What are the causes and treatments of left rib pain?

Left Rib Pain: Causes and Management

Initial Diagnostic Approach

After thorough history and physical examination, chest radiography is the most useful initial imaging test to evaluate left rib pain, though it may miss abnormalities of rib cartilages, costochondral junctions, and chest wall soft tissues. 1

Key Clinical Features to Elicit

• Painful rib syndrome presents with three specific features: pain in the lower chest or upper abdomen, a tender spot on the costal margin, and reproduction of pain when pressing the tender spot 2
• Slipping rib syndrome is confirmed by a positive hooking maneuver, where pulling the anterior edge of the lower ribs (8-12) reproduces the pain 3
• Assess for trauma history, recent cough, or prior thoracic surgery, as these increase likelihood of rib fracture or iatrogenic causes 1, 4
• Determine if pain is reproducible with palpation versus deep/visceral in nature, as musculoskeletal causes should be tender to direct pressure 2

Common Causes of Left Rib Pain

Musculoskeletal Causes (Most Common)

• Costochondritis affects the costochondral junctions and is often a diagnosis of exclusion after cardiac causes are ruled out 5
• Painful rib syndrome accounts for 3% of new referrals to general medical clinics and is more common in women (70% of cases) 2
• Slipping rib syndrome results from hypermobility of floating ribs (8-12) that are not connected to the sternum 3
• Rib fractures from cough or occult trauma may be detected in only 4.9% of cases on standard chest radiography 1
• Muscle strain and consequences of chest trauma are common but often underdiagnosed 1

Other Potential Causes

• Bone metastases, osteomyelitis, osteonecrosis, and arthritis can present with chest wall pain 1
• Mediastinal fat necrosis may be identified on chest CT 1
• Spontaneous pneumothorax can simulate chest wall pain 1
• Gastrointestinal causes (esophageal reflux, gastritis) should be considered if musculoskeletal examination is negative 1

Imaging Strategy

First-Line Imaging

• Chest radiography is appropriate as initial imaging after history and physical examination to evaluate for rib fracture, infection, neoplasm, or pneumothorax 1
• Standard rib views with radio-opaque skin markers placed at the site of pain can assist in localizing abnormalities 1
• Critical limitation: Chest radiographs are insensitive for detecting abnormalities of rib cartilages, costochondral junctions, costovertebral joints, and chest wall soft tissues 1

Advanced Imaging (When Indicated)

• CT chest has superior sensitivity for detection and characterization of chest wall abnormalities but should be reserved for patients with clinical risk factors like trauma, infection, or malignancy 1
• Unfolded rib reformatted images on CT improve diagnostic accuracy for rib fractures and decrease reading time 1
• Bone scintigraphy showed focal abnormalities in 49.4% of patients with atypical chest pain, with 42.7% being posttraumatic lesions and 4.9% costochondritis, but 15.3% of abnormalities were irrelevant to the true cause of pain 1
• MRI chest may be complementary to characterize various processes and delineate extent of chest wall or osseous involvement on a case-by-case basis 1
• FDG-PET/CT has no role as initial imaging in patients without history of malignancy 1

Treatment Approach

Musculoskeletal Pain Management

• For painful rib syndrome: The most critical intervention is explaining the benign nature of the condition and providing reassurance that the pain is real and manageable 6
• In a 4-year follow-up study, 70% of patients still had pain, but all except three had learned to live with it; no further investigations revealed significant pathology 2
• For atypical costochondritis: Multimodal treatment including rib manipulation, instrument-assisted soft tissue mobilization (IASTM), and stretching can achieve complete resolution 5
• Physical therapy with osteopathic manipulation techniques (OMT) is useful for rib dysfunction, especially in atypical costochondritis 5

Slipping Rib Syndrome Management

• Reassurance and avoiding postures that worsen pain are usually helpful 3
• In refractory cases, nerve block and surgical intervention may be required 3
• Dynamic flow ultrasound can confirm the diagnosis by showing slipping of the lowest rib over the next lowest rib 3

When to Escalate Care

• Persistent or recurring symptoms despite negative stress test or anatomic cardiac evaluation warrant evaluation for noncardiac causes 1
• If upper endoscopy is normal and symptoms persist despite acid suppression trial, consider esophageal function testing and pH monitoring 1
• Symptoms meriting early evaluation (within 2 weeks) include dysphagia, odynophagia, gastrointestinal bleeding, unexplained iron deficiency anemia, weight loss, and recurrent vomiting 1

Critical Pitfalls to Avoid

• Do not over-investigate: Painful rib syndrome is a safe clinical diagnosis requiring no investigation; 43% of patients in one series had been investigated extensively before referral, and eight had undergone non-curative cholecystectomy 2
• Do not dismiss the pain: Despite firm diagnosis, 33% of patients were referred again to hospital, highlighting the need for clear communication about the benign but real nature of the condition 2
• Do not use CT as first-line in the absence of clinical risk factors like trauma, infection, or malignancy 1
• Systematic firm palpation of the costal margin is recommended in all patients presenting with pain in the lower chest or upper abdomen to identify painful rib syndrome 2