title: Botulinum toxin treatment for slipping rib syndrome: a case report.
abstract: BACKGROUND
  Slipping rib syndrome (SRS) is a musculoskeletal cause of severe and recurrent thoracic or abdominal pain. The etiology of SRS is unknown, it seems to arise from costal hypermobility with a tendency of one of the ribs (usually from 8th to 10th but also 11th and 12th have been described) to slip under the superior adjacent rib. Its prevalence is underestimated because SRS is mainly a clinical diagnosis, frequently missed. The critical aspect of the diagnosis is knowledge of the condition itself, which, when lacking, often results in the patient being referred to many different specialists and exposed to unnecessary and costly investigations. The management of the condition includes conservative techniques such as manipulation, localized anesthetic, and steroid or anesthetic nerve block. However, where conservative therapy fails, surgical treatment, with excision of the rib, may be performed.
  
  
  METHODS
  In this paper we describe the case of a patient with persistent and debilitating flank pain who, after many investigations, was diagnosed with SRS.
  
  
  RESULTS
  The usual conservative treatment failed, after which we treated the patient with injections of incobotulinumtoxin A into muscles inserting on the inferior side of the rib cage (quadratus lumborum muscle, muscle transversus abdomini, abdominal external oblique muscle, and recto abdomini) achieving a complete relief from pain.
  
  
  CONCLUSIONS
  To our knowledge botulinum toxin has never been proposed before for the treatment of SRS. We believe that it should be considered as a therapeutic option, especially where other medical treatments have failed or as an intermediate step before surgical intervention.
authors: *Department of Medical and Surgery Sciences, School of Specialization in Geriatric Medicine, University of Brescia †Department of Rehabilitation Medicine, Fondazione Poliambulanza Brescia, Italy.
authors: Caterina
authors: C
authors: Pirali
authors: Gianna
authors: G
authors: Santus
authors: Sofia
authors: S
authors: Faletti
authors: Domenico
authors: D
authors: De Grandis
mesh_terms: D019274:Botulinum Toxins, Type A / Q000008:administration & dosage*; D059350:Chronic Pain / Q000175:diagnosis / Q000188:drug therapy*; D003286:Contracture / Q000175:diagnosis / Q000188:drug therapy*; D005260:Female; D021501:Flank Pain / Q000175:diagnosis / Q000188:drug therapy*; D006801:Humans; D007273:Injections, Intramuscular; D008875:Middle Aged; D009408:Nerve Compression Syndromes / Q000175:diagnosis / Q000188:drug therapy*; D009465:Neuromuscular Agents / Q000008:administration & dosage; D010147:Pain Measurement / Q000187:drug effects; D012272:Ribs / Q000000981:diagnostic imaging; D013577:Syndrome; D016896:Treatment Outcome; D014463:Ultrasonography
chemical_list: D009465:Neuromuscular Agents; D019274:Botulinum Toxins, Type A; C545476:incobotulinumtoxinA