What are the recommended treatments for rib pain after coughing?

Rib Pain After Coughing: Diagnostic and Treatment Approach

Initial Clinical Assessment

For patients presenting with rib pain after coughing, the most likely diagnosis is a cough-induced rib fracture, which occurs in approximately 82.4% of patients with post-tussive chest pain, most commonly affecting the 10th rib. 1, 2

Key Diagnostic Features to Elicit

• Pain characteristics suggesting musculoskeletal origin: Pain that varies with respiration, body position, is well-localized on the chest wall, and accompanied by local tenderness 1
• Red flags requiring urgent evaluation: Symptoms interrupting normal activity, cold sweats, nausea, vomiting, fainting, or severe anxiety 1
• Features arguing against cardiac causes: Pain affected by palpation, breathing, turning, twisting or bending, or pain generated from multiple sites 1

Underlying Cough Etiology

• Consider pertussis infection if cough has lasted >2 weeks with paroxysms, post-tussive vomiting, or inspiratory whooping sound 3
• Post-infectious cough should be suspected when cough persists 3-8 weeks following acute respiratory infection 3
• Chronic smokers are at increased risk for cough-induced rib fractures due to increased cough frequency and severity 2, 4

Diagnostic Imaging Strategy

First-Line Imaging

Obtain chest radiography as the initial imaging test to evaluate for rib fracture and rule out complications like pneumothorax or hemothorax. 1

• Standard chest X-rays miss up to 50% of rib fractures but detect critical complications 1
• Place radio-opaque skin markers on the site of maximal pain to help radiologists localize abnormalities 1

When Initial Imaging is Negative

If clinical suspicion remains high after negative chest radiography, obtain dedicated rib series radiographs, which are more sensitive than standard chest films for detecting cough-induced rib fractures. 1, 2

• Point-of-care ultrasound can detect rib fractures missed on chest X-ray, identifying fractures in 29% of cases with negative radiography 1, 2
• Reserve chest CT for patients requiring evaluation of other pulmonary diseases or when malignancy is suspected 1, 2

Treatment Algorithm

Analgesic Management (First-Line)

Initiate regular scheduled acetaminophen as first-line treatment for rib fracture pain. 1

1. Acetaminophen: Regular administration (not as-needed) for baseline pain control 1
2. NSAIDs: Use as second-line for severe pain, weighing potential adverse events 1
3. Low-dose ketamine: Consider 0.3 mg/kg IV over 15 minutes as an alternative to opioids for severe refractory pain 1

Adjunctive Non-Pharmacological Measures

Apply immobilization, dressings, or cold compresses in conjunction with pharmacological therapy to reduce pain. 1

Treating the Underlying Cough

Addressing the underlying cause of cough is essential to prevent recurrence of rib fractures. 2

For Post-Infectious Cough (Not Bacterial)

• Antibiotics have no role in post-infectious cough management 3
• Inhaled ipratropium bromide: Consider as first-line cough suppressant 3
• Inhaled corticosteroids: Use when cough adversely affects quality of life and persists despite ipratropium 3
• Oral prednisone 30-40 mg daily: Reserve for severe paroxysmal cough after ruling out other causes (asthma, reflux, upper airway cough syndrome), tapering over 2-3 weeks 3
• Central antitussives (dextromethorphan, codeine): Consider when other measures fail, though dextromethorphan at 60 mg has better efficacy with fewer side effects than codeine 3

For Confirmed or Suspected Pertussis

• Obtain nasopharyngeal culture for definitive diagnosis 3
• Initiate appropriate antimicrobial therapy per CDC guidelines if diagnosed early in infection course 3

Expected Recovery Timeline

• Rib fractures typically heal within 6-8 weeks 1
• Complete recovery may take up to 2 years in patients with multiple or displaced fractures 1

Surgical Considerations

Surgical fixation should be considered for patients with unstable chest walls (flail chest), severe refractory pain, or chest wall deformity. 1

Critical Pitfalls to Avoid

• Do not rely solely on chest radiographs for excluding rib fractures, as they miss up to 50% of cases 1
• Do not prescribe antibiotics for post-infectious cough unless bacterial sinusitis or early pertussis is confirmed 3
• Do not overlook pertussis in adults with prolonged cough, as it accounts for 8-26% of adults with acute cough lasting ≥5 days 5
• Do not ignore the need to address underlying cough to prevent recurrent fractures 2