Rib-Tip Syndrome


Rib-tip syndrome, also known as costo-iliac impingement syndrome, is defined as pain felt in the flank at the level of the iliac crest.


Due to the age-related increase of an existing thoracolumbar scoliosis or osteoporosis, the distal end of the 11th or 12th rib touches the iliac crest, resulting in local pain.

Signs and symptoms

In all thoracic pain, extensive anamnesis is important, particularly in patients with a history of carcinomas. General matters such as weight loss, (chronic) coughing, past trauma, thoracic surgery and infections should also be explored.

In addition, it is important to enquire about thoracic spine complaints and/or pain related to breathing or that becomes worse with coughing.

The patient should be asked about the precise location of the pain and its radiation. The character of the pain and the provoking conditions (static or dynamic load) can provide information about the aetiology and nature of the pain (neuropathic versus nociceptive).

In rib-tip syndrome, the pain is provoked by static load, such as prolonged sitting and standing, trunk rotation and walking. The pain is localised unilaterally or bilaterally.


Physical Examination

Extensive general physical and neurological examinations are always indicated in thoracic pain. The sensitivity of the thorax and abdomen should be examined. Loss of sensitivity indicates whether neuropathic pain is present.

Examination of the thoracic spine is preferably performed with the patient in a sitting position, and includes inspection at rest and palpation of the vertebra and paravertebral structures, such as the costovertebral joints.

Provocation of pain, in particular, by performing passive rotations, forward flexion, backward flexion and lateral flexions can indicate the spinal aetiology of the pain.

In upper thoracic and median and paramedian unilateral pain, shoulder function on the same side must be included in the examination.

Pressure pain of the sternum, sternocostal and costovertebral junctions is usually accompanied by a local pain pattern (e.g., Tietze syndrome), but can sometimes be associated with segmental pain.

In rib-tip syndrome, pressure pain is found at the distal end of the 11th or 12th rib. Frequently, no space can be palpated between the distal end of the 11th or 12th rib and the iliac crest. The pain can be provoked by passive lateral flexion towards the affected side.

Additional Somatic Diagnostics

Since thoracic pain is not a clinical entity and the cause cannot always be determined by anamnesis and physical examination, additional diagnostics are always necessary.

  • In uncomplicated rib-tip syndrome, no additional diagnostics are indicated.
  • In trauma, with or without osteoporosis, X-ray is necessary in order to exclude an impression fracture.
  • When there is a suspicion of malignancy, an MRI scan and/or referral to a specialist is mandatory. Particularly in patients with a history of malignancy with acute thoracic pain, additional diagnostics are important. The same is true in the case of neurological deficits.
  • When there is a suspicion of pathology in the chest wall and/or pulmonary complaints,  X-ray can be useful,  together with  possible referral to a pulmonary specialist.
  • In case of doubt or when visceral pathology is suspected, ultrasound, CT scan or referral to a specialist should be considered.
  • RAND-36 (quality of life)
  • VAS-Pain (maximal, minimal, actual, average/week)
  • PCS (catastrophising)
  • HADS (fear and depression)

Additional Psycho-cognitive Diagnostics

Multidisciplinary Treatment

Whether or not somatic treatment is indicated is based on the pain diagnosis.  Based on the findings of the pain questionnaires, additional diagnostics and/or multidisciplinary treatment comprising various non-somatic treatments may be necessary.

Non-somatic Treatment

Somatic Treatment

Pharmacological treatment:

Other Treatments

Interventional Pain Treatment


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