Chronic “Back” Pain Missed in Elderly – the Costo-Iliac Impingment Syndrome

With the loss of height from osteoporosis in the elderly, the lowermost side ribs can rub on the side wing of the hip crest, resulting in was patients describe as back pain. To make things worse, this rubbing restricts walking, making doctors think it is spinal stenosis. The patient then remains in pain and untreated.

I had an elderly lady in today that was suffering from chronic back pain. I had her sit down sideways on a chair with her back facing me. I then put my index fingers in the lower abdomen and my thumbs by the lower spine and tried to approximate them. This was fine on the right side, but impossible on the left because the ribs disappeared below the iliac crest. In that area was her back pain, and when injected (with local and steroid) the pain was numbed.

This is the third case in recent years I have seen. In each case, they have had to suffer with pain levels of 5-6/10 needlessly

Muscles play a definite role in this disorder, and I had to work the quadratus lumborum and flank muscles over a period of time to relax the muscles enough for the ribs to come out of the pelvis.

There are several names for the syndrome:

Costo-iliac syndrome
Iliocostal Friction syndrome
Costo-iliac impingment syndrome
rib impingement
rib tip syndrome
iliocostal pain
cricket bowler’s side strain.(though some are just crowded ribs)

Examination: – flexion and sidebending to side can aggravate – maybe hear a snapping sound if lucky
Bone scan can demonstrate how periostitis is diffuse so cortisone shot needs to be equally diffuse…

Differential diagnosis –

  • rib impingement of especially 11th rib where ribs are so crowded together they rub on one another
  • Thoracolumbar (TL) syndrome where pain referred from T10-12 hurts at the iliac crest point laterally – usually gluteal muscles are knotted as well. OK here’s the thing – these levels are involved anyway so facet dysfunction at these levels is almost going to be a given – making this now much more difficult to deal with.

A more complete discussion of this TL sydrome can be read in this Canadian Chiropractic article:

Thoracolumbar syndrome as a cause of low-back pain: a report of two cases
Dan Proctor, Pierre Dupuis,J. David Cassidy
The Journal of the CCA/Volume 29 No. 2/June 1985. 71-73
free full article here


  • There will probably be a scoilosis at thoracolumbar junction. Those levels that don’t follow the curve will be tender. I use an activator to thump them in position.
  • The quadratus lumborum and associated flank muslces are very tight and I use various stretch techniques to work them out so the rib is no longer pulled into pelvis. One way is to pinch the area and shake it 120 times.
  • A rib belt worn above the iliac crest is supposedly helpful but I have never got anyone to use one. One article corrected the scoliosis some by “a lumbosacral compression orthosis fitted over an underlying sacroiliac belt placed to widen the right costoiliac distance.”in:
    Gait, T. (2013).
    Iliocostal Friction Syndrome Causing Flank Pain in a Patient with a History of Stroke with Scoliosis and Compensated.
    American Journal of Physical Medicine & Rehabilitation 2013 in pressĀ  abstract herein one study:
    Patel, Shounuck I., et al.
    Iliocostal Friction Syndrome Causing Flank Pain in a Patient with a History of Stroke with Scoliosis and Compensated Trendelenburg Gait.
    American Journal of Physical Medicine & Rehabilitation 93.7 (2014): 632-633.
    they stated “lumbosacral compression orthosis fitted over an underlying sacroiliac belt”…Because this successfully provided pain relief, a custom thermoplast scoliosis brace was prescribed to separate the abutting lower ribs and iliac crest.”
    Came across a vendor recently that sold scoliosis braces:
    scoliosis braceIf anyone has tried something like that? – let us know if it workedone reference:
    suggested “back brace and corset”

    A more simple belt has been found helpful:
    Use of Rib Compression Belt for Pain in Osteoporosis
    Gerald G. Hirschberg et al
    Orthotics and Prosthetics 39(2) 75-79, 1985

    demonstrated no rubbing after:

  • I injection local and kenaolg 40 mg into the sore areas. Those that persist I will use semi-neurolytic 5% lidocaine 7.5% dextrose as nerve blocks. Some anesthetists will use alcohol blocks.
  • The upper iliac crest muscles will be affected if there is a thoracolumbar syndrome and the muscles will need injecting or needling and massaging out repeatedly.
  • Some of the literature cases (cricket ones) required rib removal as a treatment.
  • A Quadratus lumbotum stretch that does not require sidebending would be to just push down on the iliac crest with hands:

  • Myofascial release techniques would be helpful.

I’m sure there is more but the literature is either too old or foreign journals…

Addendum – working on an elderly lady with such:
1) Desensitized rib and ilaic crest margin with steroid shots.
2) Worked out Quadratus lumborum and associated muscles
3) Now pain was more in upper gluteal wing and was able to find thoracolumbar was sore (did not complain about it) – activator to TL area and injected/massaged out gluteal triggers.
4) TL better; still some upper gluteal but more pain the should have – Now what?? – well I missed the piriformis which is a friend of the Quadatrus lumborum. I thought I had checked it before; suspect it was a minor issue compared to what else she had. Have started the stretch/massage technique as per a recent article:
How Should One Investigate Chronic Back Pain and What about the Back Muscles?

She felt much better since – is amazing how many facets a problem can involve. I always expected the psoas to be a big one but haven’t noticed it yet…

addendum – a good discussion of adult scoliosis available here:


anyone else have ideas or comments?

Harbinger makes a narrow belt: – can get at Flaman in Regina

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6 Responses to Chronic “Back” Pain Missed in Elderly – the Costo-Iliac Impingment Syndrome

  1. You are right, but this is not only in the elderly and cricketers. I have been treating this condition for over 20 years and it is present to some degree in almost every patient who suffers from back pain, hip pain and sciatica. see article I published in Journal of Complementery Medicine.

  2. admin says:

    Dr. Chin has published an excellent article contending much of low back pain could have an impingment component. You can read full article here:

    He gives 4 suggestions for avoiding flares of impingment:

    1 Airbag Technique: by breathing in slowly and holding their breath, the patient can avoid ilio-costal impingement when sitting, standing, walking and when changing postures such as getting out of a chair, dressing or undressing
    2 avoid lateral and forward bending at the waist and pulling the knees up higher than the hips when sitting. Forward bending at the hips is permitted
    3 sit on dining chairs, office chairs or Swiss balls and avoid seats or recliners that are too low or have lost support
    4 avoid lying in bed but walk around in the house, progressing to the back yard while performing the Airbag Technique.

    Thank you Dr. Chin.


  3. maria molenaar says:

    I have this costo iliac sydrome but my GP will only prescribe painrelievers, but
    does not believe in surgery? Is there any info about rib resection so far?

  4. Dr Marcia Schofield says:

    Interesting article. have just seen a patient with this after thoracotomy. The left hemi thorax is “sagging” a bit and she has costoiliac impingment on that side, relieved by side bending. The pictures were very helpful in explaining the problem to the patient; who has gone off very relieved- she has been investigated up to the eyeballs (probably by people who did not observe her standing) and given a diagnosis of irritable bowel! patient not keen on injection, so we will try TNS

  5. GH says:

    Peak Scoliosis Bracing System Testimonial Video

  6. Bobby Cummins says:

    I was prescribed with Costco Illiac Syndrome by Dr Todd of TOA in Murfreesboro,TN. He prescribed rehab by physical therapy and I had 9 sessions. I was completely cured. It had been so painful for me that I had decided that I might become completely crippled. I now have no symptoms at all.

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