What is the diagnosis and treatment for a patient with dull discomfort and heaviness in the right lower rib area, both front and back, that worsens with sitting, breathing, eating, or drinking, and is reproducible when full?

Diagnosis: Likely Musculoskeletal Chest Wall Pain (Costochondritis or Slipping Rib Syndrome)

Based on your symptom pattern—dull discomfort and heaviness in the right lower rib area that worsens with sitting, breathing, and eating/drinking—this is most consistent with benign musculoskeletal chest wall pain rather than cardiac ischemia.

Why This Is NOT Cardiac

Your symptoms have several reassuring features that argue strongly against cardiac ischemia:

• Pain varies with respiration, body position, and food intake - these are classic indicators of a less severe, non-cardiac condition 1
• Reproducible with specific movements - cardiac pain does not typically reproduce with palpation or positional changes 1
• Localized to a specific rib area - cardiac ischemia rarely localizes to such a limited area 1
• Heaviness that worsens when full from eating/drinking - this mechanical exacerbation pattern is inconsistent with angina 1

The European Heart Journal guidelines explicitly state that pain which varies with respiration, body position, and food intake indicates a less severe, non-cardiac condition 1.

Most Likely Diagnoses

Slipping Rib Syndrome (Most Probable)

• Affects ribs 8-12 (floating ribs not connected to sternum), which matches your right lower rib location 2
• Classic presentation: sharp or dull pain in lower chest/subcostal region that waxes and wanes, aggravated by specific movements and postures 2
• Worsens with trunk rotation, lateral flexion, and rising from sitting - consistent with your positional worsening 3
• More common in women (3:1 ratio) 3
• Diagnosis is clinical: perform the "hooking maneuver" - hook fingers under the lower rib margin and pull anteriorly; positive if this reproduces your exact pain 2

Costochondritis (Alternative)

• Self-limiting inflammation of rib cartilage, typically manifesting as non-cardiac chest pain 4
• Focal tenderness along the anterolateral rib cage 4
• When symptoms persist beyond several weeks, termed "atypical costochondritis" 4

Twelfth Rib Syndrome (If Involving Lowest Rib)

• Constant dull ache or sharp stabbing pain lasting hours to weeks 3
• Aggravated by lateral flexion, trunk rotation, and rising from sitting 3
• Diagnosis requires: exact reproduction of pain with manipulation of the affected rib 3

Immediate Action Steps

1. Perform hooking maneuver yourself: Place fingers under your right lower rib margin and pull forward/upward - if this reproduces your exact pain, slipping rib syndrome is confirmed 2

2. Check for focal tenderness: Press along the affected rib - point tenderness suggests costochondritis or rib dysfunction 4

3. Avoid positions that worsen pain: Limit trunk rotation, lateral bending, and prolonged sitting 2, 3

When to Seek Immediate Medical Attention

Despite the benign nature suggested by your symptoms, seek emergency evaluation if you develop:

• Sudden onset of severe, ripping chest pain (suggests aortic dissection) 1
• Pain accompanied by cold sweats, nausea, vomiting, or fainting (cardiac warning signs) 1
• Pain that interrupts normal activities 1
• Shortness of breath at rest 1

Recommended Treatment Approach

Conservative Management (First-Line)

• Reassurance and activity modification: Avoid postures/movements that worsen pain 2
• NSAIDs: For anti-inflammatory effect in costochondritis 4
• Physical therapy with manual techniques: Rib manipulation and soft tissue mobilization can provide complete resolution in atypical costochondritis 4

If Conservative Treatment Fails After 4-6 Weeks

• Intercostal nerve block: Deep analgesic infiltration at the end of the free cartilage for slipping rib syndrome 5
• Dynamic ultrasound: Can visualize slipping of the lowest rib over the adjacent rib 2
• Surgical intervention: Reserved for refractory cases only 2

Important Pitfalls to Avoid

• Don't over-investigate: Imaging (CT, MRI, X-rays) is typically normal and unnecessary if clinical diagnosis is clear 2
• Don't assume all chest pain needs cardiac workup: Your symptom pattern clearly indicates musculoskeletal origin 1
• Don't ignore persistent symptoms: If pain continues beyond 2-3 months despite conservative treatment, consider skeletal tuberculosis if you have risk factors (travel to endemic areas, immunosuppression) 6
• Don't confuse with diaphragmatic pathology: While right hemidiaphragm elevation can cause discomfort, it wouldn't be reproducible with position changes or eating 7

The key distinguishing feature is reproducibility with specific movements and positions—this virtually excludes cardiac ischemia and points to a mechanical, musculoskeletal cause that responds well to conservative treatment.