What are the causes of right rib pain?

Causes of Right Rib Pain

Right rib pain is most commonly caused by musculoskeletal conditions, particularly costochondritis, rib fractures (traumatic or cough-induced), and intercostal muscle strain, though serious cardiopulmonary and gastrointestinal causes must be systematically excluded. 1, 2

Musculoskeletal Causes (Most Common)

Costochondritis accounts for approximately 42% of nontraumatic chest wall pain and involves inflammation of the cartilage connecting ribs to the sternum. 1 This condition is typically diagnosed by physical examination showing reproducible tenderness at the costochondral junctions without need for imaging. 1

Rib fractures represent the most common serious chest injury, occurring in up to 40% of trauma patients, with the middle and lower ribs (ribs 3-8) most frequently affected. 3 Importantly:

• Cough-induced rib fractures occur in approximately 82.4% of patients presenting with post-tussive chest pain, with the 10th rib most commonly involved. 2
• Standard chest radiographs miss up to 50% of rib fractures, so negative imaging does not exclude fracture. 2

Tietze syndrome involves localized inflammation of one or more costochondral junctions, distinguished from costochondritis by visible swelling at the affected joint. 1

Slipping rib syndrome occurs when ribs sublux from their joint connections, causing sharp pain that may be reproduced with specific movements. 1, 3 Dynamic ultrasound can detect this with 89% sensitivity and 100% specificity. 2

Intercostal myofascial injury and muscle strains affect the connective tissues and muscles between ribs, often related to overuse or repetitive movements. 1, 3

Pulmonary Causes (Potentially Serious)

Pleurisy causes sharp, stabbing pain that worsens with breathing due to inflammation of the pleural lining. 3

Pneumothorax presents with sudden-onset chest pain and dyspnea, requiring urgent evaluation. 1, 3

Pulmonary embolism is a life-threatening condition that typically presents with chest pain, dyspnea, and hemodynamic instability. 1, 3

Pneumonia can cause chest wall pain accompanied by fever, cough, and respiratory symptoms. 1

Gastrointestinal Causes

Gastrointestinal disorders account for 10-20% of chest pain in outpatients. 1 Right-sided rib pain may result from:

• Gastroesophageal reflux disease (GERD) causing referred pain to the chest wall. 1, 3
• Esophageal dysmotility or other esophageal disorders. 1
• Hepatobiliary pathology (gallbladder disease, liver pathology) causing right upper quadrant pain radiating to the ribs. 1

Neurological Causes

Nerve entrapment, particularly of the lateral cutaneous branch of intercostal nerves, can cause burning or sharp pain along the rib distribution. 3

Herpes zoster (shingles) presents with burning pain in a dermatomal distribution, often preceding the characteristic rash. 4

Infectious/Inflammatory Causes

Osteomyelitis of the ribs or sternum, though uncommon, can occur particularly in immunocompromised patients or those with recent chest surgery. 1

Skeletal tuberculosis should be considered in patients from endemic areas with persistent rib pain unresponsive to standard treatment. 5

Neoplastic Causes

Metastatic disease to the ribs can present as localized bone pain, particularly in patients with known malignancy. 1 Bone scintigraphy has 95% sensitivity for detecting skeletal metastases. 2

Primary chest wall neoplasms are rare but should be considered with persistent, progressive pain. 1

Diagnostic Approach

Initial evaluation should focus on identifying red flags that suggest serious pathology versus benign musculoskeletal causes. 2

Pain characteristics suggesting benign conditions include:

• Pain that varies with respiration, body position, or food intake. 2
• Well-localized pain on the chest wall with reproducible tenderness on palpation. 2
• Pain affected by breathing, turning, twisting, or bending. 2

Red flags suggesting serious conditions include:

• Symptoms interrupting normal activity. 2
• Associated cold sweats, nausea, vomiting, or syncope. 2
• Dysphagia, odynophagia, gastrointestinal bleeding, or unexplained weight loss. 1

Imaging recommendations:

• Chest radiography is the appropriate first-line imaging test after clinical assessment. 1, 2
• Dedicated rib series may be helpful for focal chest wall pain detected on examination. 2
• Point-of-care ultrasound can detect rib fractures missed on radiography in 29% of cases. 2
• CT chest should be reserved for patients requiring evaluation of pulmonary disease or when malignancy is suspected. 1, 2

Common Pitfalls

Do not rely solely on chest radiographs for excluding rib fractures, as they miss up to 50% of fractures and up to 90% of costochondral junction injuries. 2, 3

Do not dismiss persistent pain as purely musculoskeletal without reconsidering the diagnosis if symptoms fail to improve with standard treatment. 5

Do not overlook associated injuries with lower rib fractures, particularly potential abdominal organ injuries. 3