MORGANTOWN, W.Va. – Chronic pain can be debilitating. Patients who live with pain often undergo thousands of dollars of often invasive testing in order to find answers and require long-term use of narcotics in order to function. Adam Hansen, M.D., a WVU Heart and Vascular Institute thoracic surgeon practicing at WVU Medicine United Hospital Center, has found a way to bring relief to patients whose chronic pain is caused by slipping rib syndrome.
Slipping rib syndrome, in which one or more of the lower ribs becomes detached and results in pressure or irritation to the surrounding nerves, causes severe pain with every breath or movement. This often misdiagnosed condition can lead to an inability to go to work or school and withdrawal from normal activities.
“This is an obscure diagnosis that a lot of people don’t know about,” Dr. Hansen said. “These patients are in debilitating pain and often suicidal. After this procedure, their pain is like night and day. Within a week after the repair, their lives are turned around. They have hope, and they are not considering ending their own life because of the pain anymore.”
Hansen said that many of his patients have experienced this pain for 10 or more years, have seen multiple doctors, and have undergone invasive procedures, such as appendix, small intestine, or gall bladder removal, that have not relieved their pain. Others have been accused of seeking drugs, with 30 percent of patients being prescribed narcotics.
Traditional treatments for the condition call for the excision, or removal, of the affected rib or cartilage. This procedure is invasive and often does not resolve the patient’s pain. Hansen has developed a new procedure that can be performed in less than an hour using only sutures to repair the issue, leading to lasting pain relief.
“We have recently become a leading referral center for the entire world, helping patients from as far away as Germany and New Zealand,” Hansen said. “My belief is that we have these ribs for a reason, and their removal can only cause more problems. This approach restores the ribs to as close to normal as possible as opposed to removing them.”
Leaving the ribs intact allows the patient to retain the protective anatomy of their lower ribs, which prevent liver and spleen injuries. The lower ribs also attach to the diaphragm and support proper breathing. Patients who have these ribs removed often find it more difficult to breathe.
The procedure has a short recovery time in which patients often experience more pain for the first one to two weeks, then an up to 85 percent reduction in pain after one month, and reports of little to no pain after six months.
Hansen’s research has found that there are three main causes of slipping rib syndrome – degeneration, trauma, and hypermobility. Most of his patients are middle-aged women, though he has also treated men and teens.
A cross country runner sidelined
Lindsey Darnell, 15, of Clarkston, Michigan, was 12 years old and running on her middle school cross country team when she first started feeling popping in her ribs. She didn’t experience much pain at first, so she continued to run races for two years until the popping started to cause unbearable pain.
Her mother, Amy Darnell, took Lindsey to multiple specialists searching for answers to her daughter’s unrelenting pain. Urgent care doctors and her primary care provider both suggested that tight hip flexors were causing her rib pain and suggested she stretch more when running. Two days later, Lindsey ran a race and fell across the finish line in tears. Two of her ribs on the left and one on the right had popped out of place and were causing intense pain.
“My kid doesn’t cry, but she was sobbing,” Amy Darnell, said.
A physical therapist referred her to a sports psychiatrist, telling her it was in her head and that ribs do not pop. Lindsey saw more than a dozen specialists, including chiropractors, acupuncturists, sports medicine specialists, rehabilitation specialists, and a neurologist. She had three CT scans and four MRI scans. One specialist told her it had to be cancer, and they had not found it yet.
“I was in so much pain that I would throw up multiple times a day at school, and I couldn’t perform in band,” Lindsey Darnell said. “I couldn’t get out of bed without help. Every move hurt, and it was hard to breathe. I had to reach under my ribs and touch my diaphragm to get it to move so I could breathe.”
“She couldn’t sleep, she had trouble eating, she was passing out,” Amy Darnell said. “It got to the point that we couldn’t leave her alone because she would be out for several minutes when she would pass out. She couldn’t spend time with her friends, and it affected her socially.”
Finally, an orthopaedic surgeon was able to diagnose Lindsey with slipping rib syndrome, only to tell them that he did not work with ribs. She was referred to a specialist in Arizona, who has worked with patients with slipping rib syndrome.
“I began looking into the little bit of literature that exists about slipping rib syndrome. I was lucky enough to join a Facebook page where all these people were talking about Dr. Hansen, and I started researching him,” Amy Darnell said. “From the first time I heard his name to the time we had an appointment was about 24 hours. I felt like we finally had an answer that didn’t involve removing her ribs.”
She had her surgery in March on the last day WVU Medicine was able to perform non-emergent procedures before restricting access due to COVID-19.
“Once I got to West Virginia and met Dr. Hansen, I felt a lot better about the surgery,” Lindsey Darnell said. “After the surgery, I was in a lot of pain, but by six weeks I was feeling a lot better and wanted to do a lot of things. But I had to wait eight weeks. At eight weeks, I was doing backflips on my trampoline.”
While she is now able to go back to many of the activities she enjoyed before her injury, Lindsey Darnell still has a long journey. Doctors have diagnosed her with Lyme disease and believe it is what originally what made her more vulnerable to injury.
“We are now in a very hard battle against Lyme disease, but her ribs no longer cause her problems,” Amy Darnell said. “We are so grateful to Dr. Hansen. He was the first doctor we saw who spoke directly to Lindsey, physically examined her, and listened to what was really going on.”
An elite athlete injured
Lauren Kimmel, 51, of Chicago, is an elite athlete. She ran marathons and triathlons, was an elite stair climber, played women’s soccer, and had set a goal of getting her black belt in karate by the age of 45. One day in class, her life changed.
She was sparring with a man who was much larger than she was when he made a mistake and hit her in the back under her rib cage and on her spine with his knee, causing nerve and spinal damage and breaking her rib and separating it from the cartilage in the front of her chest.
“I was told by all my doctors that my rib was healed according the x-rays, but the pain just got worse,” Kimmel said.
Over the course of two years, Kimmel saw more than 20 doctors, including two neurologists, a rheumatologist, a gastroenterologist, neurosurgeons, physical therapists, chiropractors, physiatrists, and other specialists.
“They kept telling me everything was fine, and I kept telling them that I couldn’t breathe. I was sure my rib was still broken,” Kimmel said. “Nobody even touched me or did any investigation. They told me they believed I was in pain, but my rib was healed.”
Kimmel received hundreds of thousands of dollars in scans of her brain and spine, upper and lower gastrointestinal studies, and tests for multiple conditions, including Lyme disease, scleroderma, and leukemia, to no avail.
“Meanwhile, I had to give up everything, including running,” Kimmel said. “I could hardly walk or breathe.”
In her research, she happened upon an article with a footnote referencing a case study about athletes with slipping rib syndrome. The study detailed what slipping rib syndrome is, its diagnosis, and treatment.
“I was literally at home screaming because I had been diagnosed with all these other things that had turned out to have been wrong,” Kimmel said.” I learned from this article that you can easily diagnose this through something called a hooking maneuver just by putting your own hand under your rib cage and pulling on the rib and if it moves around, clicks, and reduces your symptoms, you have slipping rib syndrome. I did that exactly as described, and it worked.”
Kimmel’s father reached out to the Society of Thoracic Surgeons and obtained a list of all the thoracic surgeons in the country and started calling them, starting in California and working his way to Chicago, asking if they were familiar with slipping rib syndrome and its treatment.
A thoracic surgeon at Northwestern Memorial Hospital, the teaching hospital for Northwestern University, performed a surgery to excise a portion of the rib and cartilage that was causing Kimmel’s pain. After six months, the pain in her ribs was reduced by half and her abdominal pain had been completely relieved.
“What remained was the pain in my ribs all the way to my spine,” Kimmel said. “The rib was still there, and it was still moving around, but the pain was less and it was good enough for living.”
After her surgery, she had a spinal cord stimulator implanted to manage the remaining pain in her ribs. In combination with her surgery, the device provided what she saw as a good amount of pain management. However, in late 2019, her rib pain returned at its previous intensity.
She began to research the condition again, finding much more information than before, but few other treatment options. She found the Chest Wall Injury Society’s Ribcast podcast featuring Hansen speaking about slipping rib syndrome.
She reached out to Hansen’s office with questions, then asked her thoracic surgeon to speak to Hansen to make sure his procedure was sound. After receiving confirmation from her surgeon, she made an appointment with Hansen.
She also traveled to West Virginia as WVU Medicine was preparing to halt non-emergent procedures due to COVID-19. Because she was coming from an area that was not yet a hot spot, she was able to have her pre-operative appointment that day and her procedure the next.
Her surgery was more complicated due to her previous excision. Hansen had to rebuild her rib using a bone graft and plate before reattaching it to the cartilage using his technique.
“I felt relief within the first few weeks,” Kimmel said. “The post-surgical pain was rough, but my nerve stimulator helped. The pain in my abdomen went away and at four months out, most of my pain is at the dissolvable plate that will disappear within 12-14 months.”
Kimmel said her rib pain is 60 percent less than before Hansen’s procedure, and she is able to get back to living her life. She said she hopes her pain will continue to resolve as the nerves between her ribs recover.