Val Rider: A 29-Year-Old Female With Persistent Burning Rib Pain Following a Rib Fracture

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 broken 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 asked 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, ears, nose, throat (HEENT) exam was normal, as was her cardiopulmonary examination. Her thyroid was normal. 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 sensation from the posterior axillary line to the anterior 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