A 70 Caucasian woman presents with a several month history of pain in the right lower quadrant. It does not radiate; it is 5/10 in severity during the day and better at night. It was worse at night especially when lying on the right side. Standing straight would make it better. She denied nausea, vomiting, diarrhea, weight loss or appetite change. She denied smoking, EtOH, MJ, illicit drugs; she does not take any medications, prescription or otherwise. She had a cholecystectomy 20 years previously. On physical examination her vital signs were normal. The abnormal physical findings were limited to the abdominal exam and back. Her abdomen was flat, soft with normal bowel sounds. She had kyphosis of the thoracic spine without pain on pressure over the spines. There was pain on palpation of the ribs in the right upper quadrant. The distance between her ribs and the pelvic rim was 2 finger breadths, or about 4 cm.
The patient has ribs on pelvis syndrome (RAP).1 This entity is described in older women with osteoporosis and wedge deformities of the spines giving her an increased kyphosis. The normal distance between the ribs and pelvic rim is more like 4 FB?s or 8 cm. As the ribs get closer to the pelvic rim it is thought that the ribs press on the pelvic rim causing the pain, especially when not standing or sitting straight. The pain tends to be worse later in the day. Where RAP causes pain in the anterior part of the abdomen, a similar syndrome, costoiliac impingement syndrome causes pain in the back and groin. There is one surgical article which suggests that surgical removal of the 12th rib on the affected side may give pain relief if physical therapy is unsuccessful.2