41 Yo Male With Chronic Right Rib Pain

HISTORY: Patient is a 41-year-old male who presented to the UNLV Sports Medicine Clinic complaining of pain in the right lower rib region over the past two to three years. The patient characterizes the pain as a “dull poke in the right flank area" that affects his daily functioning and workouts. The patient states that the pain began after he participated in a kickball game and he felt a pop while playing. Since the incident the patient had been evaluated by numerous physicians and has undergone acupuncture, manipulation therapy without much relief. He has had MRIs, CT and XR of the pelvis and abdomen which have all been unremarkable. He denies any trauma to the region since the original incident while playing kickball two to three years ago. PHYSICAL EXAMINATION: Cons: NAD HEENT: Normocephalic atraumatic Eyes: EOMI, conjunctiva normal, PERRLA Respiratory: Normal respiratory effort MSK: Minimal tenderness and pain to the tip of the 12th rib on the right. Skin: Warm and dry no rashes present Neurologic: No focal deficits present. DIFFERENTIAL DIAGNOSIS: Costochondritis, Cholelithiasis, Nephrolithiasis/Ureterolithiasis, VZV, Slipped rib syndrome TEST AND RESULTS: RUQ US: small amount of gallbladder debris; negative murphy sign, no stones, or evidence of acute cholecystitis. CXR: No effusions, infiltrates, or fractures; flattened hemidiaphragm. CT Chest: Mild hyperinflated lungs, no parenchymal nodules, no effusion, liver lesion or adrenal lesion. Mild asymmetry in lower anterior chest wall at level of 9th and 10th ribs. FINAL WORKING DIAGNOSIS: Slipped Rib Syndrome TREATMENT AND OUTCOMES: This patient was evaluated by thoracic surgery and they diagnosed the patient with slipping rib syndrome. He was informed of options to treat via surgical intervention. The patient opted for more imaging after being informed that further imaging is not diagnostic in most cases. He was subsequently evaluated at the sports medicine clinic where he had a positive diagnostic thumb maneuver which demonstrated slipping of the 12th rib inferior and superior to the 11th rib which recreated the patient’s pain. A successful intercostal block of the right 11th intercostal space was subsequently completed with lidocaine and bupivacaine for pain management. Patient is back to usual activity with no restrictions or pain.