When Rib Pain Isn’t Muscular: A Hidden Liver Mass Behind Chiropractic Symptoms
Updated: Oct 20
Right lower rib pain often points clinicians toward the obvious suspects: strained intercostal muscles, irritated rib joints, thoracic spine referral, or nerve pain. In one chiropractic case report, that familiar pattern led somewhere far less expected, an incidental liver mass consistent with focal nodular hyperplasia.
The case matters because it shows how closely visceral pain can imitate musculoskeletal pain. It also shows why a careful exam, attention to non-mechanical clues, and timely imaging can change the entire direction of care.
This article is for informational purposes only and is not a substitute for medical diagnosis or treatment.
A familiar rib pain pattern hid a visceral problem
The patient in the case report was a 42-year-old man who came in with pain along the right lower ribs. The pain ran from the midsternal area toward the midaxillary line, meaning it crossed the front and side of the lower chest wall.
His symptoms sounded very much like a chest wall or nerve problem. The pain was described as:
Sharp
Aching
Radiating
Located around the right lower ribs
He also had painful and reduced right lateral bending of the thoracic spine. That finding seemed to fit a musculoskeletal diagnosis, at least at first.
But the history added an important layer. The patient had experienced a liver laceration from blunt abdominal trauma 34 years earlier. A remote injury does not automatically explain new pain decades later, but it can change how clinicians think through the possibilities.
The same region can contain overlapping pain sources. Lower rib pain may arise from the rib cage, thoracic spine, abdominal wall, gallbladder, liver, diaphragm, or nearby nerves. When a symptom map crosses those boundaries, the exam must stay open to more than one explanation.
The exam raised questions beyond the rib cage
During the chiropractic evaluation, Murphy’s sign was positive. Murphy’s sign is commonly associated with gallbladder irritation, especially when right upper abdominal pain increases during inhalation while the examiner palpates under the rib margin.
That finding did not prove gallbladder disease, but it made a purely rib-based explanation less secure.
Another clue came from palpation. When the clinician pressed on the anterior right lower ribs, the patient felt epigastric pain, meaning pain in the upper central abdomen. Pain that shifts into an abdominal region during rib palpation can suggest that deeper tissues are involved.
An Activator instrument-assisted adjustment was performed at rib 8. The pain did not improve. That lack of response also mattered. Failed relief after a reasonable musculoskeletal intervention does not rule out a rib problem, but it should prompt a reassessment.
The working diagnosis was intercostal neuralgia, a type of nerve pain that can follow the path between ribs. Given the positive Murphy’s sign, the patient was referred for a gallbladder ultrasound to rule out acute cholecystitis.
That referral changed the case.
Imaging revealed the real surprise
The ultrasound did not simply point toward gallbladder disease. Instead, it found an incidental large hypervascular liver mass.
That finding led to multiphase contrast abdominal CT, which gives more detail about how a lesion appears during different phases of contrast enhancement. The CT showed an 8.8 cm mass in the left lobe of the liver. It was mildly hyperattenuating and moderately enhancing, with a hypoattenuating central scar.
Those imaging features were consistent with focal nodular hyperplasia, often shortened to FNH.
FNH is generally considered a benign liver lesion. It is often found by accident when imaging is done for another reason. Many people with FNH have no symptoms. Still, when a lesion is large or sits in a sensitive location, clinicians may need to determine whether it is related to pain and whether follow-up is needed.
The key point in this case is not that every rib pain patient needs advanced imaging. Most do not. The point is that the clinical picture changed when exam findings suggested a possible visceral source.
Why visceral pain can mimic musculoskeletal pain
Visceral pain can be hard to localize. Organs do not always produce pain directly over the organ itself. Pain may feel vague, referred, or similar to muscle and joint pain.
The liver and gallbladder sit under the right rib cage. Irritation in that region may be felt as lower rib pain, upper abdominal pain, back pain, or shoulder-region discomfort. For a clinician seeing a patient with rib pain, this creates a diagnostic challenge.
Musculoskeletal pain often changes with motion, posture, breathing, or direct pressure. Visceral pain can also appear to change with movement because breathing and trunk motion shift pressure through the chest and abdomen. That overlap can blur the picture.
In this case, several details pushed the assessment beyond a routine rib complaint:
The pain radiated across the lower chest wall
Right lateral thoracic bending was reduced and painful
Murphy’s sign was positive
Rib palpation reproduced epigastric pain
Rib treatment did not relieve symptoms
Past liver trauma was part of the history
None of these details alone confirmed the diagnosis. Together, they supported the decision to refer for diagnostic imaging.
What clinicians and patients can take from the case
The case offers a practical reminder for conservative care settings. Chiropractors, physical therapists, and other musculoskeletal clinicians often see pain first. That puts them in a key position to identify when symptoms do not fit the expected pattern.
A good exam does not stop at the painful joint or muscle. It asks whether the pain behaves like a mechanical problem, whether the history raises concern, and whether the response to care matches the working diagnosis.
For patients, the takeaway is similar. Rib pain that feels muscular often is muscular. But medical evaluation is wise when pain is unusual, severe, persistent, linked with abdominal symptoms, or not responding as expected.
Possible warning signs include:
Fever, chills, nausea, or vomiting
Yellowing of the skin or eyes
Unexplained weight loss
Severe right upper abdominal pain
Pain after significant trauma
Chest pain, shortness of breath, or fainting
Pain that continues despite appropriate conservative care
The most useful lesson from this case is not fear. It is clinical humility. The body does not organize pain into neat categories. A symptom that starts in the ribs may still deserve a broader look.
The real value of the diagnosis
The discovery of the liver mass came from a chain of careful decisions. The clinician recognized that the case had non-mechanical features, referred for sonographic evaluation, and imaging clarified the finding.
That is the value of diagnostic imaging when it is used thoughtfully. It can prevent guesswork, redirect care, and identify conditions that would otherwise remain hidden.
Rib pain may begin as a chiropractic complaint, but the best care keeps the whole person in view. When the story does not fit the expected pattern, the next step is not more force. It is better information.
Citation
Roman Guzman IM, Halverson J. Focal nodular hyperplasia of the liver incidentally identified in a chiropractic patient with rib pain, a case report.
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