Question
Dear doctor,
three months ago I started having a pain in my right flank, exactly in one of the last ribs.
I feel this pain only If I press or when I sleep on this side.
I went to the doctor and he did ultrasound which was fine and blood test (fine too).
I am still feeling this pain and I becoming depress because I cannot find the reason.
The doctor prescribed ibupropheno but it did not work.
I am a woman, 34. My profession is spanish teacher and I have a son who is eighteen months. (I though t you'll need this information).
I apreciate your time and consideration.

Answer
Dear Ana,

Sorry to hear of your frustration with this ongoing undiagnosed problem.  Unfortunately there could be a myriad of problems or dysfunction that could be causing your pain.  It sounds as though your doctor was concerned with possible kidney dysfunction with the tests that were ordered.  Concerning the ultarasound, it is only valid for the stuctures that are being visualized.  Therefore, any tissue not visualized directly by the ultrasound may be responsible for the problem.  In addition I am not sure what blood tests were ordered...I assume that a CBC and Kidney profile were ordered which were normal.

So, now we are left with other organs in the area which could be the spleen on the left, the liver and gall bladder on the right, as well as the bowels and ovaries more toward the midline.  Any of these structures could be implicated as well as the musculoskeletal tissues that connect to the rib such as the intercostal muscles, the oblique muscles, or the rib itself.  

Concerning the liver/gall bladder there are factors that can implicate dysfunction in those organs.  Such as:  are you overweight, drink alcoholic beverages, do you have frequent gas, do you take prescription drugs.  The liver is the main filter organ of the body and has to clean the blood.  The gall bladder contributes to fat metabolism and when not working properly will result in abdominal/flank discomfort.  Afterthought:  You are a bit young for this type of problem.

Spleen...this could be implicated if you have had any illness in the past three months.  The spleen is also a filter type of organ concerning blood cells and is involved in immunity.  When you are sick, there is an increase in white blood cells, and consequently the spleen is working harder and may be enlarged or inflammed.  Infectious mononucleosis is the most common illness associated with these problems.

Ovaries...fibroids, ectopic pregnancy, any other host of female problems.  Although not as likely as the source of the problem, it should be considered.  This is really outside of my area of expertise and should be followed up with a OB/GYN for further explanantion of possible problems and consequences.  How long has it been since your annual examination?  You should relay these problems to your doctor.

Now the musculoskeletal aspect.  Did you participate in any activities that were more strenuous than normal a week before you started having the pain?  Any new activities or motions that have become daily activities or tasks in the last three months?  Any recent or old trauma to the area?  What about your posture while teaching?  Any habitual lifting on one side or another such as a backpack?  I want you to look at your activites of daily living and think if anything is different.

Conserning non-specific flank/rib pain, there are few concrete diagnoses.  Many times this type of pain is due to a non-specific inflammation due to a nerve impingement, small tissue tear in the muscles or fascial layer of tissue, and myotendinous strain can contribute to bone pain due to a pull of the periosteum, which is the outer layer of tissue that surrounds all bones..it is loaded with pain sensors.  There is also the chance that the inferior portion of lung tissue could have some adhesions/scar tissue/or inflammation which is only painfull when pressure is applied.  You see Ana, more complicated than you would think, and these are only the most common types of possible problems.

What I recommend.  Monitor your pain, when it occurs, why, how it feels, and get another examination from a different doctor.  I would recommend a chiropractic sports physician, a chiropractic orthopedist, or a medical orthopedist because of their increased education.  It is always a good idea to obtain a second opinion from another source.  When you schedule the exam/appointment, make sure that you get your ultrasound results as well as the blood tests to show the new doctor so that they will have the most current information to aid in a proper diagnostic opinion.

Please get back with me the results.  Without further examination (physical exam, orhtopedic exam, and possible radiographic exam), it si impossible to really figure out what may be happening.  I am sure this is not the answer you were looking for, But it is best to follow-up on your condition with additional examination.

Respectfully,
Dr. J. Shawn Leatherman