Costochondritis
Costal cartilage is “hyaline,” in nature which describes its glass-like or semi-translucent (see-through) appearance. However, over time, the internal structure and content of the cartilage change, impacting its appearance and attributes.
Hyaline cartilage is the most abundant type of cartilage in the body and is found in joints, the nose, and the trachea (windpipe). In adults, hyaline cartilage does not usually have a direct blood supply; instead, it gains its bloody supply from the lining of the cartilage called the perichondrium.
Costochondritis is a clinical diagnosis; that is, it is made based on history and examination only.
Costochondritis is “inflammation of the cartilage” and is a poorly understood condition that lacks high-quality data and research. It is a diagnosis made based on history and examination with no reliable supporting diagnostic tools.
The symptoms traditionally attributed to costochondritis are sharp, localised chest pain that worsens with movement, deep breathing, or coughing. However, these symptoms are non-specific and can be secondary to several other causes, creating uncertainty and potentially incorrect diagnosis and treatment.
At Rib Imaging, less than 2% of all of our patients have been diagnosed with inflammation, with an alternative diagnosis found in the vast majority of cases.
Slipping Rib Syndrome
At Rib Imaging, we define “Slipping Rib Syndrome” as the “symptomatic subluxation of floating costal cartilage resulting in neuropathic pain due to compression or entrapment of intercostal nerves”. This poorly understood condition frequently results in underdiagnosis and incorrect treatment.
The true incidence and prevalence of this condition remain unknown, but it may be more common than believed, significantly contributing to A&E and primary care visits for musculoskeletal chest pain. The term "slipping rib" might be misleading, as it usually involves abnormal motion of the cartilage tip during thoraco-abdominal movements, often without symptoms. However, in symptomatic cases, the abnormal cartilage motion impinges on adjacent nerves, causing sudden, sharp pain that can radiate to the back, abdomen, and groin, with symptoms persisting for days and sometimes accompanied by gastrointestinal issues like nausea and bloating.
Slipping rib is a dynamic problem that occurs with movement or complex manoeuvres of the chest and abdomen. Diagnosis requires a careful patient history review followed by a radiological assessment with a Dynamic Ultrasound of the Thorax and Ribs. This detailed and complex examination assesses the chest wall and cartilage anatomy and analyses cartilage motion to visualize nerve impingement directly.
Static radiology scans like CT or MR are useful for assessing chest wall anatomy but cannot directly evaluate cartilage motion or demonstrate nerve compression. At Rib Imaging, we have refined dynamic ultrasound techniques, working with the Clinical Coding and Schedule Development Group (CCSD) to recognise this as a specialised test (CCSD code IM379). Rib Imaging is the only institute in the UK offering this specialised examination.
Sternal Pathology
Among high-performance athletes, Rib Imaging has helped define and categorise several new types of complex injuries of the upper chest wall and sternum. In sports such as mixed martial arts and Brazilian jujitsu, rugby and bouldering, athletes are subjected to what we term “Low velocity, high energy injuries”, which can manifest with a range of injuries that can be extremely challenging to diagnose but with huge implications for chest wall stability and are frequently missed.
“1st rib synchondroses-sternoclavicular joint complex” injuries are one such injury that are frequently missed and challenging to diagnose but can result in significant pain and suffering. At Rib Imaging, we have devised novel imaging techniques and protocols to evaluate these injuries and help guide further management and treatment.
At Rib Imaging, We have described and treated unusual sternal pathologies, such as manubriosternal inflammation, paraxiphisternal bursitis and friction syndromes.
Muscular Injuries of the Chest & Abdominal Wall
The chest and abdominal wall have complex muscular interactions that provide both power and flexibility, enabling a wide range of motions, including bending, rotating, and side movements. This complexity makes them susceptible to various injuries that can cause significant pain.
These injuries can occur alone or alongside rib fractures. The chest wall muscles include those attached to the arms, scapula, abdomen, and pelvis, with delicate intercostal muscles between the ribs aiding in breathing.
Intercostal muscle strain, often from overuse, heavy lifting, or sudden movements, leads to localised pain and sometimes muscle spasms. At Rib Imaging, we diagnose various muscle injuries such as:
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Abdominal wall muscle tears are often linked to "costal margin rupture", which can lead to severe symptoms, including lung hernias.
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Pectoralis major muscle and tendon injuries.
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Serratus muscle injuries and myofascial pain syndromes.
Our advanced diagnostic techniques ensure accurate identification and effective treatment plans for these complex injuries.
Chest wall defects and lung hernia
The lungs and their lining (pleura) lie just underneath the ribs and the intercostal muscles. Defects in the ribs or in the muscles can be congenital or then due to an injury or previous surgery. Defects in the chest wall can lead to herniation of internal thoracic or abdominal contents such as the lung and pleura or of internal abdominal organs.
Pleurisy
Pleurisy is the inflammation of the pleura, the membrane surrounding the lungs. It can cause sharp chest pain that worsens with breathing, coughing, or sneezing. Common causes include infections, autoimmune diseases, or pulmonary embolism.
This condition is best diagnosed on a CT Chest but after a review with a clinical review with an expert chest physician.
Nerve Related Rib Pain
The intercostal nerves which supply each rib, originate from the spinal cord and exit through gaps (foramen) between the vertebrae. These nerves can be impinged upon at any point along their path resulting in pain or altered sensation.
The foramen can narrow due to various causes, including arthritic changes, inflammation, infection, bone collapse and tumours. MRI is the optimal technique for imaging the spine to diagnose these issues.
Inflammatory conditions, such as rheumatoid arthritis, often affect the spinal bones and joints. This autoimmune disorder can also impact the joints and cartilage of the ribs, leading to chronic pain, swelling, and stiffness.
Tumours of the nerve can be benign, such as “schwannomas”, or malignant, for example “, malignant peripheral sheath tumours” (MPNST). Ultrasound is a useful technique for identifying these lesions, but MR is the optimal technique for characterising these lesions more accurately.
Other Serious or Potentially Life-Threatening Causes of Chest Pain
These conditions are potentially a threat to life and require immediate treatment. These should be accessed as per local services and/or via 111 or 999 in more urgent cases
Angina and Heart Attack
Reduced blood flow to the heart (angina) or a heart attack causes chest pain that can radiate to the ribs, shoulders, arms, neck, or jaw, often with shortness of breath, sweating, and dizziness. Immediate medical intervention is needed.
Pulmonary Embolism
A pulmonary embolism (PE), usually caused by blood clots, blocks a pulmonary artery, leading to sudden, sharp chest pain, shortness of breath, rapid heartbeat, and coughing up blood. Urgent medical care is essential.
Gastroesophageal Reflux Disease
(GERD/GORD) and perforation GERD causes stomach acid to flow back into the oesophagus, leading to burning chest pain (heartburn) that can radiate to the ribs. Symptoms worsen after eating or lying down. Severe cases can cause a perforation, requiring emergency surgery.
Pneumonia
Lung infection can cause chest pain and may require hospitalisation for urgent treatment.
How Ultrasounds Help Diagnose Rib Pain
At Rib Imaging, we use the most advanced ultrasound technology to provide detailed images of the chest wall and rib structures. This safe, non-invasive technique helps in:
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Detailed Imaging: Real-time images for precise identification of abnormalities, particularly “dynamic” problems that only occur with certain movements.
Diagnosis of Inflammation and Infection: Effective identification of conditions such as perichondritis and manubriosternal joint inflammation.
Detection of Fractures: This includes subtle stress fractures that may not be visible in other methods such as x-rays, CT scans, and MR scans.
Evaluation of Muscle and Nerve Conditions: Assessing chest wall muscle strains and nerve-related conditions.
Understanding the cause of rib pain is the first step toward effective treatment and relief. At Rib Imaging, we are dedicated to providing you with the highest level of diagnostic care, using advanced ultrasound technology to ensure accurate and timely diagnoses. Trust us to help you on your path to recovery and optimal health.
Recognised as a global leader in rib and chest wall imaging.
Dr M Ali Abbasi is a pioneer in Dynamic Ultrasound of the Thorax and Ribs.
Utilising the latest ultrasound technology for accurate diagnoses.
Prioritising your comfort and ensuring a stress-free diagnostic experience.
Easy appointment scheduling and efficient diagnostic processes.
Polite and professional staff providing high-class on-site facilities.
Ensuring a discreet service, particularly for elite athletes.
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Traumatic Injuries to the Rib or Costal Cartilage
Traumatic rib fractures can lead to intense pain, especially during breathing or movement. Rib fractures occur from high-energy trauma or repetitive force on healthy bone. Severe cases may result in serious complications such as a collapsed lung (pneumothorax), requiring immediate medical attention.
At Rib Imaging, we define rib fractures as “partial or complete disruption in the rib structural integrity associated with adjacent soft tissue injuries”.
Rib fractures can also occur in weakened bones, due to conditions such as osteoporosis or after radiotherapy. In this setting, the fracture occurs from much lower-energy injuries. Rib fractures from coughing or sneezing usually indicates weakened bone, however, severe coughing can generate significant force resulting in fractures in healthy bone.
Bone rib fractures are often not visible on chest X-rays and are better seen on CT scans. Still, these scans result in significantly higher radiation doses and are therefore reserved for major trauma. Rib fractures can be seen on MR when they are recent onset, but these scans can be long and uncomfortable and are usually costly.
Dynamic ultrasound of the thorax and ribs is an effective tool for diagnosing rib fractures, including subtle stress fractures, and for assessing fracture anatomy, stability, and healing.
Rib cartilage or chondral fractures, typically from higher-energy injuries. These are challenging to diagnose on clinical assessment and frequently missed on imaging techniques such as X-rays and CT scans. By contrast, they are easily identified on focussed thoracic ultrasound, which, again, allows for assessing fracture anatomy, stability, and healing.
Surgical stabilisation of rib fractures (SSRF) can improve quality of life and recovery time, reducing pain and opioid use.
Over recent years, there has been an upsurge in interest in SSRF, with several research studies demonstrating improved outcomes from early fixation. New guidelines from the Chest Wall Injury Society from 2024 are helping to guide appropriate referrals and aim to improve patient outcomes. In the UK, the ORIF trial (https://orif.octru.ox.ac.uk) is a large multicentre study aimed at determining whether operative rib fixation improves patient outcomes.