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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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In previous comments in BMJ I have described how I drew the conclusion that lower left sided chest pain was due to postural displacement of the eighth rib (and/or by implication the 9th or 10th rib).

I also explained how I began studying the topic in 1975 with the observation that various symptoms were, on some occasions, induced by leaning forward, and later that postural factors were also involved.

During that time I was looking for independent evidence when I found a book by Paul Wood from 1956 which contained a chapter on some of the symptoms with his finding that the chest pain was relieved by the intramuscular injection of local anaesthetic, whereas cutaneous or subcutaneous injections had no effect.

I saw that as evidence of a physical cause and the pains precise location.

He then suggested possible causes which included lifting a heavy weight, cranking a car engine, faulty posture, or psychological factors.

Anxiety, for example, affects the breathing rate, so he suggested that the pain may be due to strain on the attachments between the respiratory muscles and the chest wall.

He then suggested that many patients had been timid children whose kindly mothers and doctors had protected them from the hazards of football, swimming, and gymnastics, and that they therefore grew up with a fear of exercise and sport.

However, I had played a lot of sport as a teenager, including swimming and gymnastics, so as the years went by I noted that some prominent sportsmen also had problems with similar symptoms.

I began describing my ideas in the BMJ late last year, and early this year presented some information about the chest pain when L.Sam Lewis suggested that I read a research paper about the slipping rib syndrome by Leon G. Robb.

It was a narrow area of research which I had not previously been aware of where it was reported that in most cases the cause was unknown, but I was then able to determine that it was due to postural displacement of the eighth rib.

During that process I looked at other research papers which reported that SRS was not mentioned in modern medical text books, and that most physicians were not aware of it, or the little known diagnostic method called the hooking manoeuvre, or that the pain could be cured by surgery.

They also reported cases where it occurred many months or years after chest injuries in sports such as soccer or football (McBeath &.Keene, 1975) or, in one case, immediately after an injury in cricket (Meuwly et al, 2002), and that the patients were usually assessed by many doctors using various diagnostic methods to rule out broken ribs, and pleuritic pain, and referred pain from abdominal disorders such as gastric ulcers, gall stones, or appendicitis, with nothing evident.

Since then I have found another paper by Uderman who reflect those comments and adds that the typical symptoms included intermittent sharp stabbing pains followed by a dull achy sensation, which are often aggravated by “activities such as bending, coughing, deep breathing, lifting, reaching, rising from a chair, stretching, and turning in bed”.

He then presents the case of a 22 year old competitive swimmer who was “jumping up and down and gently swinging her arms” as part of her warm up exercises, when she felt moderate diffuse pain in her lower left chest followed by discomfort during the race, which recurred episodically for more than eight months afterwards.

During that period she was examined by an athletic trainer, two physicians, and a chiropractor, had three x-rays and a bone scan, and treatment included activity modification, hot packs, anti-inflammatory medication, ultrasound, twelve sessions of spinal manipulation and electric stimulation, and ten sessions of physiotherapy which produced some temporary relief but no long term affect.

She was paradoxically “most comfortable in the slouched position”, but initial investigations with Valsalva’s manoeuvre and sit-up tests elicited the pain, and eight months later, when she eventually consulted a thoracic surgeon he suspected the slipping rib syndrome and applied “the hooking manoeuvre” which reproduced the pain to confirm the diagnosis, and then she underwent surgery for “resection of the abnormal cartilaginous attachment of ribs 11 to 10, as well as the resection of a portion of the rib 12”, which relieved the pain.

Six months of restricted activity followed, and then, after a program of gradually increasing levels of exercise, she competed in the national swimming competitions successfully.

Udermann also mentioned that many trainers and physicians were ‘relatively unfamiliar’ with the SRS which was ““often misdiagnosed or undiagnosed”, and therefore recommended that they become familiar with it’s symptoms, and the hooking manoeuvre so that diagnosis and treatment can be applied early to “avoid many months or even years of unnecessary pain and discomfort”.

He also recommends “the avoidance of movements or postures that exacerbate symptoms”.

By way of summary I conclude that the cause of SRS has remained obscure because of the delayed response to postural factors and injury, often for months or years, and because cases of injury which are followed immediately by pain are relatively uncommon, and the fact that it is not evident on standard widely known and used diagnostic tests.

Furthermore, after the rib has become loose the type of movements which cause them to slip are usually so casual and ordinary that they most often go unnoticed.

In the case of the swimmer, the pain was first noticed when she was just jumping up and down, and gently moving her arms in a warm up before a race, but the ribs were probably loosened by another incident long before that.

1. Paul Wood, 1956, Diseases of the Heart and Circulation, 2nd revised edition, Eyre & Spottiswoode, London, p.937-947.

2. Brian E. Udermann et al, 2005 (April - June) Slipping Rib Syndrome in a Collegiate Swimmer: A Case Report, Journal of Athletic Training, 40(2): p.120-122.

3. LSam Lewis, 2014, (April 28th), Re: Assessment and managementy of medically unexplained symptoms, BMJ 2008;336:1124, Actual page

4. Leon G.Robb et al, 2014 (July 21st), The Slipping Rib Syndrome: An Overlooked Cause of Abdominal Pain, Practical Pain,

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

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.

7. M.A. Banfield, 2014 (March 30th), The Posture Theory as an explanation for many previously unexplainable symptoms, The British Medical Journal (Online Rapid Responses), BMJ 2008;336:1124 Actual page of response

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

9. M.A. Banfield, 2014 (May 11th), 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

10. M.A. Banfield, 2014 (July 13th), 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,

11. M.A. Banfield, 2014 (July 30th), Four more examples to clarify the cause and effect of displacement of the ribs and chest pains, The British Medical Journal (Online Rapid Responses), BMJ 2008;336:1124, Actual page

Competing interests: No competing interests

19 November 2014
Max Allan Banfield
Unit 6, No.6 Hartman Ave., Modbury, South Australia 5092