What are the potential causes and treatments for sharp left-sided rib pain?

Sharp Left-Sided Rib Pain: Differential Diagnosis and Management

Sharp left-sided rib pain requires systematic exclusion of life-threatening cardiac, pulmonary, and vascular causes before considering musculoskeletal or gastrointestinal etiologies. 1, 2

Initial Assessment: Rule Out Life-Threatening Causes

Before attributing rib pain to benign causes, you must systematically exclude:

• Acute coronary syndrome (ACS): Obtain ECG and cardiac biomarkers immediately if any concern exists 1, 2
• Pulmonary embolism: Consider in patients with dyspnea, tachycardia, or risk factors 1
• Aortic dissection: Sudden onset "ripping" pain radiating to the back is the classic presentation 1, 2
• Pneumothorax: Sharp pleuritic pain with dyspnea, particularly after trauma 1, 3
• Esophageal rupture: Severe pain after vomiting or instrumentation 1

Key clinical decision point: If the patient has diaphoresis, tachycardia, hypotension, or radiation of pain to the jaw/arm, treat as ACS until proven otherwise 2. A focused cardiovascular examination and ECG should be performed initially 1.

Common Causes of Left-Sided Rib Pain

Traumatic Rib Fracture

• Most common thoracic injury, present in 10% of all traumatic injuries 1
• Typically affects ribs 5-9; lower ribs (8-12) are more mobile and may deflect before fracturing 1
• Chest radiograph should be the initial diagnostic test in combination with physical examination, though it may miss 50% of rib fractures 1
• CT scan is more sensitive but failure to detect fractures on chest X-ray does not necessarily alter management in uncomplicated cases 1
• The chest radiograph's primary value is detecting complications (pneumothorax, hemothorax, pulmonary contusion) rather than the fracture itself 1

Management approach: Treatment focuses on pain control and avoiding respiratory complications; isolated rib fractures have relatively low morbidity and mortality 1, 3. Aggressive multimodal analgesia is critical to prevent splinting, shallow breathing, and subsequent atelectasis 3.

Slipping Rib Syndrome

• Caused by hypermobility of floating ribs (8-12) which are not connected to the sternum but attached to each other with ligaments 4
• Presents as sharp pain in the lower chest and subcostal region, waxing and waning, aggravated by specific movements 4, 5
• Diagnosis is primarily clinical using the "hooking maneuver": Place fingers under the lower costal margin and pull anteriorly to reproduce the pain 4, 5
• Accounts for 3% of new referrals to gastroenterology clinics but remains underdiagnosed 5
• Dynamic ultrasound can confirm diagnosis by showing slipping of the lowest rib over the next lowest rib 4

Common pitfall: Patients are often extensively investigated (including unnecessary cholecystectomies in 11% of cases) before correct diagnosis 5. This is a safe clinical diagnosis requiring no investigation beyond physical examination 5.

Management: Reassurance and avoiding postures that worsen pain are usually sufficient; in refractory cases, nerve blocks or surgical intervention may be required 4, 6.

Costochondritis

• Self-limiting inflammation of costochondral junctions, typically resolving in weeks 7
• Diagnosis of exclusion after ruling out serious cardiac causes 7
• Physical examination reveals focal tenderness over affected costochondral junctions 7
• Atypical costochondritis persists beyond typical timeframe and may respond to osteopathic manipulation techniques and soft tissue mobilization 7

Diaphragmatic Hernia (Traumatic or Congenital)

• Left-sided hernias are more common (50-80% after blunt trauma) due to protective effect of the liver on the right side 1
• Can present with nonspecific respiratory and gastrointestinal symptoms; severe symptoms occur in 46% of cases 1
• CT scan is the gold standard with sensitivity of 14-82% and specificity of 87% 1
• Chest X-ray findings include abnormal bowel gas pattern, air-fluid level in chest, or hemidiaphragm elevation, but can be normal in 11-62% of cases 1

Lung Cancer

• Pleuritic chest pain suggests pleural invasion 1
• Extension into chest wall causes localized, severe pain and may cause rib destruction 1
• Any persistent chest pain in smokers with COPD warrants investigation, even with normal chest radiograph 1

Diverticulitis (Referred Pain)

• While typically causing left lower quadrant pain, severe diverticulitis can cause referred pain to the lower left chest 1
• Classic triad: left lower quadrant pain, fever, and leukocytosis 1
• CT with contrast is the preferred diagnostic test when diverticulitis is suspected 1

Diagnostic Algorithm

1. Immediate assessment: Vital signs, focused cardiovascular examination, ECG if any cardiac concern 1, 2
2. History: Trauma history, onset (sudden vs. gradual), aggravating factors (movement, breathing, position), associated symptoms (dyspnea, fever, cough) 1
3. Physical examination:
   • Palpate entire rib cage for tenderness and crepitus 1
   • Perform hooking maneuver for slipping rib syndrome 4, 5
   • Assess costochondral junctions for focal tenderness 7
4. Imaging:
   • Chest X-ray first for trauma or suspected pneumothorax/hemothorax 1
   • CT chest if concern for diaphragmatic hernia, lung pathology, or complications 1
   • Consider ultrasound for slipping rib syndrome if diagnosis uncertain 4

Treatment Priorities

For traumatic rib fractures: Aggressive multimodal analgesia to prevent respiratory complications, pulmonary hygiene with chest physiotherapy, and serial monitoring for complications 3. Hospital admission for 48-72 hours is recommended if pneumothorax is present 3.

For musculoskeletal causes (slipping rib syndrome, costochondritis): Reassurance, activity modification, NSAIDs, and physical therapy; nerve blocks or manipulation techniques for refractory cases 4, 5, 7.

Critical caveat: In women presenting with chest pain, there is risk for underdiagnosis of cardiac causes; obtain history emphasizing accompanying symptoms more common in women with ACS 1. In patients ≥75 years, consider ACS when accompanying symptoms like shortness of breath, syncope, or acute delirium are present 1.