What can cause back pain, lower anterior rib pain, and occasional chest pain?

Back Pain with Lower Anterior Rib Pain and Occasional Chest Pain

Immediate Priority: Rule Out Life-Threatening Conditions First

Before considering musculoskeletal causes, you must systematically exclude cardiac, vascular, and pulmonary emergencies that can present with this symptom pattern. 1, 2, 3

Critical Red Flags Requiring Emergency Evaluation

Perform an ECG within 10 minutes if any of the following are present 1, 3, 4:

• Cardiac: Retrosternal pressure radiating to left arm/jaw/neck, diaphoresis, nausea, dyspnea, or pain building gradually over minutes 1, 4
• Aortic dissection: Sudden "ripping" or "tearing" pain radiating to back, pulse differentials between extremities, or blood pressure difference >20 mmHg between arms 1, 2, 4
• Pulmonary embolism: Acute dyspnea with pleuritic chest pain, tachycardia >100 bpm, or tachypnea 2, 3, 4
• Pericarditis: Sharp pain worsening when lying supine and improving when leaning forward, with potential friction rub 3, 4

High-Risk Populations Requiring Lower Threshold for Cardiac Workup

Do not dismiss cardiac causes in 1, 2, 4:

• Women (frequently present with atypical symptoms)
• Patients >75 years (may have isolated dyspnea or confusion)
• Diabetic patients (atypical presentations of cardiac ischemia)
• Those with known cardiovascular disease or risk factors

Most Likely Musculoskeletal Causes

Costochondritis

This is the most common cause of nontraumatic musculoskeletal chest wall pain, accounting for 42% of cases. 1, 5

Key diagnostic features 1, 6, 5:

• Tenderness on palpation of costochondral or chondrosternal joints
• Pain reproducible with chest wall pressure
• Typically affects multiple ribs (commonly ribs 2-5)
• May radiate to back
• Usually self-limited, resolving in weeks

Coronary artery disease is present in 3-6% of adult patients with chest pain and chest wall tenderness, so cardiac evaluation is still warranted in patients >35 years or those with cardiac risk factors. 5

Inflammatory Spondyloarthritis

Anterior chest wall pain affects 30-60% of patients with axial spondyloarthritis and may be the first manifestation in 4-6% of cases. 1

Specific features 1:

• Sternoclavicular and manubriosternal joint involvement in up to 50% of patients
• Chronic symptoms lasting >6 months in 55% of cases
• MRI shows bone marrow edema, erosions, and fat infiltration with 62.5% sensitivity
• Often delayed diagnosis for many years

Other Musculoskeletal Causes

Additional considerations 1, 7, 8:

• Rib stress fractures: History of repetitive activity or overuse
• Slipping rib syndrome: Lower ribs (8-10) with hypermobility
• Fibromyalgia: Widespread pain with tender points
• Referred pain from thoracic spine: Facet joint or disc pathology

Diagnostic Approach

Initial Clinical Assessment

Obtain specific details 1, 4:

• Pain quality: Stinging (53%), pressing (35%), sharp, or dull
• Location: Retrosternal (52%), left-sided (69%), or bilateral
• Frequency: More than once daily in 63% of musculoskeletal cases
• Duration: Chronic (>6 months) in 55% of cases
• Reproducibility: Pain with palpation or specific movements

Physical Examination Findings

Palpate all costochondral junctions, sternoclavicular joints, and thoracic spine for focal tenderness. 1, 5, 7

Check for 1, 4:

• Chest wall tenderness reproduction
• Pulse differentials (aortic dissection)
• Blood pressure differentials >20 mmHg (aortic dissection)
• Friction rub (pericarditis)
• Unilateral decreased breath sounds (pneumothorax)

Imaging Strategy

For patients with reproducible chest wall tenderness and low cardiac risk, imaging is often unnecessary. 1, 5

When imaging is indicated 1:

• Chest radiograph: First-line to exclude pulmonary causes and widened mediastinum
• MRI chest: Most effective for detecting infectious/inflammatory disorders of chest wall soft tissues and osseous structures, with high negative predictive value 1
• CT chest: Useful for defining extent of osseous involvement when MRI unavailable
• Bone scintigraphy: Shows focal abnormalities in 49% of patients with atypical chest pain, including posttraumatic lesions (43%), costochondritis (5%), and neoplastic lesions (2%) 1

Treatment Approach

For Confirmed Musculoskeletal Pain

Standard management 5, 8:

• Acetaminophen or NSAIDs (where safe and appropriate)
• Avoid activities producing chest muscle overuse
• Reassurance about benign nature

For Atypical or Persistent Costochondritis

Consider osteopathic manipulation techniques and instrument-assisted soft tissue mobilization if pain persists beyond typical 2-week self-limited course. 6, 8

Critical Pitfalls to Avoid

• Do not use nitroglycerin response as diagnostic criterion - esophageal spasm and other non-cardiac conditions also respond 3, 4
• Do not rely solely on normal ECG - occurs in 1-6% of acute coronary syndrome patients 1
• Do not dismiss pain lasting only seconds - unlikely to be cardiac 4
• Reconsider diagnosis if pain fails to improve - investigate for obscure pathologies including skeletal tuberculosis in endemic areas 9