Laura McIlhenny: A 26-Year-Old Cosmetic Salesperson With Severe Knifelike Pain and a Clicking Sensation in the Lower Ribs Following a Seatbelt Injury

Learning Objectives

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Learn the common causes of chest wall pain.
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Develop an understanding of the innervation of the chest wall and pelvis.
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Develop an understanding of the anatomy of the chest wall.
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Develop an understanding of the causes of slipping rib syndrome.
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Learn the clinical presentation of slipping rib syndrome.
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Learn how to use physical examination to identify slipping rib syndrome.
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Develop an understanding of the treatment options for slipping rib syndrome.
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Learn the appropriate testing options to help diagnose slipping rib syndrome.
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Learn to identify red flags in patients who present with chest wall pain.
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Develop an understanding of the role in interventional pain management in the treatment of slipping rib syndrome.

Laura McIlhenny

Laura McIlhenny is a 26-year-old cosmetic salesperson with the chief complaint of, “I feel like somebody is stabbing me in the ribs with a knife.” Laura went on to say that she was involved in a motor vehicle accident. A distracted driver slammed into the back of her car when she was sitting at a stoplight. The impact threw her forward against her seatbelt. She was shaken up, but her car was driveable, and she went on to work. Her lower ribs on the right were sore, but she thought she would be fine. That evening, when walking out to the parking lot after work, Laura stated that she felt a sudden, sharp, stabbing pain in her right lower ribs. “At first, I thought I had been stabbed, that someone was trying to mug me. You can’t believe how bad the pain was. It doubled me over. It lasted for a minute or so and then went away as quickly as it came. The odd thing was, when I went to stand up, I felt like my ribs popped back into place, kind of a clicking sensation. It’s hard to describe, but it was very weird and rather nauseating.” Laura went on to say, “Doctor, do you think I could be pregnant or have some kind of cancer? I did a home pregnancy test, but it could have been too soon because I just had my period.” Laura said that she was really having a hard time getting the pain better in spite of trying a massage and aromatherapy. Her friend at work gave her a lidocaine patch, which seemed to help a bit. She said she took some pain pills that were left over from when she had her wisdom teeth pulled. They helped a little, but they made her loopy.

I asked Laura if she ever had anything like this happen before, and she shook her head no. She also denied any current urinary or gynecologic symptoms, hematuria, or fever or chills. She also denied a history of kidney stones. Her last menstrual period was about 5 days ago. Laura was using oral contraceptives, but she volunteered that she was fearful of having sex because she didn’t want to trigger the pain. I asked her to rate her pain on a 1 to 10 scale, with 10 being the worst pain she had ever had, and she said the pain was an 11 when it hit and a 1 after it went away. “Doctor, this pain is really scaring me. I’m scared to move for fear of triggering it. The pain is interfering with just about everything. I am afraid to bend over to tie my shoes or shave my legs. I have a hard time getting dressed, no exercise, no sex—it’s ruining everything. I just really need to get my life back.”

I asked Laura to point with one finger to show me where it hurts the most. She pointed to the area over her right lower ribs, and said, “Doctor, the pain is right here. This is where the clicking comes from. This is the spot, right here on top of the ribs.”

On physical examination, Laura was afebrile. Her respirations were 16. Her pulse was 72 and regular. Her blood pressure was normal at 118/68. Her head, eyes, ears, nose, throat (HEENT) exam was normal, as was her thyroid examination. Her cardiopulmonary examination was negative. Her abdominal examination revealed no abnormal mass or organomegaly. Examination over the right costochondral cartilage revealed some tenderness to deep palpation. Costochondral instability of the eighth rib on the right was noted, and a clicking sensation was noted with downward pressure on the costochondral cartilage. No mass or abdominal wall hernia was identified. Visual inspection of the painful area revealed no ecchymosis or evidence of infection. There was no costovertebral angle (CVA) tenderness. There was no peripheral edema. Her low back examination was unremarkable. When I asked Laura to stand up and walk, I noticed that she got up very carefully and walked with her thoracic spine flexed to splint the affected costochondral cartilage. Her lower extremity neurologic examination was completely normal. The hooking maneuver test for slipping rib syndrome was markedly positive on the right ( Fig. 7.1 ). I said, “Laura, I think I know what’s going on, and I have a pretty good idea of how to get you better.” Laura gave me a tentative smile and said, “I certainly hope so. This has been really upsetting.”

Key Clinical Points—What’s Important and What’s Not

The History

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History of recent onset of right chest wall pain following a seatbelt injury
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No history of gynecologic or urinary tract symptoms related to the pain
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No history of kidney stones
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No history of hematuria
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Character of pain is sharp, stabbing, and knifelike
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Clicking sensation associated with the pain
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Difficulty in carrying out activities of daily living
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Pain localized to the origin of the right chest wall
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No fever or chills

The Physical Examination

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Patient is afebrile
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Normal visual inspection of the right chest wall with no ecchymosis noted
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Palpation of the right lower chest wall elicited only mild pain
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Costochondral instability of the eighth costochondral cartilage
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Patient walks with flexed thoracic spine in an attempt to splint the affected costochondral cartilage
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Hooking maneuver test for slipping rib syndrome markedly positive on the right
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No abnormal mass or abdominal wall hernia identified

Other Findings of Note

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Normal blood pressure
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Normal HEENT examination
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Normal cardiopulmonary examination
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Normal abdominal examination
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No peripheral edema
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No CVA tenderness

What Tests Would You Like to Order?

The following tests were ordered:

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X-ray of right ribs
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Chest x-ray
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Dynamic ultrasound imaging of the painful costochondral cartilage
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Pregnancy test
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Urinalysis

Test Results

Plain radiograph of the ribs is reported as normal.

Chest x-ray is reported as normal.

Dynamic ultrasound imaging of the lower costochondral cartilage on the right is reported as positive with subluxation of the eighth costochondral cartilage ( Fig. 7.2 ).