What is the best course of treatment for costal (rib) pain?

Treatment of Costal (Rib) Pain

For nontraumatic costal pain, begin with chest radiography after history and physical examination to rule out serious pathology, then treat most cases conservatively with NSAIDs or acetaminophen combined with heat therapy, avoiding opioids as first-line treatment. 1, 2

Initial Diagnostic Approach

Clinical Diagnosis

• Most nontraumatic rib pain (42%) is costochondritis, which can be diagnosed clinically without imaging through identification of reproducible tenderness at the costochondral junction 1
• The painful rib syndrome presents with three key features: pain in lower chest/upper abdomen, a tender spot on the costal margin, and reproduction of pain with palpation of that spot 3
• For slipping rib syndrome, look for unilateral chest pain worsened by activity, often with a popping or clicking sensation, and a mobile rib on palpation 4

Initial Imaging Strategy

• Chest radiography is the appropriate first imaging test to evaluate for rib fractures, infection, neoplasm, or conditions mimicking chest wall pain like pneumothorax 1
• However, chest radiographs detect rib fractures in only 4.9% of nontraumatic cases and have limited sensitivity for cartilage, costochondral junction, and soft tissue abnormalities 1
• Dedicated rib series radiography adds minimal clinical value - while more sensitive than chest X-rays for fractures, detection rarely changes management 1
• Reserve CT chest for patients with suspected malignancy, infection, or when pulmonary disease evaluation is needed - it should not be first-line for uncomplicated chest wall pain 1
• Point-of-care ultrasound can detect radiographically occult rib and costochondral fractures (68.8% detection rate) and is particularly useful for diagnosing slipping rib syndrome (89% sensitivity) 1

First-Line Treatment Algorithm

Day 1: Immediate Initiation

• Start oral NSAIDs (or topical NSAIDs) as first-line pharmacologic treatment 2
• Add acetaminophen 650 mg every 4-6 hours (maximum 4g/day) if NSAIDs alone are insufficient 2
• Begin heat therapy immediately 2
• Initiate gentle exercise and activity as tolerated 2

Week 1: If Inadequate Response

• Consider adding a muscle relaxant to the NSAID regimen 2
• Consider manual therapy/spinal manipulation 2
• For costochondritis specifically, osteopathic manipulation techniques (OMT) including rib manipulation and instrument-assisted soft tissue mobilization (IASTM) may provide complete symptom resolution 5

Weeks 2-8: Persistent Symptoms

• Consider short-term corticosteroid therapy 2
• Evaluate for radiculopathy requiring nerve blocks if symptoms suggest nerve involvement 2
• Only consider opioids if severe pain persists AND NSAIDs are contraindicated or ineffective 2

Opioid Prescribing (When Unavoidable)

Opioids should be avoided as first-line therapy because nonopioid therapies are equally effective with lower risk 2

If opioids must be prescribed:

• Use immediate-release formulations only 2
• Prescribe as-needed dosing, not scheduled 2
• Limit duration to expected duration of severe pain 2
• Check prescription drug monitoring program (PDMP) database before prescribing 2
• Be aware that prescribing opioids for acute musculoskeletal pain increases risk of long-term use (adjusted OR 2.08-6.14 depending on dose) 2

Surgical Intervention

For slipping rib syndrome with persistent symptoms despite conservative management, costal cartilage excision is highly effective 4

• Consider early surgical referral to avoid unnecessary diagnostic testing and prolonged disability 4
• Median time from symptom onset to surgery in one series was 2 years, suggesting many patients suffer unnecessarily 4
• All resected cartilages show gross abnormalities, and most patients achieve symptom resolution 4

Critical Pitfalls to Avoid

• Do not perform extensive cardiac or gastrointestinal workup before considering musculoskeletal causes - 8 patients in one series underwent unnecessary cholecystectomy before correct diagnosis 3
• Do not order bone scans, PET/CT, or MRI as initial imaging - these have no role in initial evaluation of nontraumatic chest wall pain without suspected malignancy 1
• Avoid prescribing opioids or tramadol for acute musculoskeletal rib pain - this is explicitly recommended against by the American College of Physicians and American Academy of Family Physicians 2
• Recognize that 70% of patients with painful rib syndrome have persistent symptoms at 4-year follow-up, but most learn to live with it; reassurance about the benign nature is therapeutic 3, 6