Slipping Through: One Patient’s Road to a Rare Diagnosis

Ashleigh Berge was preparing for a run when she started feeling intense pain on the upper right side of her abdomen. Every stretch and step made it worse. As a passionate runner, she was familiar with aches, pains, and side stitches, but this was different. Then, with a look of horror, she realized something was trying to poke out of her chest.

As a physician assistant, she deduced that one of her ribs was the culprit, but while her internet searches led her to tentatively diagnose herself with a rare condition called slipping rib syndrome, it would be a long road before she’d finally receive the treatment she needed at Penn Medicine University City.

The rib cage is made up of 12 paired bones: seven “true ribs” that attach to the sternum directly, “false ribs” that attach to the sternum indirectly by cartilage, and the lower “floating ribs.” Slipping rib syndrome occurs when the cartilage connected to a “false rib” breaks and causes abnormal movement. A slipped rib won’t cause internal damage or puncture a lung, but the sharp pain can be exacerbated by something as simple as sneezing too hard. The pain typically radiates from the chest, back, and abdomen, but these symptoms can be attributed to everything from bronchitis to an inflamed gallbladder, adding to the difficulty of pinning down a diagnosis. Even more frustrating is the fact that while the condition can be caused by trauma or injury, it just as often isn’t prompted by a clear cause; it just shows up and sticks around.

For Berge, the “knife-stabbing pain” lasted for two years, despite her desperate efforts to find a solution. “Dr. Google” had given her a potential diagnosis, but when it came to treatments, everything seemed to point to ibuprofen, ice, and physical therapy, none of which offered a permanent solution. Her family doctor tried gently moving the slipped rib back into place with osteopathic manipulation treatment, but it would only work for a few days. Chiropractors told her they couldn’t provide much help, and multiple orthopaedists refused to see her at all, noting they did not work with rib injuries. As time went on, the once-avid athlete could barely take a few steps without pain, and exercise was excruciating.

“I’ve overcome a lot. I broke my back when I was 19, and I’ve had my fair share of bizarre injuries. I know how to cope with things, and I can normally work through pain, but this…. This stopped me in my tracks and left me in tears,” Berge said. “I was so frustrated and so stressed, and it felt like no one was listening. No one could help.”

Finally, this past spring, Berge tracked down an orthopaedist near her workplace who was willing to evaluate her. Her suspicions were finally confirmed: she had slipping rib syndrome. He referred her to Adam Shiroff, MD, FACS, director of the Penn Center for Chest Trauma and an associate professor of Surgery, to discuss the possibility of surgical intervention, and Shiroff agreed that Berge’s continuous, severe pain made her a good candidate for a procedure to remove the damaged cartilage entirely. Excited by the prospect of finally getting her life back, Berge was fully on board. Just two weeks later, Shiroff performed a minimally invasive costal cartilage excision.

“Slipping rib syndrome is an underdiagnosed condition that’s often mistaken for other issues, but I’ve performed a handful of these procedures in just the last year. Patients are often told to manage their pain and hopefully it will go away, but if we can eliminate it, why wouldn’t we?” Shiroff said. “It’s a simple and quick procedure, but it has a huge impact on quality of life. Ashleigh is young and otherwise healthy, and she was able to recover quickly. This case really showed a convergence between trauma surgery and sports medicine, and I’m glad that we were able to get an athlete back to doing what she loves.”

Berge’s pain lingered for only two days following the surgery, and within a week, she felt better than she had in years. She still can’t quite believe how well she is doing — “I still have my fingers crossed, but so far, so good!” — and after granting herself some time to recuperate, she triumphantly returned to her fitness program. She plans to ease herself back into long-distance running soon.

“I work in the medical field myself, and I know that things can be overlooked or missed. But I think it’s really important to shine a light on a condition that’s misunderstood and potentially underdiagnosed because people may still be suffering without knowing why,” she said. “I’m finally living pain-free, and I’m so grateful that Penn Medicine was willing to listen to me, help me, and to get me back to my normal self.”