Painful rib syndrome.

Painful rib syndrome EDITOR,-The painful rib syndrome recently described by Scott and Scott is, in my opinion, a misnomer. Over the years I have seen numerous cases similar to the ones they report, and have found that the tender spots they allude to are not in the ribs but in the muscles. They are, in fact, myofascial trigger points. Pain develops because of trauma induced activation ofnociceptors at these sites in what is now called the myofascial pain syndrome.' These trigger points may be found in any miuscle in the body. In the abdomen they commonly occur in the rectus abdominis and external oblique muscles. They do not only develop, however, at or near to their insertion into the ribs, but also in their bellies and at lower attachment sites such as the iliac crest, inguinal ligament, and pubic bones. The pain emanating from trigger points in this syndrome may be abolished by injecting a local anaesthetic into them.2 Recently it has been shown that pain is also relieved by stimulating A-delta nerve fibres at these sites with dry needles; treatment that is physiologically more rational besides being simpler, safer, and equally effective.3 Gastroenterologists must learn to recognise 'trigger point pain' because it is common and can be treated. The concept of the painful rib syndrome restricts the diagnosis to pain in the lower thorax and upper abdomen, as well as implying that there is no effective treatment other than reassurance. Trigger point pain may occur anywhere in the abdomen with additional sites in the perineum and back. The pain can be recognised easily so unnecessary investigations and operations are avoided. It usually responds quickly to acupuncture; further courses can be given if relapse occurs. EDITOR,-Scott and Scott review what they call the painful rib syndrome (Gut 1993; 34: 1006-8), consisting of three features: pain in the lower chest or upper abdomen, a tender spot on the costal margins, and reproduction of the pain on pressing the tender spot. In the discussion, it is stated that the cause of this syndrome is not known. It is perhaps helpful to look at history. The region at or below the cartilaginous parts of the ribs is also known as the hypochondrium from Greek hypo=below and chondros=cartilage. It was Galen from Pergamon (living AD 129-199) who first described a syndrome at this location consisting of pain in the region below the ribs, bloating, …