What is the approach to diagnosing and managing rib pain?

Approach to Rib Pain

Start with a focused clinical assessment looking for specific red flags, followed by chest radiography as your first-line imaging—not to catch every fracture, but to rule out life-threatening complications like pneumothorax or hemothorax. 1

Clinical Assessment: What to Look For

Features Suggesting Benign Musculoskeletal Pain

• Pain that varies with respiration, body position, or food intake 2
• Well-localized tenderness on the chest wall 2
• Pain affected by palpation, breathing, turning, twisting, or bending 2
• Pain generated from multiple sites on examination 2

Red Flags Requiring Immediate Imaging

• Pain interrupting normal activity 2, 3
• Symptoms accompanied by cold sweat, nausea, vomiting, or fainting 2, 3
• Respiratory symptoms or difficulty breathing 3
• Age >60 years (each rib fracture increases pneumonia risk by 27% and mortality by 19%) 1, 3
• Multiple points of tenderness suggesting multiple fractures 3
• Patients on long-term steroids or with suspected malignancy 3

Diagnostic Algorithm

Step 1: Standard Chest Radiography (PA View)

This is your initial imaging test for all patients with rib pain. 1, 2

• Detects critical complications: pneumothorax, hemothorax, flail chest, pulmonary contusion 1
• Will miss up to 50% of rib fractures, but this doesn't alter management in uncomplicated cases 1, 2
• In one study of 271 patients with minor trauma, treatment didn't differ between those with and without radiographically confirmed fractures 1

Key pitfall: Don't order dedicated rib series radiographs—they rarely change management (only 0.23% of cases in one study) and delay care. 1

Step 2: Targeted Imaging Based on Clinical Scenario

For focal chest wall pain with negative chest X-ray:

• Point-of-care ultrasound is your next step 2, 4
• Detects 29% of rib fractures missed on chest radiography 1
• Identifies costochondral fractures in 68.8% of radiographically occult cases 1
• For slipping rib syndrome: dynamic ultrasound has 89% sensitivity and 100% specificity 1, 5

For suspected malignancy or pathologic fracture:

• CT chest without contrast 2, 3
• Bone scintigraphy has 95% sensitivity for skeletal metastases 1, 2
• Consider skeletal tuberculosis in patients from endemic areas with persistent pain despite treatment 6

Never order MRI for isolated costochondral pain—there's no evidence supporting its use and it represents inappropriate resource utilization. 4

Step 3: Specific Diagnoses to Consider

Post-tussive rib fractures:

• Occur in 82.4% of patients with post-tussive chest pain 1
• Most commonly affect the 10th rib 1
• Rib series may show widening of rib spaces even without visible fractures 1

Painful rib syndrome:

• Triad: lower chest/upper abdominal pain + tender spot on costal margin + pain reproduction with palpation 7
• Accounts for 3% of general medicine referrals 7
• Clinical diagnosis requiring no investigation 7
• Systematic firm palpation of the costal margin is essential 7

Slipping rib syndrome:

• Pain at lower anterior rib cage (ribs 8-10) with upper-extremity activities, coughing, or leaning over 5
• Diagnose with dynamic ultrasound or the hooking maneuver 5

Pain Management Algorithm

First-Line: Acetaminophen

• Regular scheduled dosing, not as-needed 1, 2
• Oral and IV formulations are equivalent for efficacy 1

Second-Line: NSAIDs

• For severe pain uncontrolled by acetaminophen 1, 2
• Consider adverse event profile, especially in elderly 1

Third-Line: Low-Dose Ketamine

• 0.3 mg/kg IV over 15 minutes 1, 2
• Comparable efficacy to morphine with fewer cardiovascular events 1
• Higher rates of psycho-perceptual side effects but no life-threatening events 1

Regional Anesthesia for High-Risk Patients

Consider for patients with:

• Age >60, SpO2 <90%, obesity/malnutrition 1
• ≥2-3 rib fractures, flail segment, pulmonary contusion 1
• Smokers or chronic respiratory disease 1
• Anticoagulated patients or major trauma 1

Options include:

• Thoracic epidural or paravertebral blocks (gold standard but risk of hypotension and motor block) 1
• Erector spinae plane block or serratus anterior plane block (newer, safer alternatives) 1

Non-Pharmacological Measures

• Immobilization, cold compresses 2
• Osteopathic manipulation for rib dysfunction and costochondritis 8
• Physical therapy and stretching for myofascial pain 8

Surgical Considerations

• Flail chest with unstable chest wall 2
• Severe refractory pain or chest wall deformity 2
• Slipping rib syndrome refractory to conservative management 5

Expected Recovery and Follow-Up

• Typical healing time: 6-8 weeks 2
• Complete recovery may take up to 2 years for severe injuries 2
• Only 59% of patients return to work at 6 months 9
• If pain persists beyond expected timeframe, reconsider diagnosis and investigate for tuberculosis, malignancy, or other pathology 6

Critical pitfall: 33% of patients with painful rib syndrome are re-referred despite firm diagnosis—educate patients and primary care providers that this is a benign, self-limiting condition requiring no further investigation. 7