What are the potential causes and treatment options for right lateral lower rib pain in a patient with an unknown medical history and no previous trauma or injuries?

Right Lateral Lower Rib Pain: Diagnostic and Management Approach

Primary Diagnosis to Consider

The most likely diagnosis for right lateral lower rib pain without trauma is painful rib syndrome (also called slipping rib syndrome), which is a common but frequently missed musculoskeletal condition that can be diagnosed clinically without imaging. 1, 2

Clinical Diagnosis

Perform the hooking maneuver immediately - place your fingers under the lower costal margin and pull anteriorly to reproduce the pain, which confirms the diagnosis. 1 Look for these specific features:

• Pain location: Lower chest or upper abdomen along the costal margin 2
• Tender spot: Focal tenderness on palpation of the costal margin, particularly at the end of the lowest floating rib 3
• Pain reproduction: Pressing the tender spot recreates the patient's exact pain 2
• Movement dependency: Pain worsens with specific movements, turning, twisting, or bending 4, 3

This accounts for 3% of general medical referrals and affects 70% women with mean age 48 years. 2

When Imaging is NOT Needed

If the hooking maneuver is positive and pain is reproduced by palpation, no imaging is required - this is a safe clinical diagnosis. 2 The painful rib syndrome is characterized by hypermobility of floating ribs (8-12) that are not connected to the sternum. 1

Red Flags Requiring Immediate CT Imaging

Order contrast-enhanced CT abdomen/pelvis immediately if any of these are present:

• Severe, acute onset pain that interrupts normal activity 4
• Associated systemic symptoms: fever, nausea, vomiting, cold sweats 4
• Abdominal rigidity or peritoneal signs on examination 5
• Pain NOT reproducible by palpation or negative hooking maneuver 4

CT achieves 95% sensitivity and 94% specificity for serious pathology including appendicitis, and identifies alternative diagnoses in 94.3% of cases. 4, 5

Differential Diagnoses to Exclude

Beyond musculoskeletal causes, consider:

• Intra-abdominal pathology: Right colonic diverticulitis, appendicitis (though typically more anterior), hepatobiliary disease 5
• Diaphragmatic hernia: Can present with respiratory and GI symptoms, though chest X-ray is typically abnormal 4
• Costochondritis: Similar presentation but involves costochondral junctions rather than floating ribs 6

Treatment for Confirmed Painful Rib Syndrome

Provide reassurance and specific postural advice - this is the primary treatment:

• Explain the benign nature and that 70% still have intermittent pain at 4 years but learn to live with it 2
• Avoid postures that worsen pain: bending, twisting, reaching overhead 1, 3
• Conservative management: NSAIDs for pain relief 1
• Physical therapy: Consider osteopathic manipulation, rib mobilization, and soft tissue techniques for refractory cases 6
• Nerve block or surgical intervention: Reserved only for truly refractory cases after conservative measures fail 1

Critical Pitfalls to Avoid

• Do not order extensive imaging for typical painful rib syndrome - 43% of patients in one series underwent unnecessary investigations including cholecystectomy before diagnosis 2
• Do not dismiss the diagnosis even if symptoms persist - 33% of patients were re-referred despite firm diagnosis, with all further investigations negative 2
• Do not assume cardiac etiology - pain affected by palpation, breathing, or body position argues strongly against angina 4
• Consider iatrogenic causes - previous thoracic surgery or chest tube placement can cause slipping rib syndrome 7