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Fig. 4.8 Transverse ultrasound image of the costosternal joint.
4—A 25-YEAR-OLD FEMALE WITH CHEST WALL PAIN AND A COLD
Fig. 4.9 Proper needle placement for ultrasound-guided injection of the costosternal joint for Tieitze
syndrome.
4—A 25-YEAR-OLD FEMALE WITH CHEST WALL PAIN AND A COLD
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Fig. 4.10 Abnormalities of manubriosternal and sternocostal joints in rheumatoid arthritis. Radiograph
of a sternum from a cadaver with rheumatoid arthritis shows large erosions of the articular surface of
both the manubrium (M) and the body of the sternum (S). Subtle irregularities of the second and third
sternocostal joints are evident, most prominently in the sternal facet of the left third sternocostal joint
(arrowheads). R, Ossified costal cartilage. (From Resnick D. Diagnosis of Bone and Joint Disorders.
ed. 4. Philadelphia: Saunders; 2002:854.)
Physical modalities, including local heat and gentle range-of-motion exercises, should be introduced several days after the patient undergoes injection for
Tietze syndrome. Vigorous exercises should be avoided because they will exacerbate the patient’s symptoms. Simple analgesics and NSAIDs may be used concurrently with this injection technique.
HIGH-YIELD TAKEAWAYS
• The patient is afebrile, making an acute infectious etiology (e.g., septic arthritis)
unlikely.
• The patient’s symptomatology is clinically consistent with Tietze syndrome.
(Continued)
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4—A 25-YEAR-OLD FEMALE WITH CHEST WALL PAIN AND A COLD
• Physical examination and testing should be focused on the identification of
infection, tumor, and other pathologic processes that may mimic Tietze
syndrome.
• The patient has swelling of the second and third costosternal joints.
• The patient has point tenderness over the second and third costosternal joints.
• The patient’s symptoms are localized, which is more suggestive of a local
process than a systemic polyarthropathy.
• The patient has a positive swollen costosternal joint sign.
• Plain radiographs will provide high-yield information regarding the bony
contents of the joint, but ultrasound imaging and MRI will be more useful in
identifying soft tissue pathology.
Suggested Readings
Gologorsky R, Hornik B, Velotta J. Surgical management of medically refractory Tietze
syndrome. Ann Thorac Surg. 2017;104(6):e443e445.
Hanak JA. Tietze syndrome. In: Frontera WR, Silver JK, Rizzo TD, eds. Essentials of
Physical Medicine and Rehabilitation. ed. 4. Philadelphia: Elsevier; 2020:640645.
Waldman SD. Arthritis and other abnormalities of the costosternal joint. In: Waldman’s
Comprehensive Atlas of Diagnostic Ultrasound of Painful Conditions. ed. 4. Philadelphia:
Wolters Kluwer; 2016:513518.
Waldman SD. The swollen costosternal joint sign for Tietze syndrome. In: Physical
Diagnosis of Pain: An Atlas of Signs and Symptoms. ed. 4. Philadelphia: Elsevier;
2021:228229.
Waldman SD. Tietze’s syndrome. In: Atlas of Common Pain Syndromes. ed. 4.
Philadelphia: Elsevier; 2019:254256.
Waldman SD. Ultrasound-guided injection technique for costosternal joint pain.
In: Waldman’s Comprehensive Atlas of Ultrasound-Guided Pain Management Injection
Techniques. ed. 2. Philadelphia: Wolters Kluwer; 2020:591594.
CHAPTER
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5
Val Rider
A 29-Year-Old Female With
Persistent Burning Rib Pain
Following a Rib Fracture
LEARNING OBJECTIVES
• Learn the common causes of chest wall pain.
• Develop an understanding of the unique anatomy of the chest wall.
• Develop an understanding of the anatomy of the intercostal nerve.
• Develop an understanding of the causes of intercostal neuralgia.
• Develop an understanding of the differential diagnosis of intercostal neuralgia.
• Learn the clinical presentation of intercos tal neuralgia.
• Learn how to examine the chest wall.
• Learn how to use physical examination to identify intercostal neuralgia.
• Develop an understanding of the treatment options for intercostal neuralgia.
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5—FEMALE WITH PERSISTENT BURNING RIB PAIN FOLLOWING A RIB FRACTURE
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Val Rider
Val Rider is a 29-year-old buyer for a
local market with the chief complaint
of, “Ever since I broke my ribs, my
chest has been killing me.” Val stated
that about 4 months ago, she had a
bike accident and broke a couple of
ribs. The ribs gradually healed, but
she has been left with persistent,
burning pain over the area of the bro-
ken ribs. Val noted that in spite of trying Advil, a rib belt, and a heating pad, the pain “just isn’t getting any better.”
More recently, Val began noticing an area of numbness in the skin overlying the
painful area. “Doctor, I know that this will sound crazy, but the area where my
broken ribs were hurts and feels funny, kind of a numb feeling at the same time.
Is this all in my head? This just doesn’t make any sense.” I said that it was
unlikely it was all in her head and that together, we would figure out what was
causing her symptoms. I asked Val if she had ever experienced anything like this
in the past, and she said no. I aske d whether she had any rash in the area of the
broken ribs, and she shook her head and said absolutely not. She denied any
fever, chills, or other constitutional symptoms associated with her pain. Her last
period was 10 days ago. I asked Val what made her pain better, and she said that
sometimes a lidocaine patch provided some relief, but they were so expensive
that she only used them when the pain was really bad. I asked if she had tried ice
or heat, and she said she tried a heating pad but thought it made the pain worse.
She denied significant sleep disturbance. I asked if any specific movement made
the pain worse, and she said, “Since the ribs healed, moving or lying on the area
doesn’t seem to change things one way or the other.” I asked Val about any antecedent rib or chest wall trauma, and she shook her head no. She also denied any
recent surgery.
I asked Val to point with one finger to show me where it hurt the most. She
pointed to the top of the area overlying the 10th, 11th, and 12th ribs on the right,
and said, “Doctor, it really seems to be this whole area over where I broke my
ribs. Such a stupid accident, lucky I didn’t get killed. That idiot opened his car
door right in front of me, and I ran right into it. I went flying over the handlebars,
my bike was totaled, and so were my ribs.” Val poked her ribs on the right and
said, “It’s like the ribs that were broken hurt, but they really don’t. Even when I
really push on them, this whole area feels like a piece of wood. It just doesn’t feel
right, just kinda dead. This whole thing is just nuts.”
On physical examination, Val was afebrile. Her respirations were 16, and
her pulse was 68 and regular. Her blood pressure was 118/70. Val’s head, eyes,
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5—FEMALE WITH PERSISTENT BURNING RIB PAIN FOLLOWING A RIB FRACTURE
ears, nose, throat (HEENT) exam was normal, as was her cardiopulmonary
examination. Her thyroid was n ormal. Her abdominal examination revealed
no abnormal mass or organomegaly. There was no costovertebral angle (CVA)
tenderness. There was no peripheral edema. Her low back examination was
unremarkable. Visual inspection of the right chest wall revealed no evidence of
herpes zoster or obvious bony deformity. There was really no tenderness to
palpation of the area overlying the right lower anterolateral chest wall, but
careful sensory testing revealed decreased sensatio n from the posterior axillary
line to the anteri or chest wall and subcostal area in the distribution of the right
10th and 11th intercostal and subcostal nerves. Examinations of the left chest
wall, dorsal spine, and other major joints were unremarkable. A careful neurologic examination revealed that other than the sensory deficit of the right intercostal nerves, there was no evidence of peripheral neuropathy. Deep tendon
reflexes were normal.
Key Clinical Points—What’s Important and What’s Not
THE HISTORY
’
History of acute trauma with associated broken ribs
’
No history of previous significant chest wall pain
’
No fever or chills
’
Persistent burning right lower chest wall pain with associated numbness
’
Movement does not exacerbate the pain
’
No history of rash in the area of pain and numbness
THE PHYSICAL EXAMINATION
’
Patient is afebrile
’
Minimal tenderness to palpation of the right 10th, 11th, and 12th ribs
’
Decreased sensation in the distribution of the right 10th and 11th intercostal
and subcostal nerves
’
No evidence of infection
OTHER FINDINGS OF NOTE
’
Normal HEENT examination
’
Normal cardiovascular examination
’
Normal pulmonary examination
’
Normal abdominal examination
’
No peripheral edema
5—FEMALE WITH PERSISTENT BURNING RIB PAIN FOLLOWING A RIB FRACTURE
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’
Normal upper extremity neurologic examination, motor and sensory
examination with exception of numbness in the distribution of the right
10th and 11th intercostal and subcostal nerves
’
Examination of major joints normal
What Tests Would You Like to Order?
The following tests were ordered:
’
Plain radiographs of the chest with right lower rib details
’
Computed tomography (CT) scan of the chest
’
Electromyography (EMG) and nerve conduction velocity testing of the right
10th and 11th intercostal and subcostal nerves
TEST RESULTS
The plain radiographs of the right chest were normal.
The radiographs of the right 10th, 11th, and 12th ribs revealed healing rib
fractures.
Findings from the EMG and nerve conduction tests of the right 10th and 11th
intercostal and subcostal nerves were consistent with intercostal neuralgia.
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Clinical Correlation—Putting It All Together
What is the diagnosis?
’
Intercostal neuralgia
The Science Behind the Diagnosis
ANATOMY
The intercostal nerves arise from the anterior division of the thoracic paravertebral nerve. A typical intercostal nerve has four major branches (Fig. 5.1). The first
branch is the unmyelinated postganglionic fibers of the gray rami communicantes, which interface with the sympathetic chain. The second branch is the posterior cutaneous branch, which innervates the muscles and skin of the paraspinal
area. The third branch is the lateral cutaneous division, which arises in the anterior axillary line and provides the majority of the cutaneous innervation of the
chest and abdominal wall. The fourth branch is the ante rior cutaneous branch,
which supplies innervation to the midline of the chest and abdominal wall (see
Fig. 5.1). The anterior cutaneous branch pierces the fascia of the abdominal wall
at the lateral border of the rectus abdominis muscle (Fig. 5.2). The nerve turns
sharply in an anterior direction to provide innervation to the anterior wall. It
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Fig. 5.1 Anatomy of the intercostal nerve. (From Rendina EA, Ciccone AM. The intercostal space. Thorac Surg Clin. 2007;17:491501.)
5—FEMALE WITH PERSISTENT BURNING RIB PAIN FOLLOWING A RIB FRACTURE
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Linea alba
Rectus
abdominis
Transverse
abdominis
Fig. 5.2 Anatomy of the anterior cutaneous nerve. (From Waldman SD. Atlas of Uncommon Pain
Syndromes. ed. 3. Philadelphia: Saunders; 2014.)
Entrapped anterior
cutaneous nerve
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passes through a firm fibrous ring as it pierces the fascia, and it is at this point
that the nerve is subject to entrapment. It is accompanied through the fascia by
an epigastric artery and vein. Occasionally, the terminal branches of a given
intercostal nerve may actually cross the midline to provide sensory innervation
to the contralateral chest and abdominal wall. The 12th nerve is called the subcostal nerve and is unique because it gives off a branch to the first lumbar nerve,
thus contributing to the lumbar plexus.
CLINICAL SYNDROME
Whereas most other causes of chest wall pain are musculoskeletal, the pain of
intercostal neuralgia is neuropathic. As with costosternal joint pain, Tietze syndrome, and rib fractures, many patients who suffer from intercostal neuralgia
seek medical attention because they believe they are having a heart attack. If the
subcostal nerve is involved, gallbladder disease may be suspected. The pain of
intercostal neuralgia is the result of damage to or inflammation of the intercostal
nerves. The pain is constant and burning, and it may involve any of the intercostal nerves as well as the subcostal nerve of the 12th rib. The pain usually begins
at the posterior axillary line and radiates anteriorly into the distribution of the
affected intercostal or subcostal nerves, or both (
movement of the chest wall may slightly increase the pain of intercostal neuralgia but to a much lesser extent than with musculoskeletal causes of chest
wall pain.
Fig. 5.3). Deep inspiration or
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5—FEMALE WITH PERSISTENT BURNING RIB PAIN FOLLOWING A RIB FRACTURE
Areas of
decreased
sensation and
allodynia
Fig. 5.3 The pain of intercostal neuralgia is neuropathic rather than musculoskeletal in origin. (From
Waldman S. Atlas of Common Pain Syndromes. ed. 4. Philadelphia: Elsevier; 2019 [Fig. 63-1].)
SIGNS AND SYMPTOMS
Physical exami nation generally reveals minimal findings unless the patient has a
history of previous thoracic or subcostal surgery, or cutaneous evidence of herpes zoster involving the thoracic dermatomes (Fig. 5.4 ). Unlike patients with
musculoskeletal causes of chest wall and subcostal pain, those with intercostal
neuralgia do not attempt to splint or protect the affected area. Careful sensory
examination of the affected dermatomes may reveal decreased sensation or allodynia. When motor involvement of the subcostal nerve is significant, the patient
may complain that the abdomen bulges outward.
TESTING
Plain radiographs are indicated for all patients who present with pain thought to
be emanating from the intercostal nerve to rule out occult bony disorders,
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