From the Guidelines
For an 88-year-old woman with muscle strain in the right lower rib cage area presenting with movement-dependent pain and negative chest CT, the diagnosis is most likely musculoskeletal in nature, specifically muscle strain. Given the patient's presentation and the negative computed tomography (CT) scan of the chest, which rules out more serious respiratory or cardiac causes, the focus should be on managing the musculoskeletal injury. The differential diagnosis for noncardiac causes of acute chest pain includes musculoskeletal, gastrointestinal, psychological, and other causes, with musculoskeletal causes being the most common, including costochondritis, muscle strain, and potential consequences of recent or occult chest trauma such as rib fracture, as noted in the 2021 guideline for the evaluation and diagnosis of chest pain 1.
Key Considerations
- The patient's age and the fact that the pain is exacerbated by certain movements support a musculoskeletal cause.
- A negative CT scan helps to rule out serious conditions such as pulmonary embolism (PE), pneumonia, and pneumothorax, which are less frequent but potentially more serious respiratory causes of chest pain 1.
- Given the broad differential diagnosis for noncardiac chest pain, including gastrointestinal and psychological causes, a thorough evaluation is necessary, but the patient's presentation points towards a musculoskeletal issue.
Management Approach
- Conservative management is recommended, including rest, ice application for 15-20 minutes every 2-3 hours for the first 48 hours, followed by heat therapy.
- Pain management with acetaminophen 500-1000mg every 6 hours as needed (not exceeding 3000mg daily) is appropriate given her age.
- If pain persists, consider adding a topical NSAID like diclofenac gel 1% applied to the affected area 3-4 times daily.
- Gentle stretching exercises can begin once acute pain subsides.
- The patient should avoid strenuous activities and movements that exacerbate pain.
- Reassessment is warranted if pain persists beyond 2-3 weeks or worsens.
This approach addresses the musculoskeletal injury while minimizing systemic medication exposure in an elderly patient, aligning with the principles outlined in the guideline for the evaluation and diagnosis of chest pain 1, and prioritizes the patient's morbidity, mortality, and quality of life.
From the Research
Diagnosis Considerations
- The patient's symptoms of intermittent sharp pain in the right lower rib cage area due to muscle strain, with certain movements exacerbating the pain, could be indicative of a musculoskeletal issue 2.
- A negative computed tomography (CT) scan of the chest helps to rule out other potential causes of chest pain, such as renal cell carcinoma 3 or other visceral issues.
- The patient's presentation is consistent with slipping rib syndrome (SRS), which is a disorder of the hypermobility of the costal cartilages attached to the floating ribs 4.
- Entrapment syndromes of the intercostal nerve and its branches could also be a possible diagnosis, given the patient's symptoms of pain triggered by certain movements 5.
Differential Diagnosis
- Costochondritis, rib pain caused by stress fractures, chest wall muscle injuries, fibromyalgia, and herpes zoster are other potential musculoskeletal causes of chest pain that should be considered in the differential diagnosis 6.
- Slipping rib syndrome (SRS) and entrapment syndromes of the intercostal nerve and its branches are less common causes of chest pain, but should be considered given the patient's symptoms 4, 5.
Diagnostic Approach
- A thorough history and physical examination are essential in making a diagnosis, and can help to identify the underlying cause of the patient's symptoms 2, 6.
- Imaging studies, such as ultrasound or magnetic resonance imaging (MRI), may be necessary to confirm the diagnosis or rule out other potential causes of chest pain 4, 5.
- Dynamic ultrasound maneuvers can be useful in diagnosing entrapment syndromes of the intercostal nerve and its branches 5.