Localized Pain Under Rib Reproduced by Pressure: Causes and Management
Pain under a rib that is reproduced by palpation is most likely musculoskeletal in origin, specifically painful rib syndrome or costochondritis, and should be diagnosed clinically without imaging in most cases. 1, 2
Most Common Causes
Musculoskeletal Etiologies (Primary Consideration)
Painful rib syndrome is the leading diagnosis when pain is reproduced by pressing on a tender spot along the costal margin, accounting for the vast majority of cases in patients without trauma history. 1, 2 This condition:
- Affects ribs 8-10 most commonly and results from hypermobility of the anterior costal cartilage, causing rib tips to slip or sublux under the rib above, impinging intercostal nerves 1
- Presents with pain in the lower chest or upper abdomen, a tender spot on the costal margin, and reproduction of pain when pressing the tender spot 3, 2
- Is more common in women (70% of cases) with mean age of 48 years 2
Costochondritis accounts for approximately 42% of all nontraumatic musculoskeletal chest wall pain and involves inflammation of the costochondral or chondrosternal joints. 1, 4
Other musculoskeletal causes include:
- Tietze syndrome (localized inflammation of ≥1 costochondral junctions) 5, 6
- Slipping rib syndrome (ribs subluxing from their joint connections) 5, 6
- Intercostal myofascial injury (trauma to connective tissues between ribs) 5, 6
- Rib fractures, particularly post-tussive fractures affecting mid to lower ribs 5, 7
Important Cardiac Consideration
While pain reproduced by palpation is NOT characteristic of myocardial ischemia, it does not entirely exclude acute coronary syndrome (ACS). 5 The ACC/AHA guidelines specifically note that 7% of patients whose pain was fully reproduced with palpation were ultimately recognized to have ACS. 5 However, features that make cardiac ischemia unlikely include:
- Pain localized at the tip of one finger, particularly over a costochondral junction 5
- Pain reproduced with movement or palpation of the chest wall 5
- Pleuritic pain (sharp or knifelike pain brought on by respiratory movements) 5
Diagnostic Approach
Clinical Examination (First-Line)
Perform systematic firm palpation of the entire costal margin bilaterally to assess for reproducible tenderness and rib mobility. 1, 2 This clinical diagnosis requires no investigation in most cases. 2
If physical exam is positive for musculoskeletal pain with reproducible tenderness, no imaging is required and treatment can proceed directly. 8
When to Consider Imaging
Chest radiography may be useful as initial imaging only when:
- Evaluating for specific etiologies like rib fracture, infection, or neoplasm 5
- Ruling out conditions that simulate chest wall pain (e.g., spontaneous pneumothorax) 5
- However, chest radiographs are insensitive for costochondral junction abnormalities, detecting fractures in only 4.9% of nontraumatic chest pain cases 5
Dynamic ultrasound should be used when diagnosis is uncertain, as it has 89% sensitivity and 100% specificity for slipping rib syndrome. 1, 8
Rib series radiographs may be helpful for focal chest wall pain to assess for rib fracture, though they result in no significant change in clinical management compared to chest radiographs alone. 5
Cardiac Risk Stratification
Consider ECG and possibly chest radiograph in:
- Patients older than 35 years 4
- Those with history or risk factors for coronary artery disease 4
- Any patient with cardiopulmonary symptoms 4
Management Algorithm
First-Line Treatment
Regular acetaminophen as primary analgesic is the recommended first-line treatment. 1, 8
NSAIDs (1-2 weeks) as second-line for severe pain. 1, 8
Avoid movements or postures that worsen pain. 8
Most Critical Intervention
Provide reassurance that the condition is benign and self-limited—this is the most critical intervention. 1, 3 Explain that the pain is real and can be managed. 3
Follow-Up Considerations
Despite firm diagnosis, 33% of patients may be referred again to hospital by their general practitioner, though all further investigations are typically negative. 2 At 4-year follow-up, 70% still have pain but all except a few have learned to live with it. 2
Common Pitfalls to Avoid
Do not over-investigate. Painful rib syndrome is a safe clinical diagnosis requiring no investigation in typical presentations. 2 In one series, 43% of patients had been investigated extensively before referral, and eight had undergone non-curative cholecystectomy. 2
Do not dismiss the possibility of ACS based solely on reproducible pain. While musculoskeletal pain is most likely, 7% of patients with pain fully reproduced by palpation had ACS. 5
Do not rely on nitroglycerin response to differentiate cardiac from noncardiac pain, as it relieved symptoms in 35% of patients with active CAD versus 41% without active CAD. 5
Do not assume "GI cocktail" response rules out ACS, as relief of chest pain by antacid/lidocaine mixture does not predict absence of ACS. 5