1. 2016;19;E465-E471Multi-Modal Treatment Approach to Painful Rib Syndrome: Case Series and Review of the Literature
   Brief Commentary
   Andrew Germanovich, MD, and Francis Michael Ferrante, MD.

BACKGROUND: Mechanical chest wall pain is a common presenting complaint in the primary care office, emergency room, and specialty clinic. Diagnostic testing is often expensive due to similar presenting symptoms that may involve the heart or lungs. Since the chest wall biomechanics are poorly understood by many clinicians, few effective treatments are offered to patients with rib-related acute pain, which may lead to chronic pain.

OBJECTIVE: This case series and literature review illustrates biomechanics involved in the pathogenesis of rib-related chest wall pain and suggests an effective multi-modal treatment plan using interventional techniques with emphasis on manual manipulative techniques.

STUDY DESIGN: Case series and literature review.

SETTING: Pain clinic in an academic medical center.

RESULTS: This is a case series of 3 patients diagnosed with painful rib syndrome using osteopathic palpatory physical examination techniques. Ultrasound-guided intercostal nerve blocks were followed by manual manipulation of mechanically displaced ribs as a part of our multi-modal treatment plan. A review of the literature was undertaken to clarify nomenclature used in the description of rib-related pain, to describe the biomechanics involved in the pathogenesis of mechanical rib pain, and to illustrate the use of effective manual manipulation techniques.

LIMITATION: This review is introductory and not a complete review of all manual or interventional pain management techniques applicable to the treatment of mechanical rib-related pain.

CONCLUSIONS: Manual diagnostic and therapeutic skills can be learned by physicians to treat biomechanically complex rib-related chest wall pain in combination with interventional image-guided techniques. Pain physicians should learn certain basic manual manipulation skills both for diagnostic and therapeutic purposes.