Chris G. Koutures, MD, FAAP Pediatric and sports medicine specialist

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Comprehensive blend of general pediatric and sport medicine care with an individualized approach that enhances the health and knowledge of patients and their families



Proud physician:
USA Volleyball Mens/Womens National Teams
CS Fullerton Intercollegiate Athletics
Chapman University Dance Department
Orange Lutheran High School

Co-Author of Acclaimed Textbook

Pediatric Sports Medicine: Essentials for Office Evaluation

Orange County Physician Of Excellence, 2015 and 2016


Lower Rib Pain in Athletes

Have recently seen an interesting group of patients with significant lower rib area pain.

The pain is most often found either on the right or left side, and is particularly noted at the lowest of the twelve ribs. There might be a mass or finger-tip area of discomfort, while in others there is the pain is more spread out and may even move toward the flank or shoulder blade region.  Sometimes, the lowest few ribs actually "pop' or have excessive mobility on physical examination.

Don't tend to hear of any changes in appetite or bowel function, and if there is any evaluation of the organs or function of the abdominal cavity (liver, intestines, etc), this tends to be fairly unremarkable.

I definitely do hear about how certain body movements that can trigger issues. For some it is bending forward at the waist, while others are limited with turning/rotating or leaning back.

Here is another important commonality- they all are overhead athletes.

One is a swimmer, the next is a softball pitcher, and a third is a volleyball middle blocker, and yet another is a dancer.

As I have worked with each of them and recreate particular positions that bring about discomfort, it becomes glaringly apparent that shoulder region dysfunction is a strong contributor to the rib pain.

Now if you realize that there are three joints that make up the shoulder region, and one of them involves the scapula (wingbone) interaction with the rib cage, then the association between rib pain and shoulder function should become more clear.

Courtesy of:

Courtesy of:

  • Lower rib pain on the same side as the dominant arm, such as in a softball thrower or the volleyball hitter, often is due to tightness in the front of the shoulder that limits external rotation and eventually strength and power to hit or throw an object. To compensate for this lack of shoulder external rotation, the entire trunk may over-rotate in the direction of the dominant arm, placing abnormal traction forces on the abdominal muscles that attach to the lower rib area
  • Lower rib pain on the opposite side of the dominant arm often is due to tightness in the back of the shoulder glenohumeral joint that limits the follow through phase after hitting or throwing. To compensate, the entire trunk may over rotate to the side opposite the dominant arm and place abnormal traction forces on the abdominal muscles that attach to that opposite side lower rib area.
  • Swimmers and dancers tend to equally use both arms and thus might have pain on either side. Looking at the scapula position on the rib cage along with tightness in the front and back of the shoulder is essential to identifying causes of abnormal forces on the lower rib region.

Once these functional issues have been identified, have found that the combination of several management concepts can contribute to resolution of the lower rib pain:

  • Appropriate activity modification (limited hitting, throwing, or other provocative positions that trigger the lower rib pain)
  • Focus on increasing flexibility of the front/back of the shoulder along with addressing muscle firing patterns around the scapula
  • Evaluation of movement patterns in thoracic and lumbar spine that may be contributing to abnormalities at shoulder and lower rib area
  • Topical pain relief to lower rib area
    • This may include topical or injected anti-inflammatory medications, hot/cold, local friction massage, and acupuncture

These type of cases illustrate the importance of considering dysfunction in regions above or below the area of pain, and how the interaction of different joints continues to be a fascinating challenge for sports medicine specialists.

The above information is meant to illustrate past experience and is not meant to diagnose or act as a substitute for proper, individualized evaluation by a medical professional. It also does not guarantee the accuracy or outcomes of any diagnosis. Please do not hesitate to contact your sports medicine specialist for more information.