Expert: Gerald Anzalone, D.C. - 2/15/2010

Question
QUESTION: Dr. Anzalone,

I have a rib injury that has affected me for more than 5 years. As I have gotten older the injury has gotten a little worse over time especially in the last year. When I play sports, particularly racquetball, after a certain amount of hard spent time, I get a severe pain in my right upper rib cage for about 30 seconds at a time, then it disappears. I do feel the injury constantly, but only severe when I play sports. I had an x-ray done, and it came out negative. My guess is that I tore cartilage in this area. What would you recommend to treat this injury?

ANSWER: Eric,

Thanks for your question. I can't provide you with a precise diagnosis or treatment recommendations over the Internet, but in general, the chronic nature of your symptoms in the absence of any other symptoms suggest a number of possibilities.

One is costochondritis, inflammation of a rib or the cartilage connecting a rib. It is a common cause of chest pain.

Anti-inflammatory medicines (such as ibuprofen) are used to treat costochondritis.

Your health care provider can diagnose costochondritis by pressing on the area where the ribs meet the chest bone (sternum). If this area is tender and sore, costochondritis is the most likely cause of your chest pain. However, your doctor should make this diagnosis only after speaking with you and examining you.

See this link for additional information:

http://www.webmd.com/pain-management/costochondritis

Another possibility is intercostal neuritis (or neuralgia), inflammation of the nerves that run alongside the ribs. Causes of intercostal neuritis include diabetes mellitus and shingles (Herpes varicella zoster virus).

http://tinyurl.com/y8hvb5l

Intercostal neuritis is fairly uncommon, and probably best diagnosed by a neurologist. Drugs that control nerve pain (such as Neurontin) may be prescribed.

Strained muscles with trigger points may be another cause. Diagnosis is made by palpation of the muscle, finding tender nodules that reproduce the pain exactly when pressed. A chiropractor or massage therapist can perform this evaluation. Trigger points are extremely common, and are caused by stress or trauma.

Finally, a less common possibility might include a disc herniation in the thoracic spine. An MRI is usually needed to make this evaluation.

I hope that this helps to give you some ideas on how to pursue further evaluation of the cause of you symptoms. Ultimately, appropriate treatment will depend upon an accurate diagnosis, which I cannot provide to you via the Internet. Physical examination is necessary by a qualified health care practitioner.



---------- FOLLOW-UP ----------

QUESTION: Thank you for the interpretation Dr. The only follow up question I have is the injury is not where the chest meets the sternum. It's more on the lower part of the rib cage, where the ribs are closest to the stomach. The chiropractor says it's a sport-related injury and is very common, and can be treated with hot-cold compresses, or if that does not work an injection is needed in the appropriate area, since this injury takes longer to heal. Any other suggestions? Thank You!!!!

Answer
Eric,

Chronic pain in in the upper front of your ribcage, closer to where the sternum (breastbone) is in the center of the chest, suggests the possibility of costochondritis.

Gentle stretching of the pectoralis muscles 2-3 times a day may be beneficial. Tight pectoral muscles can be the result of poor posture, weight lifting, or other daily activities. With the help of a door way you can easily stretch this group of muscles.

  1. Stand in the middle of a door way with one foot in front of the other
  2. Bend your elbows to a 90 degree angle and place your forearms on each side of the door way
  3. Shift your weight on to your front leg, leaning forward, until you feel a stretch in your chest muscles
  4. Hold for 15 seconds
  5. Relax and return to starting position
  6. Repeat above 10 more times

Soft tissue manipulation of the muscles which attach to the ribs may also be helpful, especially if you have trigger points in those muscles. Trigger points are tiny contraction knots that develop in a muscle when it is injured or overworked. Research has shown that trigger points are the primary cause of pain 75% of the time and are at least a part of nearly every pain problem. referred pain is the defining symptom of a myofascial trigger point. Referred pain (which radiates away from the trigger point when the trigger point is pressed) is felt most often as an oppressive deep ache, although movement can sharpen the pain. Chiropractors, physical therapists, massage therapists, or acupuncturists who are skilled in the detection and treatment of trigger points (many say that they are, few actually are, depending upon their skill level and training) can treat trigger points with various manual therapy techniques.

In more severe cases, local injections with an anesthetic and an anti-inflammatory medication can virtually wipe out the trigger point/muscular pain, usually with one or two treatments. Trigger point injections are performed by a medical physician (an M.D. or a D.O.) who is experienced in finding and treating trigger points.

I hope that this helps to answer your question.