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What muscle causes rib flare?

Slipped Rib Syndrome

Slipped rib syndrome

Slipped rib syndrome was first described in the early 1900’s by Cyriax and is an underdiagnosed and often poorly understand condition of the costal arch or margin. It’s caused by excessive movement of the anterior cartilaginous part of the lower ribs as they ‘join’ the costal arch. The excessive movement or hypermobility of the anterior part of the ribs, typically the 8th, 9th or 10th rib is probably caused by either congenital or acquired (following a minor injury or repetitive strain) disruption of the fibrous junctions of these ‘false’ ribs at the costal arch, allowing the tips of the ribs to move or slip under the rib above. The movement causes lower rib or upper abdominal pain.

Slipped Rib Syndrome also known as:
Clicking Rib Syndrome
Painful Rib Syndrome
Rib-tip Syndrome
Slipping Rib-cartilage Syndrome
Twelfth Rib Syndrome
Cyriax Syndrome
Gilding Rib and Displaced Ribs

Created for the Rib Injury Clinic by AnatomikModeling

Symptoms

The pain is caused by excessive movement of the lower rib tips as they pass under the costal arch (what is sometimes called subluxing). It may be associated with a reported clicking or popping sensation. The pain is typically with certain movements or activities usually involving twisting, bending, deep breathing (so may come on after exercise) or even sneezing or coughing. The pain is often intermittent and sharp when the rib tip is moving excessively but can also be more like a dull ache particularly after an activity that ‘triggers’ movement. Resting, avoiding certain activities or even stretching out the rib cage can alleviate the pain.

Slipped rib syndrome tends to be one-sided though can affect both sides, tends to affect younger patients though any age can be affected and seems to be more common in certain sports or recreational activities such as swimming. Previous rib injury may lead to a form of acquired Slipped Rib Syndrome. Hypermobility and joint laxity also appear to be linked as does the presence of rib flare and other chest wall problems such as pectus deformities.

Investigations

Diagnosis of Slipped Rib Syndrome can often be difficult due to the nature of the pain and the many other chest or abdominal conditions that can cause pain in this part of the body. Seeing a doctor who is familiar with Slipped Rib Syndrome is important in assessing and investigating the condition. Clinical examination may relieve tenderness over the area and occasionally the hypermobile rib tip can be palpated and if moved can generate the pain (the hook Manoeuvre).

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Patients may have had multiple investigations already and often Chest CT or even MRI tends not to be helpful. Dynamic Ultrasound with a radiologist experienced with Slipped Rib Syndrome is essential and often allows the radiologist to demonstrate excessive movement of the rib tip affected.

Ultrasound Probe Position

Probe position of Ultrasound

Ultrasound Before Ultrasound After

Ultrasound images with BEFORE [sliding] and AFTER following a dynamic movement (twisting) with pain. It demonstrates movement of the left 9th rib sliding under the adjacent ribs

Ultrasound Before Ultrasound After

Ultrasound images of another patient demonstrating BEFORE (LEFT) and AFTER (RIGHT) following a dynamic movement (twisting) with generation of pain. The images demonstrate the ‘distortion’ of the intercostal muscle (shown in pink) due to excessive movement of the 9th rib. The long white arrow point to the nerve which is impinged by the muscle distortion. The red arrow is the artery.

Occasionally if the diagnosis is less clear cut, diagnostic local anaesthetic injection to the intercostal nerves corresponding to the rib tip involved can help confirm likely Slipping Rib Syndrome. Using Local anaesthetic block with or without corticosteroid may give temporary relief and occasionally complete relief of discomfort and can be considered as a potential treatment option.

Treatment

Establishing the diagnosis with a careful clinical history and examination together with a focused dynamic ultrasound scan allows a discussion with the patient different options and often a simple recognition and reassurance of the problem may be enough. Taking a conservative approach is acceptable once diagnosed and would include avoidance of activity aggravating pain, rest, NSAIDS and occasionally ‘manipulative’ physical therapy techniques may all help. If conservative treatment is not helping a trial of local anaesthetic with or without corticosteroid may be considered.

Surgery remains a good treatment with reports of excellent outcomes though recurrence of the pain has also been described. Typically, through a small targeted incision, the mobile rib tip is delivered from under the costal arch and excised. Alternately, the slipping rib can be stabilised to prevent slippage. See Surgery Treatment

Intraoperative photo of excessively mobile rib tip that has been identified, grasped and mobilised from under the costal arch

Intraoperative photo of excessively mobile rib tip that has been identified, grasped and mobilised from under the costal arch (in this case the tip of the left 10th rib)

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Rib Flare

Rib Flare

One of the most common aspects of pectus deformity is abnormality of the associated ribcage. This typically affects the lower ribs and the lower edge of the ribcage (the costal arch or margin).

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There is a lot of variation in the shape of the costal margin and its shape can change with age, differs in men and women and in body shape particularly central obesity (truncal or abdominal obesity affecting the midriff also known as belly fat). In both pectus excavatum and carinatum as well as mixed deformities the lower ribs can be flared where the ribs and the costal margin either on one (usually the left) or both sides are pulled upwards and stick out. Often Rib flaring can often appear to be the most significant deformity associated with otherwise a minor pectus excavatum or carinatum deformity. Rib flaring can also appear to be isolated without any other obvious abnormality.

Costal margin is made up of the anterior cartilaginous parts of the lower rib cage

Costal margin is made up of the anterior cartilaginous parts of the lower rib cage and is commonly affected in pectus deformities — (Created for the Pectus Clinic by AnatomikModeling)

Please click on the buttons below to see and read about patients verified experiences (in their own words) and testimonials (which generally include before and after treatment photos). The pectus clinic is very grateful to all the patients who provided feedback.

  • Testimonials Rib Flare
  • Experiences Rib Flare

Variation in the shape of the costal margin

Variation in the shape of the costal margin

Variation in the shape of the costal margin

Variation in the shape of the costal margin based on age, gender and physique

Chest CT reconstruction of young woman with left sided pectus carinatum

Chest CT reconstruction of young woman with left sided pectus carinatum (red arrows) and mild rib flare on left (blue arrows) and some rib flattening (green arrow)

Rib flaring and Pectus Excavatum

Bilateral rib flare showing a right sided costal arch with a dip (or deficit) (arrow in green) where the lower costal arch has not formed completely. In this case it was associated with slipped rib syndrome. NOTE: Incidental pectus Excavatum.

Rib flaring and Pectus Excavatum

Bilateral rib flare in a young man with no symptoms or other issues

Rib flaring and pectus excavatum. There is a lot of discussion amongst doctors about the best treatment for significant rib flaring as the standard surgical treatment for a pectus excavatum, a NUSS procedure (see Surgery) may not improve rib flaring and some reports have suggested it may even make it more pronounced though once the pectus is corrected over time the flaring may become less apparent. Open (Ravitch or modified Ravitch) procedures in experienced surgical hands may improve the appearance but rib flaring remains a difficult area for the surgeon to tackle.

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Rib flaring and Pectus Excavatum

Rib flaring and Pectus Excavatum

Rib flaring and Pectus Excavatum

Rib flaring and Pectus Excavatum

Rib flaring and Pectus Excavatum

Rib flaring and Pectus Excavatum

(A) pre-op chest CT scans showing pectus excavatum and left sided rib flare (red ring) and (B) before (left) and after (right) modified Ravitch procedure for severe pectus excavatum and left sided rib flare. See Testimonials.

Treatment for rib flare in either pectus excavatum or carinatum in young patients with flexible chest walls is a rib flare strap for milder cases or a rib flare brace for more severe cases. See Bracing treatment – rib flare.

Specific exercise regimes to target and develop core muscle groups particularly the oblique muscles (see picture) may offer the best chance of improving rib flaring but requires dedication and hard work. Physical therapy can be combined with the rib flare strap. See Bracing treatment – rib flare and treatment Physical Therapy.

Pectus Excavatum

Pectus Carinatum

Examples of rib flare in patients with Pectus Excavatum (A) and Pectus Carinatum (B)

Rib flattening of the lower rib cage, particularly with pectus carinatum can across occur between the sternum and cost margin. It is often on one side and gives its name to more severe forms of pectus carinatum Keel chest. Treatment with pectus bracing and guided physical therapy is effective in correcting. See Bracing treatment – rib flare and treatment Physical Therapy.

Mixed type of pectus deformity

Pectus carinatum with some rib flattening on the right side of the chest (red rings) before pectus bracing treatment

Mixed type of pectus deformity

And after pectus bracing treatment

Please click on the buttons below to see and read about patients verified experiences (in their own words) and testimonials (which generally include before and after treatment photos). The pectus clinic is very grateful to all the patients who provided feedback.

  • Testimonials Rib Flare
  • Experiences Rib Flare
  • Follow us on
  • St George
  • Spire St Anthony

Copyright©2014-2023 Pectus Clinic Ltd. All Rights Reserved.

Postpartum Rib Flare: This Is Why Your Bra Feels Tighter

Close-up of a woman clasping her bra, implying a tighter fit after pregnanacy due to postpartum rib flare.

A few days postpartum, I wandered into the little baby boutique at our community hospital where they fit nursing bras.

If we can ignore my engorged breasts for a sec, that’s a 4 INCH increase in the diameter of my rib cage.

But here’s the thing: This is yet one more thing that is SO normal but just doesn’t get discussed.

Table of Contents

What Is Rib Flare?

Maybe you’ve noticed your bra is fitting tighter.

Or maybe you’ve noticed you’ve got sticky-out ribs.

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Or that you can’t get your arms overhead without shoving your chest out.

This phenomenon is postpartum “rib flare”.

And it can happen in two dimensions.

1) Your whole rib cage can flare upwards as a unit, creating a hinge point in your spine.

A side-by-side image of myself demonstrating a neutral rib cage (nipples pointing forward) and a flared rib cage (nipples pointing to the ceiling).

2) Your rib cage becomes WIDER.

The angle created by the lower ribs (the rib angle or infrasternal angle), hinging at the sternum becomes flatter.

Side-by-side pictures of myself outlining my lower ribs with my hands to demonstrate a narrow and wide rib cage angle.

What Causes Flared Ribs?

As your sweet babe grows inside of you, your body needs to make space.

Just as your pelvis CHANGES SHAPE to accommodate your growing babe, so does your rib cage.

As your internal organs press upwards, the rib cage tips upward and becomes wider to accommodate the demand.

Is Rib Flare Dangerous?

Do you want to address it?

4 Reasons to Address Rib Cage Flare:

Rib flaring leads to muscle imbalances and those lead to an array of body aches, pelvic floor symptoms and reduced strength.

1) Aches and pains

If the rib cage is flared UPWARD, the abdominal muscles get stuck in a “stretched” state.

And where something is stretched, something else gets compressed.

In this case, the muscles of your lumbar spine.

I’m looking at you Low Back Pain.

2) You won’t feel as strong

If the rib cage flares WIDE, the diaphragm gets caught in a stretched position as well.

The diaphragm drives the deeep core canister and the deep core cansiter is responsible for stability of your spine and creating a platform for strong movement.

If the diaphragm is rests in a stretched position, it can’t efficient charge the core cansiter and you won’t feel as strong.

3) Pesky pelvic floor symptoms

Efficient contraction of the diaphragm leverages a strong abdominal wall.

If your abs are stretched because you’re rib cage flares up, you’re diaphragm is at an additional disadvantage.

If your diaphragm’s not happy, the rest of the team (pelvic floor, abs, back extensors) are not happy either.

When your core is off it’s game, you may experience pesky pelvic floor symptoms.

This could manifest as pelvic floor dysfunction, including persistent abdominal separation, pelvic floor tightness, prolapse symptoms or incontinence.

4) It’s harder to take a good breath.

Maybe I should have led with this one??

Okay. This is all to say:

Let’s address your rib flare. And let’s not make a big ol deal out of it.

How To Fix Rib Flare After Pregnancy

There’s no one single best exercise for rib flare.

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Treating rib flare is multi-factorial.

But bringing awareness to your body alignment, creating expansion in your back body and improving rib cage mobility through breathing exercises can work wonders.

1) Check in with your body alignment.

If your rib cage flares UP, you can begin to address this with intentional rib cage positioning.

Exhale your ribcage down and then relax your abs. Don’t grip your abs to hold your rib cage in position.

2) Create expansion in your back body.

Relax those compressed back muscles using (you guessed it) breathing.

Here’s my favorite:

Rock Back Breathing

3) Get really serious about your exhales.

Practice blowing out ALL of your air until your feel your deep abs kick on which will help pull those low ribs towards one another.

You can also try these variations:

Connection Breath With Reach

The reach will help position your rib cage down.

360 Breathing in 90/90 Position

360 breathing in 90/90 is fantastic if you know you have a bit of anterior pelvic tilt. It will help reposition your pelvis AND your rib cage.

“Ha” Breathing

The Ha Breath does a little better job of recruiting the intercostal muscles (muscles between the ribs) that draw the ribs back down and together. See how it feels!

4) Invest in strength training.

Ultimately, you need great strong (balanced!) core muscles to maintain the orientation of your rib cage and pelvis.

As you return to exercise after pregnancy, build strength from the inside out. Start with retraining your deep core and then progress to full body strength workouts.

If you’re paying attention to your breath and body alignment during your full body workouts, you’ll continue working your core with each rep.

Can You Fix Rib Flare?

More than likely, your rib cage will eventual reset to it’s previous diameter.

But you might not reset it’s shape without a little intentional effort.

If you’d like additional guidance, you can consult a pelvic floor physical therapist or a qualified postpartum personal trainer. I offer strategy sessions and individualized personal training to address your unique postpartum concerns.

So now I’m dying to know:

Did you notice that your bra’s been fitting tighter?

Did you know they could impact your pelvic health?

And of course: Will you try these exercises? Leave a comment!

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