“When you hear hoof beats, think horses, not zebras.” This aphorism encourages physicians to consider conditions that are more common and likely rather than jumping to rare or unusual diagnoses. But Adam Shiroff, MD, FACS, a trauma surgeon at Penn Medicine University City and director of the Penn Center for Chest Trauma, has become quite adept at spotting a certain type of zebra, even after other doctors have insisted that it’s just a normal horse.
Slipping rib syndrome is an underdiagnosed issue that occurs when a person’s rib moves around abnormally. The rib cage is made up of 12 paired bones — true ribs that attach to the sternum directly, false ribs that connect to the sternum indirectly via cartilage, and lower floating ribs; slipping rib syndrome is most often caused by the breakdown of cartilage attached to a false rib. The slipped rib generally will not cause internal damage, but it can poke out, make clicking noises, irritate intercostal nerves, cause radiating pain exacerbated by sneezing, eating, or exercise, and overall have a debilitating impact on a person’s quality of life. However, because the condition flies under the radar, many patients report that it’s not just the pain that gets to them, but the feeling that no medical professionals believe them.
The journey to a diagnosis can be long and challenging, partly because many doctors haven’t heard of the condition, and partly because slipping rib syndrome is hard to see with imaging. “These CAT scans are read as normal almost universally,” Shiroff said. “With sophisticated software, I can evaluate the cartilage anatomy and match that up with the patients’ symptoms.” Once diagnosed, Shiroff is able to intervene with a simple orthopaedic suture, a minimally invasive outpatient procedure.
In the fall of 2019, a slipping rib patient named Ashleigh Berge shared her experience with the Presby Bulletin. Over the last year, Shiroff has received countless calls and emails from people across the United States who found the article while searching for answers, realized it mirrored their own experience, and came to Penn for help. Here are a few of their stories:
A Relentless Self-Advocate
Heather Dobos, 35, wanted to lose a little weight for her wedding, but the number on the scale kept dropping even after she said, “I do.” Between her September 2018 nuptials and March 2019 move to Minnesota, she lost 40 pounds. Her parents were terrified, her collarbones were poking out, and she couldn’t bear the excruciating pain and “exorcism-worthy” stomach noises she experienced while trying to eat.
She bounced from specialist to specialist, and as she underwent countless endoscopies, colonoscopies, MRIs, and pain management injections, her exhaustion was compounded by her doctors’ insistence that there didn’t seem to be anything wrong. “I started to feel like I was crazy,” Dobos said. “I had to look in the mirror and remind myself, ‘You’re not going to live like this.’ If I didn’t have that fight in me, I feel like I would have succumbed to it.”
She turned to the internet and came upon Berge’s Presby Bulletin interview. Shocked by the possibility that there was another person who had experienced the same pain and frustration, she tucked the phrase “slipping rib syndrome” in the back of her mind. Just a few weeks later, the phrase came up again after a physical therapist examined Dobos’ ribcage and suggested that she was dealing with this condition. It was time to act. With her family’s encouragement, Dobos reached out to Shiroff — “the first doctor I felt comfortable with and who believed me.” She flew to Philadelphia with her husband at her side, and she successfully underwent surgery on July 27, feeling immediate relief the moment she opened her eyes.
“I planned my life around pain, but now I can sleep at night. I can eat foods that I haven’t had in years. I’ve started working out again. I can give real hugs. I can do whatever I want and feel good doing it,” Dobos said. “I’m sad that I missed out on so much, but now I’m so grateful, and I’m not taking anything for granted. Life can be scary, but now I’m ready to live my life with endless possibilities.”
Rebuilding Hope and Strength
Though slipping rib syndrome often occurs without a clear cause, 26-year old South Carolinian Guy Cilento can point to the two specific moments that led up to his condition. In 2015, he was bitten by a coral snake and wound up suffering several connective tissue injuries. Six months later, he visited a chiropractor whose overly aggressive adjustment left him with recurring spasms that upended his entire athletic lifestyle.
Cilento tried to keep up with physical therapy, but he experienced severe nerve pain that spread like fire throughout his torso and constant clicking and cracking. Like Dobos, he also experienced intense GI distress. “I altered my entire diet and ate in a very specific way, but I still felt bloated and in pain,” he said. Doctors suggested that it was a back problem or a hernia, but offered little help. “No matter what I did, it just got worse, and no one was listening.”
In November 2019, he came across an online forum centered on slipping rib syndrome and was struck by the descriptions others shared. A few Google searches led him to Berge’s article, and everything clicked; this was the answer he had been searching for. He connected with Shiroff and, after Penn started rescheduling non-emergency procedures following the COVID-19 surge, he set up an appointment in July. His examination revealed that his fifth true rib had actually torn away rather than the typical false rib, but Shiroff was able to repair it the same day. Immediately after surgery, Cilento recognized that the pain that had plagued him for five years was finally gone.
“I’m able to do things I haven’t done in years. A physical therapist told me I’d never be able to run again, and I’m jogging. I rode my bike recently. I can stand up straight after fighting against my own body for so long. And it’s all because Dr. Shiroff was willing to hear me out and help,” Cilento said. “When COVID’s over, I’m going to take another trip to Philadelphia and run up the art museum steps like Rocky in celebration.”
A Family’s Fight for Answers
Parents of teenagers are used to mercurial moods, but when 14-year old Alex Hollowell transformed into a totally different person overnight, her parents were baffled. It started at mealtimes; Hollowell would eat one or two bites, then double over in pain. An avid athlete who participated in sports year round, she suddenly couldn’t rebound a basketball for her teammates, let alone actually practice with them. She started sleeping on the couch, and her sunny personality faded into irritability and frustration. Initially, her family attributed the changes to typical teenage stress, but as she became increasingly miserable, Hollowell’s mom Amy knew something was wrong.
Nine hours in the emergency room, two CAT scans, two X-rays, four ultrasounds, and an endoscopy, fluoroscopy, and MRI later, every doctor pointed to a stomach or gallbladder issue. An ultrasound tech did flag that one side of her ribcage seemed hazier than the other, but Hollowell was just given acid reflux medications and sent home.
“In four months, there wasn’t a two-week period where Alex wasn’t getting tests done,” her mom said. “Her pediatric gastroenterologist agreed that this wasn’t normal. She researched it and said that Alex’s symptoms matched up with slipping rib syndrome, even though at the time, she didn’t know that trouble eating and drinking were also common symptoms. She told us that there wasn’t anything they could do for her in Oklahoma, but gave us Dr. Shiroff’s name and encouraged me to keep researching.”
Hollowell’s mom sent a lengthy email about her daughter’s situation, and 20 minutes later, Shiroff replied requesting X-rays and offering a virtual visit. Within three weeks, Hollowell was scheduled for surgery — the youngest patient to undergo this procedure at Penn. “Two weeks after that, I had my girl back,” her mom said. “She’s smiling, laughing, sleeping, and eating, and the quality of life for our whole household has changed.”
“Dr. Shiroff could have said, ‘We're dealing with COVID, so we can’t help you.’ He could have said, ‘We’re not a pediatric hospital, so we can’t help you.’ But he didn’t. My kid was hurting, and he listened,” she continued. “I hope this never happens again, but if her pain comes back, we know exactly where to go.”
Sound familiar? Penn Medicine can help.
If these patients’ experiences with slipping rib syndrome resonate with you and you believe your symptoms match up, give the Penn Center for Chest Trauma a call today at 215-662-9207.