What to do when a patient presents with rib pain?

Management of Rib Pain

For patients presenting with rib pain, a thorough clinical assessment followed by appropriate imaging is recommended, with chest radiography as the initial imaging test to evaluate for specific etiologies such as fracture, infection, or neoplasm. 1

Initial Assessment

• Pain characteristics that suggest a less severe condition include: pain that varies with respiration, body position, food intake, is well localized on the chest wall, and/or is accompanied by local tenderness 1
• Indicators of potentially serious conditions include: symptoms that interrupt normal activity or are accompanied by cold sweat, nausea, vomiting, fainting, or anxiety/fear 1
• The highest diagnostic information against the presence of cardiac angina is: pain affected by palpation, breathing, turning, twisting or bending, or pain generated from multiple sites 1

Diagnostic Approach

Initial Imaging

• After clinical assessment, chest radiography is the recommended first-line imaging test to evaluate for specific etiologies of rib pain and to rule out conditions that may simulate chest wall pain, such as spontaneous pneumothorax 1
• Standard chest radiographs may miss up to 50% of rib fractures but can detect important complications like pneumothorax or hemothorax 2

Secondary Imaging

• For focal chest wall pain detected on physical examination, a dedicated radiographic rib series may be helpful to assess for rib fracture or other rib lesions 1
• Radio-opaque skin markers placed on the site of pain can assist radiologists in localizing abnormalities 1
• Point-of-care ultrasound has shown utility in detecting rib fractures in emergency settings, with 29% of cases showing rib fractures after negative chest radiography 1, 3
• CT chest should be reserved for patients who require evaluation of other pulmonary diseases or when there is high suspicion for malignancy 1, 3

Common Causes of Rib Pain

Cough-Induced Rib Fractures

• Cough-induced rib fractures are documented in approximately 82.4% of patients who present with post-tussive chest pain, with the 10th rib being the most frequently affected 3
• Severe coughing fits can cause widening of rib spaces, with approximately 44% of patients developing associated rib fractures 3

Costochondritis

• Costochondritis is a self-limiting, benign condition that manifests as non-cardiac chest pain 4
• Diagnosis is typically made by exclusion after ruling out serious causes of chest pain 4
• Atypical costochondritis that does not self-resolve is associated with high medical expenses and psychological burden 4

Slipping Rib Syndrome

• Characterized by hypermobility of the floating ribs (8 to 12) which are not connected to the sternum 5
• Diagnosis is primarily clinical, with the "hooking maneuver" being a simple test to reproduce pain 5
• Dynamic ultrasound can detect slipping rib syndrome with high accuracy (89% sensitivity, 100% specificity) 1

Management Approaches

Analgesic Management

• For rib fractures, the American College of Emergency Physicians recommends regular administration of acetaminophen as first-line treatment 2
• NSAIDs can be used as second-line treatment for patients with severe pain, considering potential adverse events 2
• Low-dose ketamine (0.3 mg/kg over 15 minutes) can be used as an alternative to opioids for severe pain 2

Non-Pharmacological Measures

• Immobilization, application of dressings, or cold compresses in conjunction with pharmacological therapy can help reduce pain 2
• Manual manipulation techniques have shown effectiveness for rib-related pain, especially in cases of mechanical displacement 6, 4
• For slipping rib syndrome, reassurance and avoiding postures that worsen pain are usually helpful; in refractory cases, nerve block and surgical intervention may be required 5

Surgical Considerations

• Surgical fixation should be considered for patients with unstable chest walls (flail chest) 2
• Surgical intervention may also be appropriate for patients with severe refractory pain or chest wall deformity 2

Special Considerations

• In patients with known or suspected malignancy, additional imaging with CT chest is recommended after a normal chest radiograph 1
• Bone scintigraphy has 95% sensitivity for detection of skeletal metastases and may be useful in characterizing primary chest wall neoplasms 1
• Consider tuberculosis in patients with persistent rib pain and risk factors or recent travel to endemic areas 7
• Rib fractures typically heal within 6-8 weeks, but complete recovery may take up to 2 years in some patients, especially those with multiple or displaced fractures 2

Pitfalls to Avoid

• Failing to reconsider the diagnosis when a patient's pain persists despite appropriate initial management 7
• Overlooking serious underlying conditions such as malignancy or tuberculosis in patients with persistent symptoms 7
• Relying solely on chest radiographs for diagnosis, as they may miss up to 50% of rib fractures 2
• Neglecting the psychological impact of chronic rib pain, which can lead to significant disability and reduced quality of life 8