subsided”.

However a year later “she complained of episodic soreness and a popping sensation with deep breathing at the anterior margin of the right tenth rib of six month duration”.

The authors then presented a similar case of a 22 year old woman who was injured in the anterior ribs during a game of football five years earlier, and another example of a 34 year old woman who had been experiencing episodic chest pain since she bruised her ribs seven years earlier in a snowmobile accident, and the aggravating factors included deep breathing, vomiting, abducting the right arm, and laying on the side.

In 2002 J. Meuwly et al provided an example of a 20 year old cricketer who was admitted to the emergency department with acute pain in the upper right abdomen occurring abruptly after the over stretching of the abdominal wall during a game of cricket, and on clinical examination the inferior anterior border of the thoracic wall was also painful.

Various diagnostic methods were used to determine that the injury stretched the attachments between two ribs and made one of them loose, and in some cases it caused immediate pain, and in others it didn’t have any effect until several months or years later when a relatively minor incident resulted in it slipping over another and impinging an intercostal nerve to cause the pain.

In relation to my more recent suggestions of 13-7-14, such injuries would be more likely to result in chest pains in people who already had kyphosis and vertical sternums and would, in combination, shed light on the causes in other cases.


1. 2014 (May 11th), Banfield M.A. An example of injury to rib attachments as a cause of previously unexplainable chest pains, The British Medical Journal (Online Rapid Responses), BMJ 2008;336:1124, Actual page of response is

2. 2014 (July 13th), Banfield M.A. The Banfield explanation for anterior displacement of the eighth rib and the cause of previously unexplainable chest pain, The British Medical Journal (Online Rapid Responses), BMJ 2008;336:1124.

3. 1975 (September), A.A.McBeath & J.S.Keene, The Rib Tip Syndrome, The Journal of Bone and Joint Surgery, Vol.57-A, No.6, p.795-797.

4. 2002 (March 1st), Jean-Yves Meuwly et al, 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

30 July 2014
Max Allan Banfield
Unit 6, No.6, Hartman Ave., Modbury, South Australia