Learning Objectives
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Learn the common causes of chest wall pain.
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Develop an understanding of the unique anatomy of the chest wall.
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Develop an understanding of the anatomy of the intercostal nerve.
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Develop an understanding of the causes of intercostal neuralgia.
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Develop an understanding of the differential diagnosis of intercostal neuralgia.
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Learn the clinical presentation of intercostal neuralgia.
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Learn how to examine the chest wall.
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Learn how to use physical examination to identify intercostal neuralgia.
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Develop an understanding of the treatment options for intercostal neuralgia.
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
The History
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History of acute trauma with associated broken ribs
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No history of previous significant chest wall pain
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No fever or chills
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Persistent burning right lower chest wall pain with associated numbness
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Movement does not exacerbate the pain
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No history of rash in the area of pain and numbness
The Physical Examination
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Patient is afebrile
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Minimal tenderness to palpation of the right 10th, 11th, and 12th ribs
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Decreased sensation in the distribution of the right 10th and 11th intercostal and subcostal nerves
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No evidence of infection
Other Findings of Note
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Normal HEENT examination
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Normal cardiovascular examination
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Normal pulmonary examination
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Normal abdominal examination
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No peripheral edema
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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
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Examination of major joints normal
What Tests Would You Like to Order?
The following tests were ordered:
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Plain radiographs of the chest with right lower rib details
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Computed tomography (CT) scan of the chest
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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.
Clinical Correlation—Putting It All Together
What is the diagnosis?
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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 anterior 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 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.
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