What is the treatment for rib pain?

Treatment of Rib Pain

Start with scheduled acetaminophen every 6 hours as first-line treatment, add NSAIDs like ibuprofen or ketorolac for inadequate pain control, and combine with non-pharmacological measures including ice application and breathing exercises. 1, 2

Initial Clinical Assessment

Before initiating treatment, determine if the rib pain represents a benign condition or requires urgent evaluation:

Reassuring features that suggest musculoskeletal origin include:

• Pain that varies with respiration, body position, or food intake 1
• Well-localized tenderness on the chest wall 1
• Pain reproduced by palpation, breathing, turning, twisting, or bending 1

Red flags requiring immediate evaluation:

• Symptoms interrupting normal activity with cold sweats, nausea, vomiting, or fainting 1
• Sudden worsening of chest pain, increasing shortness of breath, or fever 2
• Age >60 years, oxygen saturation <90%, or anticoagulation therapy 2, 3

Pharmacological Management Algorithm

First-Line: Acetaminophen

• Administer acetaminophen 1000 mg every 6 hours on a scheduled basis (not as-needed dosing) 1, 2
• Oral formulations are equally effective as intravenous for pain control 2
• Scheduled dosing provides superior pain control compared to PRN administration 2

Second-Line: NSAIDs

When acetaminophen alone provides insufficient relief:

• Add ibuprofen 400 mg every 4-6 hours (maximum 3200 mg/day, though doses above 400 mg show no additional benefit for acute pain) 4
• Alternatively, use ketorolac 60 mg IM initially for severe pain (maximum 120 mg/day for patients 17-64 years) 3

Critical contraindications to avoid:

• Aspirin/NSAID-induced asthma 1, 3
• Active peptic ulcer disease or GI bleeding 4
• Pregnancy or cerebrovascular hemorrhage 3
• Severe renal impairment 1

Third-Line: Ketamine (Opioid Alternative)

• Low-dose ketamine 0.3 mg/kg IV over 15 minutes provides analgesia comparable to morphine but with more psycho-perceptual side effects 1, 2
• Consider for severe pain when NSAIDs are contraindicated or ineffective 1

Non-Pharmacological Interventions

Implement these measures alongside medications:

• Apply ice or cold compresses to the painful area for 15-20 minutes several times daily 1, 2
• Encourage deep breathing exercises and incentive spirometry to prevent atelectasis 5
• Gentle mobilization and avoiding prolonged immobilization 1

Advanced Interventional Options

For refractory pain despite multimodal therapy:

Regional anesthesia techniques (considered gold standard for severe cases):

• Thoracic epidural blocks 3
• Paravertebral nerve blocks 3
• Ultrasound-guided intercostal nerve blocks 6

Manual manipulation techniques may benefit specific mechanical rib dysfunctions, particularly in painful rib syndrome or slipping rib syndrome 6

Diagnostic Imaging Considerations

Chest radiography is the initial imaging test to exclude fractures, pneumothorax, or other serious pathology 1

Important caveats:

• Standard chest X-rays miss up to 50% of rib fractures, but treatment remains unchanged 1, 2
• Dedicated rib series or point-of-care ultrasound can detect fractures missed on chest X-ray 1
• CT chest should be reserved for suspected malignancy or when pulmonary disease evaluation is needed 1

Special Clinical Scenarios

Painful Rib Syndrome (Musculoskeletal)

This benign condition presents with:

• Pain in lower chest or upper abdomen with tender spot on costal margin 7
• Pain reproduced by pressing the tender spot 7
• No investigation required beyond clinical diagnosis 7
• Reassurance about the benign nature is the most critical intervention 8, 7

Twelfth Rib Syndrome

• Conservative treatment with heat/ice, rest, and oral analgesics as first-line 9
• Intercostal nerve blocks for persistent symptoms 9
• Surgical rib resection for refractory cases 9

Rib Fractures

Risk stratification determines intensity of management:

• Multiple fractures (≥3), flail chest, or displaced fractures require aggressive pain control 2, 3
• Surgical stabilization should be considered within 48-72 hours for unstable chest wall or severe displacement 2
• Healing typically occurs within 6-8 weeks, though complete recovery may take up to 2 years 2

Follow-Up and Monitoring

Schedule follow-up within 1-2 weeks for all patients with rib pain 2

Arrange earlier follow-up (3-5 days) if:

• Age >60 years 2
• Chronic lung disease or smoking history 2
• Three or more rib fractures 2
• Taking anticoagulation 2

Refer to physical therapy if pain persists beyond 4-6 weeks 2

Common Pitfalls to Avoid

• Relying solely on chest radiographs when clinical suspicion for fracture is high (50% false-negative rate) 1, 2
• Using PRN dosing instead of scheduled acetaminophen 2
• Failing to identify high-risk patients who need aggressive multimodal analgesia 2
• Ordering extensive imaging for painful rib syndrome, which is a clinical diagnosis 7
• Underestimating morbidity in elderly patients, where each rib fracture increases pneumonia risk by 27% and mortality by 19% 5