What causes right lateral chest pain when coughing?

Right Lateral Chest Pain When Coughing

Right lateral chest pain triggered by coughing is most commonly caused by musculoskeletal injury to the chest wall, including intercostal muscle strain, costochondritis, or rib fractures, which occur in up to 82.4% of patients presenting with post-tussive chest pain. 1

Primary Musculoskeletal Causes

Rib fractures are the leading documented cause of lateral chest pain with coughing:

• Cough-induced rib fractures occur in approximately 82.4% of patients with post-tussive chest pain 1
• The 10th rib is most frequently affected 1
• Severe coughing fits cause widening of rib spaces, with 44% developing associated fractures 1
• Point-of-care ultrasound detects rib fractures in 29% of cases after negative chest radiography 1

Intercostal muscle strain and hematomas represent another significant mechanism:

• Violent or sustained cough can cause internal oblique muscle hematomas, presenting as acute lateral flank pain 2
• Abdominal wall hematomas can occur even without anticoagulation therapy 2
• These injuries manifest as painful masses in the lateral chest or abdominal wall 2

Underlying Cough Etiologies to Address

The pain is secondary to the cough itself, so identifying the cough cause is essential 1:

For acute cough (<3 weeks):

• Postinfectious cough is most common 3
• Upper respiratory tract infections 3

For chronic cough (>8 weeks):

• Upper airway cough syndrome/postnasal drip syndrome (33.2%) 3
• Asthma (15.8%) 3
• Gastroesophageal reflux disease 3
• Nonasthmatic eosinophilic bronchitis (5.4%) 3
• ACE inhibitor-induced cough (consider if patient takes these medications) 3

Diagnostic Approach

Initial evaluation should focus on:

• Red flags requiring immediate attention: hemoptysis, severe dyspnea, or life-threatening symptoms 3
• Chest radiography is the appropriate initial imaging for chronic cough with chest pain 3
• Radiographic rib series are more sensitive than standard chest X-rays for detecting rib fractures 1
• Point-of-care ultrasound can identify rib fractures missed on plain films 1

Physical examination specifics:

• Palpate the lateral chest wall for point tenderness over ribs or intercostal spaces 1
• Assess for painful masses suggesting hematoma 2
• Evaluate for signs of underlying respiratory disease 3

Management Algorithm

Step 1: Address the underlying cough cause 1

• This is essential to prevent recurrence of musculoskeletal injury 1
• Follow systematic evaluation per CHEST guidelines for cough duration 3
• Consider empiric treatment trials for common causes (postnasal drip, asthma, GERD) 3

Step 2: Manage musculoskeletal pain

• Conservative management without blood transfusion is typically sufficient for hematomas 2
• Pain control with NSAIDs or acetaminophen
• Chest wall support/binding may provide symptomatic relief

Step 3: Follow-up evaluation

• Reassess within 4-6 weeks if cough persists 3
• Use validated cough severity tools to monitor response 3
• Consider CT chest if symptoms persist despite treatment or concerning findings emerge 3

Critical Pitfalls to Avoid

Do not miss serious underlying pathology:

• Pulmonary embolism causes cough in nearly half of cases and can present with lateral chest pain 3
• Pneumothorax or pneumomediastinum from tracheal rupture (rare but reported with severe coughing) 4
• Mediastinal lesions can impinge on airways causing both cough and chest pain 3

Do not overlook medication causes:

• ACE inhibitors cause chronic dry cough in 5-50% of patients depending on ethnicity 5
• Beta-blockers, inhaled medications, and other drugs can trigger cough 3
• Consider therapeutic withdrawal trial if drug-induced cough suspected 3

Do not assume all lateral pain is benign:

• Chronic pain and chronic cough are interrelated conditions that confer risk on each other 6
• Patients with chronic cough frequently report musculoskeletal chest pains as part of the disease burden 3
• Quality of life can be significantly impaired and warrants formal assessment 3