What are the potential causes of acute onset rib pain in a young adult female without a history of injury?

Acute Onset Rib Pain in a 19-Year-Old Female Without Injury

Most Likely Diagnosis

In a 19-year-old female with acute onset rib pain and no trauma history, costochondritis is the most probable diagnosis, followed by slipping rib syndrome and painful rib syndrome as the primary differential considerations. 1, 2

Systematic Diagnostic Approach

Initial Clinical Assessment

Perform focused palpation of the costal margin and costosternal junctions to identify a tender spot that reproduces the patient's pain. 1, 3

Key examination findings to elicit:

• Pain characteristics: Well-localized chest wall pain that varies with respiration, body position, or trunk movement strongly suggests a benign musculoskeletal cause rather than cardiac or visceral pathology 1
• Hooking maneuver: Hook fingers under the lower costal margin and pull anteriorly—reproduction of pain indicates slipping rib syndrome with 89% sensitivity and 100% specificity 1, 4
• Focal tenderness: Systematic firm palpation of each costochondral junction and costal margin; reproduction of pain with palpation is diagnostic for painful rib syndrome 3
• Movement provocation: Pain worsened by lateral flexion, trunk rotation, or rising from sitting suggests twelfth rib syndrome 5

Red Flags to Exclude

While cardiac causes are extremely unlikely in this demographic, immediately assess for symptoms that interrupt normal activity, cold sweats, nausea, vomiting, or anxiety/fear, which would necessitate cardiac evaluation. 1, 6

Initial Imaging

Obtain a standard chest radiograph as the first-line imaging test to exclude pneumothorax, infection, or neoplasm, though recognize that up to 50% of rib fractures may be missed. 1, 7

• Place radio-opaque skin markers on the site of maximal tenderness to help radiologists localize abnormalities 1
• Standard chest X-ray is sufficient for initial evaluation; dedicated rib series is only indicated if focal chest wall pathology is strongly suspected on examination 1

Most Common Specific Diagnoses

Costochondritis (Most Likely)

Costochondritis presents as focal tenderness at costosternal junctions (most commonly 2nd-5th ribs) with pain reproduced by direct palpation. 2, 8

• This is a clinical diagnosis of exclusion requiring normal ECG, laboratory values, and imaging 2
• Self-limiting in typical cases, resolving within 2-3 weeks 2
• More common in women (70% of cases) 3

Slipping Rib Syndrome (Second Most Common)

Slipping rib syndrome affects the floating ribs (8th-12th) due to hypermobility, with pain in the lower chest or upper abdomen that worsens with specific movements. 4, 1

• Positive hooking maneuver is pathognomonic 4, 1
• Dynamic ultrasound can confirm diagnosis if clinical examination is equivocal (89% sensitivity, 100% specificity) 1
• More common in women (3:1 ratio) 4

Painful Rib Syndrome

Painful rib syndrome consists of three features: pain in lower chest/upper abdomen, tender spot on costal margin, and reproduction of pain with pressure on the tender spot. 3

• Accounts for 3% of general medical/gastroenterology referrals 3
• Predominantly affects women (70%) with mean age 48 years, though can occur in younger patients 3

Twelfth Rib Syndrome

Twelfth rib syndrome presents as constant dull ache or sharp stabbing pain aggravated by lateral flexion, trunk rotation, and rising from sitting. 5

• More common in women (3:1 ratio) 5
• Diagnosis requires exact reproduction of symptoms with manipulation of the affected rib 5

Cough-Induced Rib Fracture

If the patient has recent history of severe or prolonged coughing, consider cough-induced rib fracture, which occurs in 82.4% of patients with post-tussive chest pain. 1

• The 10th rib is most frequently affected 1
• Standard chest X-rays miss up to 50% of rib fractures 1
• Point-of-care ultrasound detects 29% of rib fractures missed on chest radiography 1

Management Algorithm

First-Line Treatment

Initiate regular acetaminophen as first-line analgesic therapy. 1

• NSAIDs can be added as second-line for severe pain, weighing potential adverse effects 1
• Immobilization, cold compresses, and activity modification reduce pain when combined with pharmacological therapy 1

Refractory Cases

For costochondritis not resolving within 2-3 weeks (atypical costochondritis), consider osteopathic manipulation techniques and instrument-assisted soft tissue mobilization. 2

• Address posterior rib hypomobility, costovertebral joints, and thoracic spine mobility 8
• Regional interdependence should be evaluated—cervical and thoracic spine examination is essential 8

For slipping rib syndrome with refractory pain, nerve block or surgical intervention may be required. 4

Critical Pitfalls to Avoid

• Do not order extensive cardiac or gastrointestinal workup when clinical examination clearly reproduces musculoskeletal pain 3—33% of patients with painful rib syndrome are re-referred for unnecessary investigations despite firm diagnosis 3
• Do not rely solely on chest radiographs to exclude rib fracture—they miss up to 50% of fractures 1
• Do not diagnose costochondritis without systematic palpation of all costochondral junctions and costal margins—this is a clinical diagnosis requiring reproduction of pain 3
• Do not overlook examination of lateral ribs, costovertebral joints, and thoracic spine—posterior hypomobility often perpetuates anterior chest wall pain 8