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10 Rib Pain Causes, Treatments & More

Acute costochondritis (chest wall syndrome)

Acute costochondritis is the inflammation of the flexible cartilage that connects each rib to the breastbone. Costochondritis is caused by excessive coughing or by straining the upper body, as with weightlifti..

Normal occurence of chest pain

Sometimes chest pain is not a sign of a heart attack. The following symptoms are usually typical of more benign conditions:

If the pain is brief, like a short shock, and subsides right away, it is most likely from an injury such as a broken rib or pulled muscle in the chest.

Sharp pain in the chest that improves with exercise is probably from acid reflux or a similar condition, and will be eased with antacids.

A small, sharp pain anywhere in the chest that actually feels worse on breathing is probably from a lung inflammation such as pneumonia or asthma.

An actual heart attack involves intense, radiating chest pain that lasts for several minutes; worsens with activity; and is accompanied by nausea, shortness of breath, dizziness, and pain in the arms, back, or jaw. Take the patient to the emergency room or call 9-1-1.

If there is any question as to whether the symptoms are serious or not, a medical provider should be seen as soon as possible.

Rarity: Common

Top Symptoms: chest pain, rib pain

Symptoms that always occur with normal occurrence of chest pain: chest pain

Symptoms that never occur with normal occurrence of chest pain: being severely ill, shortness of breath, fainting, severe chest pain, crushing chest pain, excessive sweating, nausea or vomiting

Urgency: Phone call or in-person visit

Atypical chest pain

Atypical chest pain describes the situation when someone’s chest pain is unlikely to be related to heart or lung disease. There are many other possible causes that could explain chest pain, like sore chest wall muscles or psychological factors like stress and anxiety.

Rarity: Common

Top Symptoms: chest pain, shortness of breath

Symptoms that always occur with atypical chest pain: chest pain

Symptoms that never occur with atypical chest pain: fever

Urgency: Primary care doctor

Chronic costochondritis (chest wall syndrome)

Costochondritis is an inflammation of the cartilage that connects a rib to the breastbone. Pain caused by costochondritis may mimic that of a heart attack or other heart conditions.

Rarity: Uncommon

Top Symptoms: rib pain, chest pain, chest pain that is worse when breathing, rib pain when moving, pain when pressing on the chest

Urgency: Phone call or in-person visit


Acute bronchitis is an inflammatory reaction to an infection in the airways. Most cases of acute bronchitis are caused by a viral infection, although some cases may be due to a bacterial infection.

Symptoms include an acute-onset cough with or without sputum production, low-grade fever, shortness of breat..

Rib bruise or fracture

Broken or bruised ribs are usually caused by a fall or a blow to the chest, although occasionally this can happen due to severe coughing. With a broken rib, the pain is worse when bending and twisting the body.

Rarity: Uncommon

Top Symptoms: rib pain that gets worse when breathing, coughing, sneezing, or laughing, rib pain from an injury, sports injury, rib pain on one side, injury from a common fall

Symptoms that always occur with rib bruise or fracture: rib pain from an injury

Urgency: Primary care doctor

Bacterial pneumonia

Bacterial pneumonia is an infection of the lungs caused by one of several different bacteria, often Streptococcus pneumoniae. Pneumonia is often contracted in hospitals or nursing homes.

Symptoms include fatigue, fever, chills, painful and difficult breathing, and cough that brings up mucus. Elderly patients may have low body temperature and confusion.

Pneumonia can be a medical emergency for very young children or those over age 65, as well as anyone with a weakened immune system or a chronic heart or lung condition. Emergency room is only needed for severe cases or for those with immune deficiency.

Diagnosis is made through blood tests and chest x-ray.

With bacterial pneumonia, the treatment is antibiotics. Be sure to finish all the medication, even if you start to feel better. Hospitalization may be necessary for higher-risk cases.

Some types of bacterial pneumonia can be prevented through vaccination. Flu shots help, too, by preventing another illness from taking hold. Keep the immune system healthy through good diet and sleep habits, not smoking, and frequent handwashing.

Rarity: Common

Top Symptoms: fatigue, cough, headache, loss of appetite, shortness of breath

Symptoms that always occur with bacterial pneumonia: cough

Urgency: In-person visit

Viral pneumonia

Viral pneumonia, also called “viral walking pneumonia,” is an infection of the lung tissue with influenza (“flu”) or other viruses.

These viruses spread through the air when an infected person coughs or sneezes.

Those with weakened immune systems are most susceptible, such as young children, the elderly, and anyone receiving chemotherapy or organ transplant medications.

Symptoms may be mild at first. Most common are cough showing mucus or blood; high fever with shaking chills; shortness of breath; headache; fatigue; and sharp chest pain on deep breathing or coughing.

Medical care is needed right away. If not treated, viral pneumonia can lead to respiratory and organ failure.

Diagnosis is made through chest x-ray. A blood draw or nasal swab may be done for further testing.

Antibiotics do not work against viruses and will not help viral pneumonia. Treatment involves antiviral drugs, corticosteroids, oxygen, pain/fever reducers such as ibuprofen, and fluids. IV (intravenous) fluids may be needed to prevent dehydration.

Prevention consists of flu shots as well as frequent and thorough handwashing.

Rarity: Uncommon

Top Symptoms: fatigue, headache, cough, shortness of breath, loss of appetite

Urgency: Primary care doctor

Chest bruise

A bruise is the damage of the blood vessels that return blood to the heart (the capillaries and veins), which causes pooling of the blood. This explains the blue/purple color of most bruises. Bruises of the chest are common, given how exposed this area of the body is.

Rarity: Common

Top Symptoms: rib pain, constant rib pain, rib pain from an injury, recent chest injury, bruised chest area

Symptoms that always occur with chest bruise: rib pain from an injury, recent chest injury, constant rib pain

Urgency: Self-treatment

Common Causes of Rib Pain and When to Seek Treatment: Jason Ablett, DC: Chiropractor

Pain in or around your ribs can feel hard to pinpoint. Is it muscular? Is there a problem with one of your ribs itself? Is something going on underneath your rib cage that’s causing your discomfort?

Fortunately, figuring out what’s causing your rib pain doesn’t have to be a daunting challenge you take on by yourself. As a rib pain specialist, Jason Ablett, DC, helps patients at Pinnacle Health Chiropractic identify the root cause of their rib pain and find solutions for it. From our office in Kirkland, Washington, he and the rest of our team work with you to find relief. 

To get you started, let’s take a look at four of the most common causes of rib pain and your options for treating each. 

#1: Rib fractures or breaks

The bones that make up your rib cage are fragile. They can get fractured — or even broken — during a slip-and-fall accident, a sports injury, a car accident, or any other incident that applies force to your ribs.

If you think you might have a rib fracture or break, Dr. Ablett can stabilize the area using kinesiology tape and work with you to help the injured rib heal. It’s also important to get an X-ray to understand the extent of the damage. 

#2: Inflammation

Rheumatoid arthritis, costochondritis (inflammation in your rib cage’s cartilage), and other forms of inflammation can cause discomfort in your ribs. Pleurisy, a condition characterized by inflammation in the lining of your lungs, can also cause rib pain. 

With regular chiropractic care, Dr. Ablett has helped many people with inflammation-caused rib pain — including people with arthritis — find relief. 

#3: A strained muscle

The intercostal muscles between your ribs play a key role in your body, attaching your ribs, helping you breathe, and supporting your torso. When you strain these muscles, you might feel pain in your ribs or tenderness when you touch the area. You might also have trouble breathing. 

Fortunately, the strained muscle will heal with time. To support and even shorten your recovery, you can get chiropractic care from Dr. Ablett. 

#4: Other conditions

Your rib pain might not be stemming from a problem with your ribs themselves, but from another underlying condition.

Medical conditions that commonly cause rib pain include:

  • Fibromyalgia
  • Osteoporosis
  • Liver problems
  • Kidney stones
  • Spleen problems
  • Pancreatitis

If you’re experiencing rib pain, it’s a sign that something isn’t right in your body. Make an appointment at our office so Dr. Ablett can give you a thorough checkup and work toward identifying the cause of your rib pain. 

You shouldn’t have to live with pain in your ribs — and ignoring it could let a medical condition go untreated. To start the process of diagnosing the cause of your rib pain so you can treat it and find relief, call our office or schedule an appointment online today.

Rib Cage Pain | causes | diagnosis | treatment | home remedies

By Medicover Hospitals / 4 Jan 2021
Home | symptoms | rib-cage-pain

  • Traumatic injury, muscle strain, joint inflammation, or chronic pain may cause rib pain that appears to come from a rib, and varies in severity.
  • Article Context:
    1. What is rib cage pain?
    2. Causes
    3. Diagnosis
    4. Treatment
    5. When to visit a Doctor?
    6. Home remedies
    7. FAQ’s

    What is rib cage pain?

  • Rib cage pain can be sharp, dull, or achy and is felt in the chest or below the chest or above the belly button on both sides. It can occur after an obvious or unexplained injury.Rib cage pain can be caused by a variety of things, ranging from a pulled muscle to a broken rib.
  • Pain can occur immediately after an injury or develop slowly over time. It may also be a sign of the underlying health problem. You should report any unexplained rib cage pain to your doctor immediately.
  • Causes:

  • There are many possible causes of pain in the rib cage. A doctor will diagnose the underlying cause using a physical exam and imaging scans. Common reasons for pain in the rib cage include:
  • Injury:

    • Chest injuries from falls, traffic collisions, and sports-related contact are the most common cause of pain in the rib cage. Types of injuries include:
      • broken ribs
      • bruised ribs
      • fractured ribs
      • stretched muscle
    • Rib cage pain that begins after a wound is usually diagnosed with an X-ray to highlight bone fractures and fractures. Magnetic resonance imaging (MRIs) and other scans can detect soft tissue injury.


    • Another common cause of chest pain is costochondritis or Tietze syndrome.
    • This condition is defined by inflammation of the cartilage in the rib cage. It usually occurs in the cartilage that connects the upper ribs to the breastbone, an area called the costosternal joint.
    • The pain in the rib cage due to costochondritis ranges from mild to severe. Symptoms include tenderness and pain on contact with the chest. Serious cases can cause pain that radiates to the limbs or pain that interferes with everyday life.
    • Some cases of costochondritis go away without treatment, while others require medical intervention.


    • Pleuritis, also called pleuritis, is an inflammatory condition that affects the walls of the lungs and chest.
    • The pleura are thin tissues that line the lining of the chest and the lungs. In their healthy state, they glide smoothly over each other. However, the inflammation causes them to rub, causing significant pain.
    • Since the advent of antibiotics, pleurisy is much less common than it used to be. Even when it happens, it is often a mild condition that resolves itself. Pleuritis generally lasts from a couple of days to two weeks.
    • Other inflammatory conditions of the lungs, such as bronchitis, can also cause pain around the rib cage.


    • One of the symptoms of lung cancer is rib cage pain or chest pain that gets worse with deep breaths, coughing, or laughing. Other symptoms to watch out for include coughing up blood or phlegm, shortness of breath, and wheezing.
    • The outlook for lung cancer is worse than that of other forms of cancer and is the leading cause of cancer death in both men and women. People with early-stage lung cancer have a better chance of being cured, which underlines the importance of early intervention.
    • Metastatic lung cancer, or cancer that starts in one area and spreads to the lungs, is a potentially fatal disease. It will also create pain in the rib cage or chest.


    • It is a chronic disease causing pain throughout the body. According to estimates from the American College of Rheumatology, fibromyalgia affects between 2% and 4% of people, 90% of whom are women.
    • The pain associated with fibromyalgia can be a burning, throbbing, stabbing, or aching sensation. These pains are usually felt in the rib cage, although any part of the body can be affected.
    • Some research suggests that non-specific chest pain, including chest pain, is the most common co-occurring disease that leads to the hospitalization of people with fibromyalgia.

    Pulmonary embolism:

    • Pulmonary embolism (PE) occurs when an artery entering the lungs is blocked. The blockage is often caused by a blood clot rising from one of the legs.
    • The pain associated with fibromyalgia can be a burning, throbbing, stabbing, or aching sensation. These pains are usually felt in the rib cage, although any part of the body can be affected.
    • In addition to chest pain, PE can cause the following symptoms:
      • shortness of breath
      • rapid breathing
      • cough, including coughing up blood
      • anxiety
      • dizziness
      • sweat
      • irregular heartbeat
    • PE is a serious disease that can damage the lungs and other organs due to reduced oxygen in the blood. Anyone who has symptoms of PE should see a doctor.


    • When talking to your doctor, describe the type of pain you feel and the movements that make the pain worse. The type of pain you are feeling and the area of ​​pain can help your doctor determine which tests will help them make a diagnosis.
    • If your pain started after an injury, your doctor may order an imaging test such as an x-ray. A chest x-ray may show broken bones or bone abnormalities. Detailed rib x-rays are also helpful.
    • If any abnormalities, such as abnormal growth, appear on your x-ray or during your physical exam, your doctor will order soft tissue imaging, such as an MRI. An MRI gives the physician a detailed view of your rib cage and the surrounding muscles, organs, and tissues.
    • If you experience chronic pain, your physician may order a bone scan. Your doctor will order a bone scan if they think bone cancer may be causing the pain. For this test, they will give you a small amount of radioactive dye called a tracer.
    • Your physician will then use a special camera to scan your body for the tracer. The image on this camera will highlight bone defects.


  • The treatment for rib cage pain depends on the cause of the pain.
    • If the rib cage pain is due to a minor injury, such as a pulled muscle or a bruise, you can use a cold compress on the area to reduce the swelling. If you experience severe pain, you can also take over-the-counter pain relievers such as acetaminophen (Tylenol).
    • If over-the-counter medications do not relieve pain from an injury, your doctor may prescribe other medications, as well as a compression wrap. A compression bandage is a large elastic bandage that wraps around your chest.
    • The compression wrap firmly holds the area to prevent further injury and greater pain. However, these wraps are only needed in rare cases because the tightness of the compression band makes it difficult to breathe. This can increase your risk of pneumonia.
    • If bone cancer is causing pain, your doctor will discuss treatment options with you depending on the type of cancer and where the cancer is coming from. By determining the origin of cancer, you will be your doctor, whether it started in the ribs or spread to another area of ​​the body. Your doctor may suggest surgery to remove or biopsy the abnormal growths.
    • In some cases, surgical removal is not possible or maybe too dangerous. In these cases, your doctor may choose to reduce them with chemotherapy or radiation therapy. Once the growth is small enough, they can then remove it surgically.

    When to visit a Doctor?

  • Pain in the rib cage can be attributed to many underlying injuries or medical conditions. A person should always see a doctor in all cases of unexplained chest pain.
  • If chest pain or pressure is severe and breathing becomes difficult, a person should seek emergency medical attention as these symptoms may indicate a heart attack.
  • Home Remedies:

  • Some causes of rib pain such as muscle tension or joint inflammation can probably be treated at home.
    • Over-the-counter pain relievers: If the rib pain is due to muscle tension or inflammation at the junction of the cartilage in the ribs, over-the-counter pain relievers like ibuprofen can help relieve the pain.
    • Rest: If the rib pain is due to muscle tension or inflammation at the rib cartilage junction, rest can help. Avoid activities that make the pain worse for a week or two to allow the inflammation to subside.

    Frequently Asked Questions:

  • The more frequent cause of chest pain is costochondritis. Costochondritis occurs when the cartilage connecting your ribs to your breastbone is inflamed.
  • Liver disease, liver cancer, or liver infection can each causing pain in the right upper abdomen. The pain may be dull and chronic. You may feel the pain under your right ribs. Other symptoms include nausea, jaundice, fatigue, dark-colored urine, swollen feet and ankles, contusions, and weight loss.
  • Pleurisy on the left side can cause pain under the left rib cage, but the main symptom is a sharp, throbbing pain when you breathe. See a doctor if you experience severe chest pain while breathing.
  • What causes right rib pain? Symptoms and treatment options

    It’s the rare person who hasn’t self-diagnosed various aches and pains. It turns out one of the most popular internet searches is something along the lines of: “I have a pain under my right rib. OMG, am I dying?”

    Luckily, that pain in the few inches of space right below your right ribs isn’t necessarily an indicator something is seriously wrong.

    “Sometimes a pain under the rib is nothing more than you slept wrong, or you exercised too hard,” said Dr. Gregory Cooper, a gastroenterologist at the University Hospitals Cleveland Medical Center. But if the pain is severe enough — or you are stressing yourself out enough — that you’re actually spending time online self-diagnosing, it may be time to get checked out, he noted.

    The pain could potentially be something more serious like gallbladder issues. Or it could be “referred” pain from another area of the body. The key is to look at other symptoms you may be experiencing, the severity of the pain, whether it is intermittent or constant, or whether it goes away only to return at a later date, he added.

    Here’s a brief rundown of some causes of what that right-under-the-right-rib ache could mean:

    1. Gallbladder gone rogue

    Your gallbladder (located on the right side of your body, beneath the liver) may be the cause of your misery. There’s a host of conditions plaguing this pear-shaped organ and you might be experiencing one of them.

    The most likely culprit may be biliary colic. Pain is sudden and often gets worse. You usually feel that pain in the abdomen, right under the right ribs or the center of your abdomen. Pain may be “referred” or felt in the right shoulder blade. It might be fleeting, lasting just a few minutes, or it can last a few hours. You might feel nauseous and your abdomen may be tender for a day or so.


    Another issue could be acute cholecystitis, or the gallbladder attack. Basically, your gallbladder has become inflamed — most likely due to a gallstone blocking the cystic duct. Symptoms include pain, fever, chills, nausea and vomiting. The pain is usually severe and steady.

    You might also be suffering from acute pancreatitis, which is sometimes linked to gallstones.

    2. Liver issues

    An isolated ouch under your right ribs probably doesn’t mean your liver is diseased.

    But this football-shaped organ is located on the right side of the body and is prone to numerous problems. Aside from pain, which can be dull or very severe, liver problems usually include some combination of jaundice, itchy skin, darkened urine, changes in stool color (including pale or tar-colored stool), fatigue, and appetite loss, among others.


    3. Gas problems

    Gas in the intestines can cause real-deal pain for some folks. If you have a pain under your ribs from gas, you’re not alone. Your large intestine has two points under the rib cage where it bends. The right-sided bend is called the hepatic flexure. Gas can accumulate in this area, causing pain and tenderness, especially if you have IBS. Gas can accumulate on the left side, too. That’s called splenic flexure syndrome. Right-sided gas pain is often confused with gallstones.

    4. Bruises, breaks and strains

    Musculoskeletal issues can cause pain on your right side under your ribs. That pain can be caused by something as simple as lousy posture and sitting at your desk for too long. But if you’ve taken a fall or got hit during a sporting event, you could have a bruised rib, maybe even a fracture. For bruising or breaks, symptoms include pain when breathing in or coughing. The area may be tender or swollen. The rib cage contains intercostal muscles that allow it to move. If you’ve twisted your body forcefully or played 18-holes of golf without a warm-up, you could have strained an intercostal muscle.

    Don’t be a hero

    Searching the internet for answers on pain can make you more miserable and scared. So heed this advice: “If the pain is keeping you from working or just enjoying your day, then see your doctor,” says gastroenterologist Dr. Amit Bhan of the Henry Ford Health System in Detroit.

    Don’t be embarrassed if that pain can be fixed by buying a new mattress, stretching before exercise — or eating more fiber.

    “There’s nothing we like more than telling someone that everything is OK or finding something more serious in the earliest stages so treatment is most effective” he adds.


    An Overlooked Cause of Abdominal Pain

    This series of cases illustrates the authors’ experiences of using intercostal nerve blocks and local infiltration of anesthetics to diagnose and treat this obscure syndrome.

    In 1921, Alexander Tietze first described a syndrome characterized by a painful affliction of the costochondral cartilages (area between the ribs and costal cartilages).1 He described a benign, painful, nonsuppurative swelling involving one or more of the costochondral or sternoclavicular junctions. The following year, Davies-Colley described two women in whom severe abdominal pain was caused by atraumatic, spontaneous overriding of the ninth and tenth ribs.2 This syndrome has been dubbed Tietze syndrome, costal margin syndrome, clicking rib, rib tip syndrome, and now commonly slipping rib syndrome.3-5 Even though this disorder was described more than 60 years ago, it is often overlooked in the differential diagnosis of abdominal or chest pain.6,7 This article will review the diagnosis and treatment of the syndrome and present case examples.


    The pathophysiology of the syndrome was further clarified by Holmes in 1941, and later by McBeath and Keene in 1975.3,4 They examined the gross and microscopic anatomy of the costochondral, sternal, and subcostal regions in normal individuals and identified recurring subluxation (dislocation) of the costal margins of the eighth, ninth, and tenth ribs due to hypermobility of their anterior edges. Actually, the rib tips do not sublux unless the fragile, fibrous articulations are disrupted. Unlike ribs one to seven, which are attached to the sternum, the eighth, ninth, and tenth ribs are attached only to each other by loose fibrous tissue. Paradoxically, when the fibrous tissue between the ribs is incised, they come in contact with each other and become locked behind the adjoining rib.

     Holmes’ anatomic studies revealed that the cartilage ends curl upward inside the ribs so that they come in close relationship to the intercostal nerves.8 The fibrous hammocks surrounding the synovial membranes of the interchondral cartilages of the eighth, ninth, and tenth ribs also involve the terminal branches of the intercostal nerves. These nerves are particularly vulnerable to even trivial trauma. On careful examination, Holmes did not find the synovial membranes to be pathologic; thus, he concluded that the cause of the pain was recurrent, repetitive irritation of the intercostal nerves, not a synovitis of the interchondral cartilages. These factors support the hypothesis that direct or indirect trauma is the cause of the syndrome. The trauma may, at times, be completely covert and not directly implicated.4,9

    Upon physical examination, the pain is clinically recreated when the rib margins are displaced upwards and anteriorly; thus, the “hooking maneuver” can be used to corroborate the diagnosis (Figures 1 and 2). In all our cases, local anesthesia intercostal blockade relieves the pain. We have found that the relief could be prolonged by infiltration of the subcostal rib margins. In several cases, this has completely relieved the pain permanently.

    Figure 1. Schematic illustration of the hooking maneuver. The fingers are hooked beneath the costal margins, displacing them upward and anteriorly.

    Figure 2. Use of the hooking maneuver to demonstrate slipping

    Our Clinical Experience

    The slipping rib syndrome should be considered whenever a patient is referred with a complaint of upper quadrant abdominal pain of obscure and uncertain etiology, especially if it involves the subcostal upper quadrants of the abdomen. Most often all diagnostic studies had ruled out underlying visceral pathology. In many cases, the patients had already undergone abdominal explorations with negative findings. The pain is often confused with cholecystitis, subphrenic abscess, pleurisy, or hepatic pathology. As in many cases, the pain may radiate to the right lower quadrant mimicking appendicitis or renal lithiasis. In some cases, it may create epigastric symptoms of such proportion that myocardial infarction is suspected.

    The diagnosis often can be made by physical examination. Palpation of the tips of the eighth, ninth, and tenth ribs or of the posterior intercostal margins often reproduces the pain. A sensation of clicking or slipping is felt beneath the examining hand when the hooking maneuver is applied. The hooking maneuver often aggravates or recreates the typical pain sensation, but often cannot be done due to severe sensitivity of the subcostal margins. If the pain is absent, the maneuver may reproduce it. The condition is most often unilateral10 and performing the maneuver on the contralateral side will not evoke a pain response. The diagnosis is further confirmed by intercostal local anesthesia nerve blockade of the eighth, ninth, and tenth ribs as well as subcostal infiltration. After the block has taken effect, the hooking maneuver will not evoke pain.

    If a conduction block is used for diagnostic purposes only, then another block may be performed using the combination of local anesthesia 0.5% bupivacaine and 40 mg triamcinolone. This has been found to relieve the problem unless further trauma recreates the pathology. If residual pain persists, or should reoccur, then follow-up with another local anesthesia steroid blockade may be performed.

    Prolotherapy also has been used with great success and prolonged amelioration of the syndrome.11 A more profound blockade may be obtained by the use of the extract of the pitcher plant (Sarapin). The duration of the anesthesia may be prolonged in difficult cases by use of a neurolytic block with phenol 6%. Alcohol should not be used due to the potential for severe neuritis. Our cases all responded to local anesthesia and steroids. Surgery and further injections were unnecessary.

    Case Reports

    First Case Example

    A 34-year-old woman was referred to our pain clinic complaining of right upper quadrant pain of 4 months duration. The pain prevented her from teaching school and performing her activities of daily living. She rated her pain as 10 out of 10 on visual analog scale (VAS).

    There was no history of trauma. The subcostal abdominal pain was aggravated by distention of the abdominal wall and there was associated nausea without vomiting. There were no other gastrointestinal (GI) symptoms. The pain was not affected by eating or taking antacids, belladonna, cimetidine, or other GI medication.

    All laboratory and radiological studies, including abdominal computed tomography scan, were negative. A short trial of non-steroidal anti-inflammatory indomethacin 50 mg 3 times daily and supplemental hydrocodone 10 mg every 4 hours, did not alter the symptom complex. Deep palpation produced pain in the right upper quadrant, with pain radiating posteriorly to the upper dorsal back. Palpation of the margins of the eighth, ninth, and tenth ribs and anterior displacing of the rib margins enhanced the pain. Characteristic snapping or clicking was not induced when performing the hooking maneuver.

    Based on the history, clinical, and laboratory findings, the patient was diagnosed with slipping rib syndrome and treated with intercostal blockade of the eighth, ninth, and tenth ribs in conjunction with subcostal local anesthetic and steroid infiltration.

    The patient’s pain was reduced from a 10 to 2 on VAS. The patient returned 1 week later and described only residual soreness, which was completely eliminated by treatment with percutaneous electrical nerve stimulation (electroacupuncture). She has been pain free ever since.

    Second Case Example

    A 23-year-old Hispanic male was evaluated in the hospital for severe, intractable right flank and lower quadrant pain. He had been hospitalized 8 months earlier, and had been seen in the emergency room on 5 occasions for the same complaint. Each time he was sent home on several analgesics after a thorough workup proved to be negative.  

    On initial physical examination, there were no GI findings. There were abdominal scars indicative of 2 previous laparotomies, which were reported to be negative for intra-abdominal pathology. The patient initially indicated that he had no history of trauma, but upon further careful questioning he revealed that prior to all of the previous incidents—including this hospital admission—he had undergone some trauma to his chest wall. This information had been withheld since there was involvement of gang activity. He was an orderly in the hospital, and was concerned about losing his employment.

    On this hospital admission, further evaluation revealed a healthy but somewhat pale man with acute right upper quadrant pain. Cardiac and pulmonary examinations were negative. Electrocardiogram and chest x-ray did not reveal pathology, but careful physical examination revealed bruises over the center of the sternum and on his face. There was tenderness to deep palpation of the right upper quadrant, with some radiation to the right lower quadrant. There was no rebound but some right flank costovertebral angle tenderness. Bowel sounds were active and the abdominal scars were well healed and nontender.

    Right subcostal displacement using the hooking maneuver (Figures 3 and 4) produced severe right upper quadrant pain. A diagnostic blockade of the eighth, ninth, and tenth intercostal nerves was performed at the level of the xiphoid process at the anterior axillary line. This completely relieved the pain, which then could not be reproduced by the subcostal hooking maneuver. Following this, 0.5% bupivacaine 10 mL containing 40 mg of triamcinolone was infiltrated along the subcostal margin. The pain was totally relieved and had not reoccurred. He was subsequently instructed to avoid any further altercations.

    Figure 3. Costal margin hooking recreates the abdominal pain.

    Figure 4. Costal margin hooking recreates the abdominal pain.

    Third Case Example

    An obese 41-year-old woman was referred to our clinic with a complaint of recurrent right upper quadrant pain, which had been present for several months. The most recent episode occurred approximately 1 month prior to the examination. The workup by a gastroenterologist was found to be negative for intra-abdominal pathology. Large doses of propoxyphene (Darvon) were being used for pain relief (prior to the manufacturer’s removal of the drug from the market based on FDA recommendations). She had been beaten by her husband prior to being seen, but she was unable to delineate the exact areas of trauma.

    There was marked tenderness in the right upper quadrant, and hooking the margins of the ribs and anterior displacement caused excruciating pain in the abdomen, with radiation to the right dorsal spine—confirming the diagnosis. Subcostal infiltration of the eighth, ninth, and tenth intercostal nerves with local anesthetic and subcostal injection of steroids and local anesthesia completely relieved the pain. It has not reoccurred since she left her husband and no longer is being battered.

    Fourth Case Example

    A 50-year-old black man was evaluated for a complaint of severe right upper quadrant pain. He was in the care of a neurologist for Parkinson’s disease (paralysis agitans). His pain was exacerbated by deep inspiration, coughing, and straining. The patient had been involved in an automobile accident 3 years previously, at which time he sustained left chest trauma and fractures of several ribs. His pain had been present intermittently for 2 years in varying degrees of intensity and severity. In the week prior to being evaluated, however, the pain became so severe that it was unmanageable at home due to the development of severe rigidity and uncontrolled tremors. The patient was usually able to tolerate his medication for Parkinson’s, but the chest pain precluded him taking his medication.

    On examination, his abdomen was mildly tympanitic with a moderate degree of gaseous distention and tenderness in the right upper quadrant. The hooking maneuver was performed on the right costal margins and created severe pain on that side. The procedure was performed on the left and did not cause pain. An intercostal block of the eighth, ninth, and tenth ribs on the right and subcostal infiltration with steroids completely relieved the pain.

    The patient was subsequently able to tolerate the Parkinson’s medication and the symptoms resolved. He was re-evaluated 6 months later and there was mild resurgence of the pain. He required one further intercostal nerve block and has been pain free since that time. On further questioning it was determined that, in addition to his car accident, he had fallen several times traumatizing his right chest.

    Last Case Example

    A 50-year-old woman was seen in pain consultation following treatment for postherpetic neuralgia. This problem responded well to sympathetic blocks and a workup for intra-abdominal pathology was negative. The patient described right upper quadrant pain that was deep, aching, and sharp—different than the burning dysesthesias she had experienced with postherpetic neuralgia. She recalls leaning over a trash bin, which caused pressure on her right costal area.

    On examination, deep palpation of the abdomen exacerbated the pain and hooking maneuver produced radiating pain posteriorly to the level of the eighth, ninth, and tenth costal vertebral junctions. There was no cutaneous hypersensitivity usually seen with postherpetic neuralgia. Intercostal nerve blocks at the appropriate levels and subcostal infiltration completely relieved her pain. Six months later, she was relatively pain free although she still complained of some subcostal discomfort, which was thought to be related to the postherpetic neuralgia.


    The trauma that precipitates this syndrome often goes unnoticed. In our first case and those of Wright,10 no history of trauma could be obtained. In our second case, a history of trauma became evident only after careful questioning. Often the cause may be straining—such as during violent coughing, sneezing, or vomiting. Pressure by the gravid uterus on the costal margins also has been reported to produce this syndrome.9

    Although not in our cases, the ribs and adjacent structures can be the source of pain simulating visceral disease. Epigastric tenderness can be caused by a similar mechanism when the xiphoid cartilage is involved. The xiphoid is in close proximity to the articulations of the lower ribs.12,13 It is remarkable that often cardiac, gastric, or gallbladder disease can be diagnosed by the finding of xiphoid tenderness. Pain at the xiphoid cartilage often merely simulates these disease entities. This may be due to the xiphisternal innervations, which are by dorsal intercostal nerves 6 and 8. Local anesthetic infiltrated into the xiphisternal junction may well abolish the pain and make further diagnostic and therapeutic studies unnecessary.14

    Prior to the use of nerve blocks for the different diagnosis and treatment of slipping rib syndrome, many patients were treated by rest and, in many cases, surgery. In 1950, Telford reported spontaneous atraumatic episodic pain that was attributed to the slipping rib syndrome.15 Treatment consisted of avoidance of any precipitating physical activities, although surgery was a definite consideration and was discussed. Slipping rib syndrome was reported in a collegiate swimmer.16 This champion female swimmer had 8 months of unresolved pain and disability, which ultimately were treated with resection of the cartilaginous attachments and a portion of the rib. The diagnosis originally was made by the hooking maneuver. No nerve blocks or subcostal infiltration was performed prior to surgery. Many of the cases reported in the literature, which were surgically treated, could have avoided surgery if the blocking procedures were used prior.


    Our cases illustrate the use of intercostal nerve blocks and local infiltration of anesthetic in the chest cartilaginous articulations, which can be used to diagnose and treat this overlooked and obscure cause of abdominal pain. In our experience, when used judiciously they may allow patients to avoid surgery.

    Last updated on: October 28, 2014

    Pancreatic Cancer Patient Story | Roxanne W.

    Listening to the pain

    In 2012, when I was 60 years old, I began feeling intermittent pain on my left side. I’d been treated for breast cancer years earlier, but did not know at the time that I had the genetic abnormality known as BRCA 2. This abnormality is associated with pancreatic cancer, as well as breast cancer and ovarian cancer. I had some lower back pain, which I thought was due to driving, and had also lost my appetite.

    I spoke with my internist and asked if the pain could be related to my gallbladder. She said no, because the gallbladder is on the right side, not the left. I told her I felt the discomfort under my left rib cage, and she told me that the pancreas is on the left side, but that she thought the pain was likely due to driving. At the time, I was an Account Executive with an Environmental Service company. I covered the Southeast and drove on average 800 to 1,000 miles a week.

    Although, she did believe it was nothing to be worried about she did a test for pancreatic enzymes, but the results of this test showed the enzyme levels to be normal, not elevated. She suggested that I see my gynecologist to have my left ovary examined. (I had my right ovary removed when I was in my late 20s and had a solid cyst that engulfed my ovary.) She also recommended having a colonoscopy with a gastroenterologist. 

    I asked my internist what her next step would be if the examinations of my ovary and colon did not identify the cause of the pain, and she told me if that happened, she would do a CT scan. Eight weeks later, I still had no diagnosis. I went to see my internist again for blood tests and told that the pain had worsened and was now in my stomach, and that I’d lost more weight. She ordered a CT scan for me. Two days later, she called to tell me there were lesions on my pancreas.

    The right treatment

    I began treatment with an oncologist near my home in South Carolina. I wanted to make sure to get a second opinion. I knew I had just one chance to get the right treatment.

    In December of 2012 I called Cancer Treatment Centers of America® (CTCA) and spoke with Matt Owens, a representative based in Chicago. Within two weeks I was at CTCA in Tulsa for a week of meetings with my Care Team.

    The chemotherapy that I’d started in South Carolina continued at CTCA. I had six rounds in total of a regimen known as FOLFIRINOX. The goal of treatment was to shrink the cancer to the point where it was operable. After six rounds of chemotherapy, a PET scan showed that the tumor in the tail of the pancreas was gone, but that there was cancer in the abdominal lymph nodes.

    After an additional six rounds of chemotherapy, a PET scan showed no visible signs of cancer. My surgeon, Dr. Greeff, conferred with several other oncologists, who agreed that I would likely benefit from surgery. The procedure was risky, but I had no other health risks like smoking or being overweight, so it made sense to go ahead with it.

    In September of 2013, I underwent a 10-hour sub-Whipple procedure, which removed 60 percent of my pancreas, all of my spleen, my left adrenal gland, my left fallopian tube, my right ovary and the covering of my stomach. I also had intraoperative radiation therapy during the surgery.

    The treatments were difficult to get through at times. My hands became numb and I had very painful mouth sores that lasted throughout chemotherapy. After the six hours of chemotherapy infusion, there were times when I could not make it to my room unassisted.

    But the truth is, I never had to make it to my room unassisted. There was always someone there to help. My Care Team did their best to help reduce the pain of the mouth sores and to provide comfort in whatever way they could.

    Life begins again

    Today I am feeling great. I have had three additional PET scans since completing chemotherapy and surgery, all of which showed no visible signs of cancer. I return to Tulsa every four months for follow-up visits, and I am preparing for additional preventative surgery.

    I can take long walks, go to yoga classes, and work out with free weights. I am starting to think again about the trip to Europe that I put on hold. I meet friends for lunch. And I’m hoping to get my golf swing back to where it was before I was diagnosed.

    I had one grandchild before I was diagnosed with pancreatic cancer, and now I have two—the second one was born the day after I finished chemotherapy. My family keeps me motivated—I need to be here to watch my grandchildren grow up—as does my simple love of life. I have a long list of adventures still to come.

    Warning Signs: Serious Aches and Pains

    In the spectrum of pain, the two ends are childbirth in a cab (paramedics please!) and a stubbed toe (cured with a yelp). But the really dangerous pains are the ones that feel innocent enough to ignore yet are actually the smoke signals to a health fire that could be burning inside you. Chances are, the majority of your minor pains are no reason to reserve the corner plot. But to protect yourself, you need to know how to make sure your harmless pains are just that — and nothing more.

    Tummy Turmoil

    Make Sure It’s Not… What feels like indigestion after eating a fatty, fried, or greasy meal may actually be your gallbladder trying to contract and squeeze bile out in response to that beef chalupa. But the bile can’t get out because gallstones — solidified bits of cholesterol and other matter — are blocking the exit. The result: “It’s kind of a dull, vague pain that can wax and wane over several hours,” says Beth Schorr-Lesnick, M.D., a gastroenterologist in Yonkers, New York. The pain, felt just below the rib cage on the right side, may even radiate into the right shoulder blade. Thanks to estrogen, we’re also three times as likely to develop gallstones as men (20 percent of us will have them by the time we’re 60), and being on the Pill and being pregnant raises the risk. Ignore it and the pain will worsen — it’s almost like childbirth going on in the upper right part of your belly. An ultrasound or sonogram will detect gallstones, and your doctor will likely schedule a laparoscopic cholecystectomy to remove the gallbladder (done under general anesthesia and about a 2-day hospital stay, it’s now one of the most common surgeries in the United States). To help thwart stones, eat more insoluble fiber. A recent study published in the American Journal of Gastroenterology reports that a 5-gram increase in insoluble fiber intake drops your risk of developing gallstones by 10 percent. Good sources include whole grains like quinoa, nuts, and the edible skins of fruits and vegetables like tomatoes, cucumbers, squash, apples, berries, and pears.

    Sore Throat

    Make Sure It’s Not… Tea, honey, or lozenges may be well and good to relieve the curl-up-in-bed soreness. But know this: a heart attack can also grab you in the gullet. University of Rochester researchers recently found that during a heart attack, women reported feeling discomfort in their throats 12 times more than men. (And 90 percent of women who had heart attacks reported that they experienced “new” or “different” symptoms.) “Often, women will say that their heart attack symptoms were not the type of intense pain they expected, but rather an uncomfortable feeling — more of a tightness or heaviness,” says Kathleen King, R.N., Ph.D., a professor of nursing at the University of Rochester. Throat pain may result from the same thing that causes chest pain in heart attack sufferers: lack of blood flow to the heart, says Paula Johnson, M.D., a cardiologist and executive director of Women’s Health at Brigham and Women’s Hospital in Boston. Yet heart attack pain manifests itself differently in men and women (35 percent of heart attacks in women go unnoticed or unreported), and many women don’t recognize the subtle signs, which also can include nausea, sweatiness, and fatigue. To better protect yourself, oil up: A study in the journal Chest found daily supplements of 2 grams of fish and soy oils, which contain heart-healthy omega-3 fatty acids, significantly improved participants’ heart function in just 2 weeks.

    Burning Belly

    Make Sure It’s Not… Stomachaches typically come from hunger, nerves, indigestion, or whiny interns. But if you feel the discomfort underneath the notch of the sternum, the burn could indicate an ulcer. Try this test: “With an ulcer, when you eat the food kind of buffers it and relieves the pain very promptly,” says Patricia Raymond, M.D., a gastroenterologist in Chesapeake, Virginia. You can’t blame your mother-in-law, boss, or traffic for this one. Most ulcers form when a type of bacteria — called Helicobacter pylori (H. pylori) — burrows in your stomach lining, weakening a protective layer of mucus and then allowing acid to eat at that lining. If you don’t treat it, you risk perforating it (requiring surgery) and you also increase your risk of gastric cancer. In fact H. pylori may be responsible for up to 55 percent of gastric cancer cases. A blood test or a no-needle breath test can detect the bacteria, and then antibiotics will usually clear it up. While you’re at it, pucker up: In one study drinking a tall glass of cranberry juice every day for 90 days significantly suppressed H. pylori. “It looks like it works by decreasing the adhesion of the bacteria to the stomach,” Dr. Raymond says.

    Sore Gums

    Make Sure It’s Not… You can stop strong-arming your toothbrush, but the truth is even a little soreness in your gums suggests periodontal disease, which destroys gum tissue and the bone that keeps your teeth in place. Symptoms like pain, bleeding, and even bad breath may surface only when your hormones are imbalanced — for example, during menstruation, pregnancy, menopause, or while on birth control pills. If soreness lasts for more than a few days, get checked, says Kenneth Krebs, D.M.D., president of the American Academy of Periodontology. Otherwise you’re at higher risk of atherosclerosis, heart attack, stroke, respiratory diseases, and infertility. Save your smile and choose automatic over manual. A study published in the British journal The Cochrane Library found that electric brushes with heads that rotate in one direction and then the other were 11 percent more effective at removing plaque and 6 percent more effective at reducing gingivitis (early-stage periodontitis).

    Major Cramps

    Make Sure It’s Not… When menstrual cramps make you feel like you’ve got a blender spinning inside, you usually chalk it up to a bad month or bad genes. But some experts say that severe cramps may indicate endometriosis. The cause is unknown but the danger isn’t. “Endometriosis can affect other organs, and that can lead to infertility,” says Ozgul Muneyyirci-Delale, M.D., director of the Center for Treatment and Study of Endometriosis at the SUNY Downstate Medical Center. What’s more, the National Institutes of Health reports that women with endometriosis are more likely to have allergies, asthma, and immune diseases. One caveat: Severe cramps don’t automatically mean you have endometriosis. While surgery is the only way to diagnose endometriosis, your doctor may suggest other options for pain relief. Studies have shown that taking 200 milligrams of vitamin E twice a day a couple of days before your period arrives and through the first 3 days of bleeding may relieve cramps.

    Hoarse Voice

    Make Sure It’s Not… We usually write off that Demi Moore voice as a sign of an oncoming cold or the end of a Springsteen concert. But hoarseness — however subtle or sporadic — lasting more than 2 weeks (the time it takes viral infections to clear up) may signal an underlying problem like hypothyroidism or reflux. “People can have hoarseness as the only sign of reflux,” says Mona Abaza, M.D., assistant professor of otolaryngology at the University of Colorado. But it could also be caused by simply speaking loudly (like in a crowded restaurant). “You can have small hemorrhages in your vocal folds, and they can be the start of polyps or nodules,” Dr. Abaza says. If not tended to, these noncancerous, fleshy growths cause chronic hoarseness. See a doctor if symptoms last more than 2 weeks and drink lots of water to keep your throat lubricated. Avoid cold medications with antihistamines, alcohol, caffeine, and chocolate, which tend to dry out and further irritate your vocal cords. Caffeine does it by stimulating your body to get rid of its excess water, while antihistamines have a drying effect on the mucous membranes, says Clark Rosen, M.D., director of the Voice Center at the University of Pittsburgh Medical Center’s Eye and Ear Institute.

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    Dreary tenderness | Our Children

    It’s been two weeks since I started the notebook. I had not fed for several days, and a piercing feeling of sadness began to visit me. This happens when you leave forever a place where you felt very good. Everything becomes unbearably dear, dear.

    I recalled the freshly squeezed pain that was during the establishment of feeding – bright stars in front of my eyes when the baby tightly clasps a cracked nipple.Ridiculous silicone pads, the smell of bepanten, the measured hum of the breast pump. All this stopped gushing memory, and was recalled in those days with special sadness, condescending and affectionate. Even what used to annoy me, for example, the twitching of the second nipple, which sometimes drove me to a frenzy, to a silent fury, now seemed like a cute little thing. Two weeks ago, I would never have called THIS a cute little thing. Something was happening to me.

    The breast was swollen and cried in rare drops of milk.It seemed that all that melancholy tenderness that had been rushing over the chest for several days had accumulated in the cups of the bra.

    Yes, I heard that depression is a private companion to the end of breastfeeding, it is associated with hormonal changes in the body. Feels like a girlfriends story about a closed town, not marked on all maps. And here I am passing through it. So-so place. There are all business travelers – someone lingers longer, and someone sees his bleak outlines only from the car window.There is nowhere to go in the town, only one street – in honor of the completion of lactation. And now the endless gray-eyed rain, I am driving along this street and no matter how much I gas, the speed is still a turtle. I know this street will end, but I have no idea when.

    But how can I make myself easier? How to let go of this astringent melancholy? The summary of the forums was like the Herald of the Healer – drink sage in liters, tighten your bra and stuff it with cold cabbage leaves.

    A few days later, in a faded office, the doctor mumbled something in a paper voice.Then the dull chemist beat off the pills and the hematogen. And after a couple of days it became easier, and colored laughter was born in the world again.

    Funnel deformity in children is a violation of the development of costal cartilage and anterior ribs. The defect is accompanied by an abnormal change in the normal anatomical processes in the sternocostal complex in the form of sinking.

    The degrees of funnel-shaped deformity are different in manifestation, type, form and severity of pathology.

    First degree – the depth of the funnel is up to 2 cm, no displacement of the heart is observed.

    The second degree – the depth of the funnel is up to 4 cm, the heart is mixed by 2-3 cm.

    Third degree – the depth of the funnel is more than 4 cm, and the shift of the heart is more than 3 cm.

    Stages of development of funnel chest:

    • Compensated stage – cosmetic defect, no functional impairment, the first degree of deformity.
    • Subcompensated stage – significant functional changes in the work of the lungs and heart, the second degree of deformity.
    • Decompensated stage – extensive functional disorders of the heart and lungs. third degree.

    The funnel-shaped sternum can be regular or flat-funnel-shaped in shape, and symmetrical and asymmetrical in appearance.

    Funnel-shaped deformity in newborns has the appearance of a slight depression during inhalation (exhalation), during screaming, crying. According to statistics, in half of the children, the sunken chest passes as they grow up, in the other half it increases.A shoemaker’s chest during the first six months after birth can cause dysfunction of the chest organs. The child will be prone to chronic lung and respiratory problems.

    The funnel chest will be pronounced by 3 years of age. In this period, there is a fixed curvature of the chest, ribs and, as a result, posture. Thoracic kyphosis intensifies, the back is rounded, the spine is curved at the sides.

    Diagnosis of a funnel chest by a doctor begins with an examination and measurement of the depth of the cavity.The depth of the depression is measured relative to the plane that connects the two edges of the depression to the top of the funnel. There are cases of the location of the depression almost near the spine. With severe degrees of VDHK, the diaphragm, heart and lungs are significantly displaced. Bulging of the abdomen and an increase in kyphosis are characteristic.

    The final stage in the formation of the cobbler’s breast pathology occurs during puberty.

    Acquired funnel-shaped deformity may result from previous rickets.The difference from congenital deformity is the protrusion of the arches of the ribs. With timely treatment of rickets, the cavity will shrink and may completely disappear.

    At the first degree of deformity, conservative methods of treatment are prescribed. Treatment should begin as soon as the abnormality is detected.

    Types of conservative effects on VDHK: muscle massage, breathing and water exercises, wearing a corset. You should also teach children how to properly “exhale” hard. Here you should exhale with a narrowed and covered glottis.It will be great if the child will combine “tense exhalation” with sternum squeezing from the sides.

    Conservative treatment is effective until the depth of the funnel is small. Otherwise, children are operated on, as there is a violation of the respiratory system and heart.

    Korolev Pavel Alekseevich, thoracic surgeon

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