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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

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The purpose of the following comments is to show the relationship between posture, leaning forward, pressure on the anterior chest wall, the slipping rib syndrome, and symptoms due to the impaction of intercostal nerves, by using kidney aches as an example.

When I was in my early twenties I noticed that when I leaned toward a desk I would feel a vague ache in my left kidney area, and when I leaned back it would stop.

On some occasions where the ache persisted it was accompanied by a sense of nausea, and although nothing was evident at the time it was later followed by the diagnosis and treatment of a kidney stone.

Soon after that I noticed that leaning forward caused upper abdominal pain, and then on another day it caused breathlessness, and an hour later faintness, and I became curious about why.

I eventually began studying medicine and later concluded that all of those pains were related to the shape of my spine, which was curved forward, and was placing downward pressure on my chest and abdomen.

I later considered that there were various ways of leaning forward which may account for the different symptoms.

For example, it is possible to read by bending the neck to face the pages on a desk, or to bend the spine into a C-shaped curve to bring the head and eyes closer to the page, or to bend from the hips while keeping the back straight.

I also considered the possibility that as the person leans forwards, the back muscles also move forwards, so, for example, the kidney could be compressed from behind, and that presented the additional possibility that the ache could be from strain on the loin muscles.

However, the association of the ache with kidney stones and nausea made it more likely to be due to pressure on the kidney.

About twelve years later I found information which led me to conclude that postural pressure on internal organs such as the stomach, or the kidneys might be pushing them out of shape and position.

In some cases it might be bending or kinking the tubes leading in or out of those structures to cause partial blockage and congestion of the kidneys, and for example, to cause salts in fluids to deposit out as a kidney stone.

I have discussed some of those ideas in my recent comments in BMJ, and also described the postural cause of lower left sided chest pains.

L.Sam Lewis then suggested that I look at an August 2013 research paper by Leon G.Robb et al on the topic of the slipping rib syndrome.

Robb described how slippage of the eighth, ninth, or tenth ribs could cause unilateral subcostal pains in the upper abdominal quadrant by impinging an intercostal nerve.

He also presented the case of a 34 year old woman who had right upper quadrant pain for four months where there was no history of chest injury, and where the subcostal abdominal pain was associated with nausea without vomiting.

Soon after that I found a research paper from May/June 2013, by Rajender Kumar, who described a 32 year old woman who had been experiencing intermittent right loin pain for the previous two years.

She reported that the sitting, and leaning forward was likely to produce the symptom, particularly when she was sitting at a “swing machine” (which I presume is a misspelling of “sewing machine”).

Investigation and treatment by various specialists were not effective, and when examined by Kumar it was found that manipulation of the twelfth rib reproduced the exact pain which was ultimately cured by a series of nerve blocks.

He then presented the case of a 40 year old woman who had intermittent right loin pain for ten months which was made worse by the rotation of her trunk, and similar tenderness of the twelfth rib was found and treated effectively.

His third case was a 22 year old female who developed sudden and acute pain in her left loin when she bent forward or lifted heavy items.

The tenderness of the twelfth rib and treatment were similar to the other examples.

He reported that it was a common problem, and that the pain sometimes occurred on both sides of the back, but was usually unilateral and related to movement or manipulation of the 10th, 11th, or 12th rib tips.

He also mentioned that it was sometimes related to a previous chest injury, but that in many cases no such incident occurred, so he attributed the problem to the irritation of intercostal nerves by the hypermobility of the rib cartilages and advised patients to avoid the type of activity which induced the episodes of pain.

By way of summary I note the evidence that kyphosis moves the head and shoulders forward where the weight is directed down along the anterior rib cage and strains and stretches all of the sternal and rib attachments and disposes to the slippage and impingement of nerves to produce the various symptoms related to the focus of pressure, which explains why they often occur separately in response to the same movement.

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

2. 2014 (February 9th), Banfield M.A., Kyphosis as a cause of the chronic fatigue syndrome, The British Medical Journal, BMJ 2013;347:f5731,
(more detail about the kidney ache).

3. 2104 (April 28th), L.Sam Lewis, Response to the article on “Assessment of management of medically unexplained symptoms, The British Medical Journal, BMJ 2008;336:1124, Actual page

4. 2014 (March 30th), Banfield M.A., The Posture Theory as an explanation for many previously unexplainable symptoms, The British Medical Journal, BMJ 2008;336:1124, Actual page of response for 30-3-14 is

5. 2014 (May 6th),Banfield M.A., The postural and bio-mechanical causes of nerve pain in previously unexplainable chest pains, The British Medical, BMJ 2008;336:1124, Actual page of response is

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

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

Competing interests: No competing interests

17 August 2014
Max Allan Banfield
Unit 6, No.6 Hartman Ave., Modbury, South Australia 5092