What are the causes of rib pain aside from falls?

Causes of Rib Pain Beyond Falls

Rib pain has numerous non-traumatic causes, with musculoskeletal conditions being most common (particularly costochondritis), followed by gastrointestinal, respiratory, and other systemic etiologies that require systematic evaluation to exclude life-threatening conditions. 1

Musculoskeletal Causes (Most Common)

Costochondritis

• Inflammation of the cartilage connecting ribs to sternum, accounting for approximately 42% of nontraumatic musculoskeletal chest wall pain 1, 2
• Diagnosed primarily by physical examination with reproducible tenderness over costal cartilages 3
• Pain typically worsens with breathing, movement, or direct palpation 2
• Usually self-limited and benign, though can significantly impact quality of life 3

Slipping Rib Syndrome

• Occurs when ribs 8-10 sublux from their joint connections, causing impingement of soft tissue and intercostal nerves 2, 4
• Dynamic ultrasound detects this condition with 89% sensitivity and 100% specificity 5
• The hooking maneuver (pulling anteriorly on the rib margin) reproduces symptoms and confirms diagnosis 4, 6
• Most commonly affects the 10th rib (44.4% of cases), with insidious onset in 72% of patients 6

Other Musculoskeletal Conditions

• Tietze syndrome: localized inflammation of costochondral junctions with visible swelling 2
• Intercostal myofascial injury involving connective tissues between ribs 2
• Muscle strains or spasms, particularly of pectoral muscles 2
• Nerve entrapment, especially the lateral cutaneous branch of the third intercostal nerve 2

Respiratory Causes (Potentially Serious)

Pulmonary Conditions

• Pulmonary embolism, pneumonia, and pneumothorax are less frequent but potentially life-threatening causes 1
• Many patients present with dyspnea in addition to chest pain 1
• Pleurisy (inflammation of pleural lining) causes sharp, breathing-dependent pain 2

Cough-Induced Rib Fractures

• Documented in approximately 82.4% of patients presenting with post-tussive chest pain 5
• The 10th rib is most frequently affected 5
• Standard chest radiographs miss up to 50% of these fractures 5, 2

Gastrointestinal Causes

Esophageal and Gastric Disorders

• Account for 10-20% of chest pain in outpatients presenting with chest discomfort 1, 2
• Gastroesophageal reflux disease is the most common esophageal cause of recurring unexplained chest pain 1
• Pain may be described as squeezing or burning, lasting minutes to hours, often occurring after meals or at night 1
• Esophageal motility disorders (achalasia, distal esophageal spasm, nutcracker esophagus) present with squeezing retrosternal pain often accompanied by dysphagia 1
• Medication-induced esophagitis from NSAIDs, potassium supplements, iron, or bisphosphonates 1

Neoplastic and Infectious Causes

Malignancy

• Primary chest wall neoplasms or skeletal metastases can present as rib pain 1, 5
• Bone scintigraphy has 95% sensitivity for detection of skeletal metastases 5
• CT chest is recommended after normal chest radiograph in patients with known or suspected malignancy 5

Infection

• Chest wall surgical site infections, though relatively uncommon 1
• Osteomyelitis of ribs or sternum 1
• Risk factors include age, malnutrition, diabetes, smoking, obesity, immunosuppression 1

Systemic Inflammatory Conditions

Spondyloarthropathies

• Anterior chest wall pain affects 30-60% of patients with axial spondyloarthritis and may be the first manifestation in 4-6% of cases 1
• Sternoclavicular and manubriosternal joints involved in up to half of patients 1

Psychological Causes

• Usually diagnoses of exclusion but merit consideration in appropriate clinical context 1
• Should be considered when persistent symptoms occur despite negative cardiac and anatomic evaluations 1

Diagnostic Algorithm

Initial Assessment

• Pain characteristics suggesting benign etiology: pain varying with respiration, body position, food intake, well-localized on chest wall, accompanied by local tenderness 5
• Red flags requiring urgent evaluation: symptoms interrupting normal activity, cold sweat, nausea, vomiting, fainting, anxiety/fear 5
• Highest diagnostic value against cardiac angina: pain affected by palpation, breathing, turning, twisting or bending, or pain from multiple sites 5

Imaging Approach

• Chest radiography is the recommended first-line imaging test after clinical assessment 1, 5, 2
• Dedicated rib series for focal chest wall pain detected on physical examination 5
• Radio-opaque skin markers placed on pain site assist in localizing abnormalities 5
• Point-of-care ultrasound detects rib fractures missed by chest radiography in 29% of cases 5
• CT chest reserved for patients requiring pulmonary disease evaluation or high malignancy suspicion 5, 2

When to Pursue Gastrointestinal Workup

• Upper endoscopy indicated for: dysphagia, odynophagia, gastrointestinal bleeding, unexplained iron deficiency anemia, weight loss, recurrent vomiting 1
• Trial of empiric acid suppression therapy reasonable for patients without alarm symptoms 1
• Esophageal function testing and pH monitoring if symptoms persist despite normal endoscopy and acid suppression trial 1

Common Pitfalls to Avoid

• Do not rely solely on chest radiographs—they miss up to 50% of rib fractures and up to 90% of costochondral junction injuries 5, 2
• Do not assume all chest wall pain is benign—coronary artery disease is present in 3-6% of adult patients with chest pain and chest wall tenderness 3
• Patients older than 35 years or those with cardiac risk factors require electrocardiogram and possibly chest radiograph even with reproducible chest wall tenderness 3
• Do not overlook medication history—NSAIDs, potassium supplements, iron, and bisphosphonates can cause esophagitis mimicking rib pain 1