What causes pain between the 8th and 9th false ribs?

Pain Between Ribs 8 and 9: Causes and Evaluation

Pain between the 8th and 9th false ribs is most commonly caused by musculoskeletal conditions, particularly slipping rib syndrome, costochondritis, intercostal muscle strain, or rib fractures, though gastrointestinal and pulmonary causes must also be considered. 1

Most Common Musculoskeletal Causes

Slipping rib syndrome is the leading diagnosis to consider for pain in this specific location, as ribs 8-10 (the false ribs) are most susceptible to hypermobility and subluxation from their cartilaginous attachments. 2, 3 This condition occurs when the costal cartilage slips, causing the rib to displace beneath the adjacent superior rib, resulting in intercostal nerve impingement and sharp, localized pain. 4

• Clinical presentation: Sudden onset pain with jerking motions, often reproduced by specific movements or positions, and relieved by postures that offload the impinged nerve. 4
• Diagnostic maneuver: The "hooking maneuver" (pulling the anterior costal margin anteriorly and superiorly) reproduces the pain and is highly specific for slipping rib syndrome. 5, 6
• Imaging: Dynamic ultrasound is the most useful diagnostic tool, detecting slipping rib syndrome in 89% of cases and ruling it out in 100% of negative cases. 2

Costochondritis and intercostal muscle injury are also common causes of lateral rib pain in this region, characterized by inflammation of the costochondral junction or damage to connective tissues between ribs. 1

• Physical examination: Systematic firm palpation of the costal margin reproduces localized tenderness at the affected rib junction. 5
• Key distinction: Unlike slipping rib syndrome, costochondritis typically lacks the mechanical clicking or popping sensation and is not reproduced by the hooking maneuver. 1

Traumatic Causes

Rib fractures affecting ribs 8-9 are common, as the middle and lower ribs (ribs 3-8) are most frequently fractured and critical for respiratory mechanics. 1

• Presentation: Localized pain that worsens with breathing, movement, or direct palpation, often with a history of trauma (though occult fractures can occur). 1
• Imaging pitfall: Standard chest radiography misses up to 50% of rib fractures; ultrasound is the preferred initial imaging modality for suspected costochondral junction injuries. 1
• Management priority: Adequate pain control is essential to prevent respiratory complications including atelectasis and pneumonia. 1

Non-Cardiac Chest Pain Differential

After excluding life-threatening cardiac causes (which should be considered first in appropriate clinical contexts), the differential for pain in this region includes: 7

Gastrointestinal causes account for 10-20% of chest pain in outpatients and include: 7

• Gastroesophageal reflux disease (most common esophageal cause)
• Esophageal dysmotility disorders
• Gastritis from medications (NSAIDs, potassium supplements, iron, bisphosphonates)

Pulmonary causes are less frequent but potentially serious: 7

• Pulmonary embolism
• Pneumonia
• Pneumothorax
• Pleurisy (inflammation of pleural lining causing sharp chest pain) 1

Nerve entrapment, particularly of the lateral cutaneous branch of intercostal nerves, can cause burning or sharp pain in the lateral rib region. 1

Diagnostic Algorithm

1. Perform focused physical examination looking for:

   • Reproducible chest wall tenderness with palpation of ribs 8-9 5
   • Positive hooking maneuver (suggests slipping rib syndrome) 4, 6
   • Localized tenderness at costochondral junction (suggests costochondritis) 1
   • Pain worsening with deep breathing or movement (suggests fracture or pleurisy) 1

2. If musculoskeletal cause suspected and hooking maneuver positive:

   • Consider dynamic ultrasound to confirm slipping rib syndrome 2
   • Trial of intercostal nerve block provides both diagnostic confirmation and therapeutic relief 4, 6

3. If trauma history or severe localized pain:

   • Obtain ultrasound (preferred) or rib series radiographs to evaluate for fracture 1
   • Avoid relying solely on chest X-ray, which misses up to 50% of rib fractures 1

4. If persistent symptoms despite negative musculoskeletal evaluation:

   • Evaluate for gastrointestinal causes with trial of empiric acid suppression therapy 7
   • Consider upper endoscopy if alarm symptoms present (dysphagia, weight loss, bleeding) 7
   • Evaluate for pulmonary causes if dyspnea present 7

Management Approach

For slipping rib syndrome:

• Initial treatment: Rest, ice, NSAIDs for symptomatic relief 4
• Intercostal nerve block with local anesthetics and steroids provides diagnostic confirmation and pain relief 4, 6
• Definitive treatment: Surgical fixation (minimally invasive sutured rib fixation without cartilage excision shows 75-80% pain improvement at 1-6 months) 3

For costochondritis/muscle strain:

• Non-opioid analgesics (NSAIDs, acetaminophen) as first-line therapy 1
• Avoid movements and postures that worsen pain 1

For rib fractures:

• Aggressive pain control with non-opioid analgesics first-line, opioids for severe pain based on fracture displacement and number 1
• Monitor for respiratory complications, especially in elderly patients (≥65 years) or those with multiple fractures 1

Critical Pitfalls to Avoid

• Do not rely solely on chest radiographs for diagnosing rib fractures or costochondral injuries, as they miss up to 50-90% of these injuries. 1
• Do not dismiss the diagnosis as "non-specific chest pain" without performing the hooking maneuver, as slipping rib syndrome is underdiagnosed and causes prolonged suffering when missed. 5, 4
• Do not underestimate the importance of adequate pain control in rib injuries, as inadequate analgesia leads to splinting, hypoventilation, and respiratory complications. 1
• Do not overlook gastrointestinal causes in patients with recurrent pain and negative cardiac/pulmonary workup, as 10-20% of chest pain is gastrointestinal in origin. 7