What is the cause of a burning sensation around the ribs in an 18-year-old female with no other symptoms?

Burning Sensation Around Ribs in 18-Year-Old Female

The most likely diagnosis is slipping rib syndrome or costochondritis, both benign musculoskeletal conditions that require only clinical diagnosis and reassurance, though cardiac causes must be briefly excluded given the chest location. 1, 2

Initial Approach: Exclude Life-Threatening Causes First

While musculoskeletal pain is the most common diagnosis in young patients with isolated chest symptoms, you must systematically rule out serious pathology before making a benign diagnosis 3:

• Cardiac causes are extremely unlikely in an 18-year-old female with no other symptoms, no exertional component, and burning quality pain (burning is less typical for cardiac ischemia) 3
• Pulmonary embolism, pneumothorax, and aortic dissection are also highly unlikely without dyspnea, sudden onset, or hemodynamic instability 3
• A focused physical examination looking for reproducible chest wall tenderness, normal vital signs, and absence of respiratory distress is sufficient to exclude emergent causes in this low-risk patient 3

Most Likely Diagnoses

Slipping Rib Syndrome

This is a frequently underdiagnosed condition causing burning pain in the lower chest and upper abdomen, particularly common in middle-aged patients but can occur at any age. 1, 4, 5

• The syndrome results from hypermobility of the lower ribs (8-12) with entrapment of the intercostal nerve, causing characteristic burning pain 1, 4, 6
• Diagnosis is purely clinical using the "hooking maneuver": hook your fingers under the costal margin and pull anteriorly to reproduce the pain 6
• Pain typically worsens with specific movements, breathing, or palpation 1, 5
• No imaging is required for diagnosis - radiographs, CT, and MRI are typically normal 5, 6

Costochondritis

This involves inflammation of the cartilage connecting ribs to the sternum and is another common benign cause. 1

• Presents with localized tenderness over costochondral junctions 1
• Pain reproduced by direct palpation of the affected area 1
• Also a clinical diagnosis requiring no investigation 2

Painful Rib Syndrome

This accounts for 3% of general medical referrals and consists of three features: pain in lower chest/upper abdomen, tender spot on costal margin, and reproduction of pain with pressure. 2

• Predominantly affects women (70% of cases) 2
• This is a safe clinical diagnosis requiring no investigation 2
• Systematic firm palpation of the costal margin is recommended in all patients with lower chest pain 2

Diagnostic Algorithm

1. Perform focused physical examination 3:

   • Palpate the entire costal margin systematically for point tenderness 2
   • Perform hooking maneuver for slipping rib syndrome 6
   • Check if pain is reproduced by palpation, breathing, or movement 1

2. If examination reproduces the pain with chest wall palpation: diagnosis is musculoskeletal, no further testing needed 2

3. If any red flags present (sudden severe onset, hemodynamic instability, respiratory distress): obtain ECG and consider imaging 3

Management

Reassurance is the cornerstone of treatment - explain that this is a benign condition that does not require investigation 2, 5:

• Non-opioid analgesics (NSAIDs, acetaminophen) for pain control 1
• Avoid postures and movements that worsen pain 6
• 70% of patients will have persistent symptoms but learn to live with them 2
• Nerve blocks or surgical intervention reserved only for truly refractory, disabling cases 1, 6

Critical Pitfalls to Avoid

• Do not order extensive investigations - 43% of patients with painful rib syndrome had been investigated extensively before diagnosis, including 8 who underwent unnecessary cholecystectomy 2
• Do not rely on imaging - chest radiographs, CT, and ultrasound are typically normal and unnecessary for musculoskeletal chest wall pain 2, 5, 6
• Despite firm diagnosis, 33% of patients are re-referred by their GP - provide clear documentation and patient education to prevent this 2
• Greater awareness of these syndromes could save both patient and doctor time and unnecessary concern 5