Journal of Orthopaedic Medicine

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Diagnosis and Treatment of Iliocostal Friction

Syndromes

Gerald G Hirschberg, Kathryn A Williams & Jennifer G Byrd

To cite this article: Gerald G Hirschberg, Kathryn A Williams & Jennifer G Byrd (1992) Diagnosis
and Treatment of Iliocostal Friction Syndromes, Journal of Orthopaedic Medicine, 14:2, 35-39, DOI:
10.1080/1355297X.1992.11719682

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 Journal of Orthopaedic Medicine Vol 14 1992 No 2 35
DIAGNOS IS AND TREATM ENT OF
ILIOCOSTAL FRICTIO N SYNDROMES
GERALD G HIRSCHBERG, MD, KATHRYN A WILLIAMS MD,
JENNIFER G BYRD, MD
El Cerrito, California

ABSTRACT
Friction of a lower rib against the iliac crest may be the such as lumbar compression fractures, multiple disc
cause of severe pain at the lower chest margin, in the low narrowings, lumbar vertebral collapse from infection or
back, hip and groin with radiation into the chest and thi gh. metatascs (Figure I b).
The Iliocostal Friction Syndrome may be deLCctcd clinically
by palpation of the iliac crests which are extremely tender 3 Lumbar or lumbodorsal scoli osis (Figure I c).
and in contact with lower ribs. If the ribs are moved away
from the iliac crest by compression of the lower chest 4 A combination of any of these three factors.
margin, pai n is immed iately relieved.
F igure l c shows a patient with a lowered rib cage and a mild
Treatment consists of compress ion of the lower chest by an lumbar scoliosis, leadi ng to iliocostal contact and unilateral
elastic belt and infiltration of the iliac crest with sc lcrosant friction. In patients with scoliosis, the ICFS is usually
so lution. unilateral. Patients with lowered rib cage without scolios is
most often have bilateral ICFS. In this case, the lower rib
DEFINITION cage has the same width as the pelvis (Figure I b).
The iliocostal friction syndrome (ICFS) is a painful condition
caused by friction of the lower ribs aga inst the iliac crest, The structures irritated by iliocostal fri ction are the tendons
leading to irritation of soft tissues in the area of contact. of the muscles inserting at th e iliac crest and the lower rib
cage. These are the obliquus intemus and extemus, the
INTRODUCTION quadratus lumborum and the transversus abdomini s.
With a large number of patients complaining about pain in
the low back, hip and groin, it is often diffi cult to localise Tendon pain is referred to a distant area. Therefore, the
the etiology anatomically. patient may complain of widespread pa in in the hip, low
back, groin , thigh and chest. This makes it difficult for the
The objective of thi s paper is to draw attention to the ICFS clinician to think of a single origin of pain in terms of
because it is little known, can be eas ily diagnosed and anatomical locali sation .
immedi ate pain relief can be provided. Our first two cases
were seen in September 1978. Since then , 19 more cases INCIDENCE
have been seen. Jn reviewing the literature on this subject, In patients presentin g with low back and hip pain, the
we have found only one paper reporting 6 cases ofiliocostal incidence of iliocostal friction syndrome reported thus far
friction 1 • is rather small. However, considering the large number of
patients seen in physicians' offices with low back and hip
ETIOLOGY pain, the syndrome may be more common. Since 1978, we
Normally there is enough di stance between the lower ribs have seen 7 cases of bilateral iliocostal friction syndrome
and th e iliac crest so that no contact occurs, even on lateral (Table I) and 12 cases of unilateral iliocostal friction
bending of the trunk. The last two ribs, not attached to the syndrome (Table 2) in our practice. There are 6 cases
sternum, easily moveoutofthe way, and the tenth rib never reported by Wynne et aJI which are shown in Table 3. At
reaches the iliac cres t. thi s time, the data available to us are insufficient to establish
the true incidence.
In pathological conditions, there can be contact of the
tenth , eleventh or twelfth rib with the iliac crest. As a SYMPTOMS
result, there is fri ction and damage to pain sensitive soft The major symptom is low back pai n. The pain is always
tissue structures. In association with severe osteoporosis, felt in the low back area, but there can be radiation to the
the followin g conditions can cause iliocostal contact: groin, buttock, thigh and lower rib cage. In patients with
lumbar spine compression, or Pott's Disease, the pain is
I Severe dorsal kyphosis due to dorsal, wedge shaped bilateral; while in scoliotic patients, the pain is unilateral
compression fractures 2 (Figure Ia). and is felt from the spine to the axillary line.

2 Conditions which lower the he ight of the lumbar spine , Pain is usually relieved by immobility in any position -
 36 Journal of Orthopaedic Medicine Voll4 1992 No 2

Ilia costal
Friction

Figure ta Figure 1c

diminished height or marked curvature of the lumbar spine.

The fact that low back pain is common in these patients and
usually attributed to osteoporosis or scoliosis, may also
alert the clinician to the possibility of rib contact with the
iliac crest. Attention to the iliocostal syndrome should be
attracted by the severity of pain and its occurrence on the
slightest motion.

On examination in standing position, scoliosis, gibbus or

shortening of the lumbar spine is noted in inspection.
Palpation of the iliac crests from the anterior superior iliac
spine to the posterior superior iliac spine reveals extreme
tenderness. The ribs are in direct contact with the iliac
crest, either unilaterally or bilaterally. The inferior borders
lliocostal of the ribs in contact with the iliac crest are also tender to
Friction palpation. Forward bending and backward bending are
very painful. The most severe pain is caused by attempted
lateral bending, which is usually impossible toward the
painful side. If the examiner places his hands on the lower
rib cage in the axillary line and compresses the ribs forcefully,
so that the lower ribs move inside the pelvis, the patient is
able to bend forward, backward and sideways without pain,
or with only minimal discomfort. Infiltration of the tender
iliac crest and lower rib margin with lidocaine also gives
Figure tb marked pain relief.
standing, sitting or lying. It is aggravated by mobility, The differential diagnosis consists of finding which pathology
when changing the position of the body from lying to causes the pain. Radiologically obvious possibilities are
sitting, or to standing and more severe when the patient compression fractures, scoliosis or simply osteoporosis,
bends or twists the spine. which are frequently considered responsible for Jnin. Possible
causes which do not show on x-ray are low back sprains,
DIAGNOSIS which usually cause pain on lateral bending. Finally, there
The diagnosis is easily made by clinical examination, when is the possibility of a lumbar root irritation which can be
one looks for the possibility of ICFS in patients with substantiated by a lumbar MRI. Patients frequently have
 Journal of Orthopaedic Medicine Vol14 1992 No 2 37
Immediate symptomatic relief can be obtained by the use
of a 3" strong elastic belt which compresses the lower ribs
and removes them from contact with the iliac crest3 • We
refer to the strong elastic belt as a 'rib compression belt' to
distinguish it from the 'rib belt' used for stabilisation in rib
fractures.

The rib compression belt (RCB) is a heavy elastic band, 3"

in width with velcro closure. It is made of 1 1/2" wide
elastic pieces which are sewn together with a zig zag
Improved Position attachment. The belt is then 3" wide. A I" wide velcro
of Ribs Original Position strap closure is used in an 8" long piece, which closes and
(away from of Ribs pulls back on itself through a plastic I" buckle (Figure 3).
Iliac Crest) (contact with
Iliac Crest) The RCB is applied immediately above the iliac crest and
adjusted tightly enough to move the ribs away from the
iliac crest. Initially it should be worn day and night. After
a few months, the belt need only be worn for pain producing
activities, or may not be needed at all if permanent
displacement of the lower ribs has occurred.

3 Prolotherapy
In most cases the damage done to the tendons inserting
Figure 2
into the iliac crest and the lower rib margin may
perpetuate the pain. It has been shown that this damage
pain from several causes which all need to be treated. Then can be re~red by injection of small amounts of sclerosing
it is not the differential diagnosis which counts, but the agent at the osseo-tendinous junction4 ·s. Because of the
additional diagnosis of ICFS which needs to be made. In marked proliferation of fibrous tissue, this treatment
cases of tenderness and rib contact at the iliac crest, the rib has been called 'prolotherapy' 6• The simplest medication
compression test should be used to affirm the diagnosis of used for this treatment is hypertonic dextrose ( 12.5% to
ICFS. 25%). Sterile dextrose comes in 50% solution and can
be diluted with lidocaine to the desired concentration.
TREATMENT One half cc of this solution is deposited atl cc intervals
Three therapeutic measures have been used successfully: along the tender area of the iliac crest. The tip of the
needle must be in contact with bone. Six treatments at
1 Surgery weekly or bi-weekly intervals are usually sufficient to
Surgical removal of the twelfth and sometimes also the relieve tenderness in this area. It is best to have the
eleventh rib has bee reported to give permanent relief!. patient lie on one side over a pillow to open up the space
between the iliac crest and rib.
2 Lower Rib Compression
Since the four lowest ribs are attached by flexible PROGNOSIS
cartilage to one another and to the sternum, they can If properly treated the prognosis for this pain syndrome is
easily be pushed to the inside, away from the iliac crest very good. Wynne followed 6 patients for6 months after rib
(Figure 3). resection 1• There was no recurrence of pain.

With our non-surgical treatment, pain relief is instantaneous

after the application of the rib compression belt.

In 6 of our patients, no other treatment was required and the

belt could be discarded after 3-6 weeks without recurrence
of pain. The remainder of the patients required infiltration
of the painful iliac crest with lidocaine and dextrose. Most
of them were able to discard the rib compression belt
permanently after tenderness of the iliac crest was diminished.

Only two patients with severe lumbar rotary scoliosis had

Figure 3 a less favourable response. One was able to discard the
RCB after 6 months, but had to wear it again periodically.
The second patient, who had a very severe rotary scoliosis,
was not entirely free from discomfort, even while wearing
 38 Journal of Orthopaedic Medicine Vol14 1992 No 2

No Date Patient Age Sex Symptoms Spine Pathology Treatment

1 Sep 1978 JP 70 F Low back pain Osteoporosis and RCB

compression fractures
2 Sep 1978 CM 70 M Pain in low back and Osteoporosis and left RCB
lower chest margin lumbar scoliosis
3 Apr 1980 JEH 72 F Right low back pain Osteoporosis and multiple RCB and Hoke Corset
compression fractures
4 Jan 1981 AK 74 F Pain along lower Osteoporosis and RCB and Prolo
chest margin compression fractures
5 Aug 1982 VB 79 F Right hip pain Osteoporosis and L3 RCB and Prolo
compression fracture
6 Aug 1990 BB 78 F Pain in both legs and Osteoporosis RCB
low back pain
7 Sep 1991 SB 38 M Upper and lower back Dorsal kyphosis RCB and Prolo
pain

Table 1
Cases with Bilateral ICFS

No Date Patient Age Sex Symptoms Spine Pathology Treatment

Jul 1977 MK 62 M Pain in anterior right Osteoporosis and severe RCB and Prolo,
thigh left lumbar rotary scoliosis and Hoek Corset
2 Aug 1982 EH 82 F Left hip pain Left lumbar rotary scoliosis Prolo and Hoke Corset
3 Jul 1989 SP 49 F Low back pain Left dorsolumbar scoliosis RCB and Prolo
4 Dec 1989 SE 76 M Left hip and low back Right lumbar rotary RCB and Proto
pain scoliosis
5 Aug 1990 SM 71 M Right low back pain Left lumbar scoliosis RCB
6 Oct1990 EN 72 G Pain in right lower Left lumbar scoliosis RCB
rib cage
7 May 1991 we 72 M Pain in right thigh Osteoporosis RCB and Prolo
8 May 1991 CR 82 M Low back pain Right lumbar scoliosis RCB and Prolo
9 Jull991 MT 60 F Pain in left lower Left lumbar scoliosis RCB and Prolo
10 Aug 1991 EJ 74 F Right low back pain Right rotary lumbar RCB and Prolo
scoliosis
11 Aug 1991 JB 60 F Chronic pain Left lumbar scoliosis RCB
12 Scp 1991 PL 48 M Right low back pain Right lumbar scoliosis RCB and Prolo

RCB -Rib Compression Belt Prolo - Prolotherapy

Table2
Cases with unilateraiiCFS

No Age Sex Symptoms Spine Pathology Height Loss Treatment

1 52 F Constant pain in left loin Osteoporosis 4cm Resection 12th left rib
2 65 F Nagging pain left loin Osteoporosis Scm Resection 12th left rib
3 65 F Back pain radiating to left loin Osteoporosis 6cm Resection 12th left rib
4 35 M Low back pain and bilateral Osteoporosis Scm Resection 11th and 12th
loin pain right and left ribs
5 48 F Bilateral loin pain None 2.5cm Resection right and left
12th ribs
6 58 F Intermittent back and loin pain Osteoporosis 9cm Resection right and left
12th ribs

Tab/e3
Cases reported by AT Wynne, MD
(J of Bone & Joint Surg 67:91 124-125 [1985))
 Journal of Orthopaedic Medicine Vol 14 1992 No 2 39
the RCB. However, he stated that without it he is entirely 2 Riggs BL (1991) Overview of osteoporosis West
unable to move and by wearing the belt he is able to go J Med Jan 154 63-77
about his business. He has not considered surgery. 3 Hirschberg GG, Johnson A et al (1985) Case
report:Use of rib compression belt for pain in
CONCLUSION osteoporosis Orthotics and Prosthetics 39 :2 75-
Because of the multiple complaints of the elderly and the 77
spinal pathology associated with the ICFS, the diagnosis is 4 Liu UK, Tipton CM et al (1983) An in situ study
easily overlooked . These patients are treated unnecessari ly of the influence of a sclerosing solution in rabbit
with NSAIDs, analgesics, narcotics and physical therapy medial collateral ligaments and its junction
and suffer from the side effects of these measures. Awareness strength Connective Tissue Research Vol II 95-
of the existence of the ICFS should lead to routine palpation 102
of the iliac crests in standing posi tion. Detection of the 5 Klein R, DormanT, Johnson C (1989)
ICFS will permit the institution of simple, harmless measures Prolotherapy in back pain J Neurol & Orth Med &
to provide permanent pain relief. Surg 10 123-126
6 Hackett GS, Hemwall GA, Montgomery GA
REFERENCES Ligament and Tendon Relaxation Treated by
1 Wynne AT, Nelson MA, Nordin BEC (1985) Prolotherapy 5th Edition
Costo-iliac impingement syndrome J of Bone & Gustav A Hemwall, MD, Oak Park, Illinois
Joint Surg 678:1 124-125

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