What is the most likely cause and recommended management for persistent right upper abdominal pain under the ribs (both anteriorly and posteriorly) with normal laboratory studies, normal functional testing, and a normal MRI with and without contrast?

Musculoskeletal Chest Wall Pain (Slipping Rib Syndrome or Intercostal Neuralgia)

With completely normal labs, normal functional testing, and normal MRI with contrast, your patient most likely has a musculoskeletal cause of pain—specifically slipping rib syndrome or anterior cutaneous nerve entrapment syndrome—which can be diagnosed at the bedside with physical examination and does not require further imaging. 1, 2, 3

Why This Is Not Biliary or Visceral Disease

• Normal MRI with and without contrast effectively rules out all significant hepatobiliary pathology, including gallbladder disease, bile duct obstruction, liver masses, and pancreatic inflammation 4
• The American College of Radiology confirms that MRI with MRCP provides 85-100% sensitivity and 90% specificity for detecting choledocholithiasis and biliary obstruction—your patient's normal study excludes these diagnoses 4
• Normal laboratory studies exclude acute cholecystitis, cholangitis, hepatitis, and other inflammatory or obstructive biliary conditions 4
• When both advanced imaging (MRI/MRCP) and labs are normal, continuing to pursue visceral causes leads to unnecessary testing, radiation exposure, and often non-curative surgeries 1

Physical Examination Maneuvers to Confirm Diagnosis

Perform these specific bedside tests:

• Hooking maneuver: Hook your fingers under the costal margin and pull anteriorly—reproduction of the patient's exact pain confirms slipping rib syndrome 3
• Point tenderness test: Palpate systematically along the entire costal margin with firm pressure—a discrete tender spot that reproduces the patient's pain indicates painful rib syndrome 1
• Carnett's sign: Have the patient tense their abdominal muscles (lift head/shoulders off table) while you press on the tender area—pain that increases (rather than decreases) with muscle tensing confirms an abdominal wall source rather than visceral pathology 2

These physical findings have been validated in multiple case series, with the painful rib syndrome accounting for 3% of general gastroenterology referrals and slipping rib syndrome being a common but underdiagnosed cause of chronic upper abdominal pain 1, 3

Pathophysiology

• Slipping rib syndrome results from hypermobility of the floating ribs (ribs 8-12), which are not connected to the sternum but attached to each other with ligaments that can become lax 3
• The lower ribs can slip over adjacent ribs during movement, causing sharp pain in the lower chest and upper abdomen 3
• Anterior cutaneous nerve entrapment occurs when intercostal nerves are impinged as they penetrate the abdominal wall, mimicking visceral pain 2
• Both conditions cause pain that is sharp, waxing and waning, aggravated by specific movements, and localized to the lower chest/subcostal region 3

Recommended Management Algorithm

Initial conservative therapy (first-line):

• Reassurance that this is a benign condition requiring no further imaging 1
• Avoid postures and movements that worsen pain 3
• NSAIDs or acetaminophen for analgesia 3
• Physical therapy focused on core strengthening and posture correction 3

For refractory cases (if conservative therapy fails after 4-8 weeks):

• Local anesthetic injection (lidocaine or bupivacaine) at the point of maximal tenderness—both diagnostic and therapeutic 2
• Corticosteroid injection combined with local anesthetic for longer-lasting relief 2
• Surgical resection of the affected rib cartilage in severe, treatment-resistant cases 3

Critical Clinical Pitfalls to Avoid

• Do not repeat imaging studies—ultrasound, CT, and additional MRI add no diagnostic value after your comprehensive negative workup and expose patients to unnecessary radiation and cost 4, 1
• Do not refer for HIDA scan—hepatobiliary scintigraphy is indicated only when there is clinical suspicion of biliary dyskinesia or acalculous cholecystitis, which your normal labs and MRI exclude 5
• Do not refer for ERCP—this invasive procedure carries risks of pancreatitis (3-5%), bleeding (2%), and cholangitis (1%), and is inappropriate without evidence of biliary obstruction on non-invasive imaging 4
• Recognize that 33% of patients with painful rib syndrome are re-referred to specialists despite a firm diagnosis, leading to years of fruitless testing and even non-curative cholecystectomies 1

Long-Term Prognosis

• In a 4-year follow-up study of 76 patients with painful rib syndrome, 70% still had pain but all except three had learned to live with it 1
• No patients died from the condition or developed serious complications 1
• All further investigations in re-referred patients were negative, confirming the benign nature of the diagnosis 1

When to Reconsider Visceral Causes

Only pursue additional biliary workup if:

• New laboratory abnormalities develop (elevated bilirubin, alkaline phosphatase, or transaminases) 4
• New symptoms appear (jaundice, fever, or constitutional symptoms) 4
• The physical examination is negative for musculoskeletal findings 1, 2