HomeAnswersRheumatologyrib cage painWill Ankylosing spondylitis cause pain in lower ribs?

I get pain in my lower ribs while coughing and taking deep breath with history of AS. Please help.

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The following is an actual conversation between an iCliniq user and a doctor that has been reviewed and published as a Premium Q&A.

Medically reviewed by

Dr. Vinodhini J.

Published At June 4, 2020
Reviewed AtJuly 25, 2023

Patient's Query

Hello doctor,

I have been having pain around my lower ribs towards the back side (left side) for the past eight days. The pain gets worse while lying down and trying to change sides in the night. It also hurts while sneezing or coughing (feel better if I cough or sneeze by holding the area with my hand). It hurts a little sometimes while deep breathing. While sitting or standing straight, the pain is almost not there and also it does not hurt while bending forward or backward. But it hurts a little while bending sideways. I did a course of Aceclofenac + Paracetamol + Tramadol for five days and the pain did come down slightly.

However, it again got bad last night. I was diagnosed with ankylosing spondylitis. Since then I have had two episodes of severe pain in my lower back right side (sacroiliac joint). But it has never had pain in the area of the ribs like what is happening now. I have also had multiple episodes of uveitis over the past eight to nine years. I am HLA-B27 positive. I do not have any other symptoms. My appetite is fine and I do not feel any other discomfort. My motion is regular. Also, I am not on any regular medication. My BP is normal (measured using an electronic commercial machine at home) and my vitals were mostly normal (apart from slightly high cholesterol) when I did my health checkup three years back.

Hi,

Welcome to icliniq.com.

In light of the fact that you are HLA B27 (Human Leukocyte Antigen B27) positive, the pain that you are experiencing is due to the same problem. This is called enthesitis, and it occurs due to inflammation at the attachment of muscles to bones. So the treatment also remains similar to that of AS. You need to take a full dose of NSAID (non-steroidal anti-inflammatory drugs) whichever suits you best. For the present, you could take tablet Diclofenac Sodium twice daily with an antacid like tablet Pantoprazole. If things are still bad, tablet Sulfasalazine may be added. Calcium and Vitamin D must be continued. Regular physical exercise is a must to control this disease. Please make sure you follow this.

I hope this helps.

Patient's Query

Thank you doctor,

Could you please tell me for how many days should I take the Diclofenac Sodium before I take a call whether or not to add Sulfasalazine? Also, I had taken a combination of Aceclofenac + Paracetamol + Tramadol for five days last week.

Hello,

Welcome back to icliniq.com.

I think depending on how well you feel with Voveran take it twice a day for at least one week, then you can probably reduce it to once a day for another one week, by then we can take a call.

Patient's Query

Thank you Doctor.

Hello,

Welcome back to icliniq.com.

I could not see the photo. However, yes, there is no problem in switching to Indomethacin 75mg twice daily if the tablet Diclofenac Sodium is not helping. Give it a try and see if it works better than tablet Diclofenac. Additionally, remember to take supplements for calcium and vitamin D. If needed, you can also take an antacid like tablet Pantoprazole.

Thank you.

The Probable causes

HLA-B27 positive.

Differential diagnosis

Pleuritis of other causes.

Probable diagnosis

Ankylosing spondylitis.

Treatment plan

Tablet Indomethacin 75mg bd for two weeks.

Preventive measures

Exercise.

Patient's Query

Thank you doctor for the reply,

I am once again trying to upload a picture showing the exact spot of swelling and the main pain. With the help of the internet, I am trying to provide you with the anatomical name of the muscle where the swelling is, in case you are still unable to see the photo latissimus dorsi muscle (under my left arm). The area feels tender and pains even more when pressed. Yesterday, I started taking Indomethacin as discussed. However, unlike Diclofenac Sodium, the Indomethacin did not provide immediate relief with the first capsule. The pain slowly became intolerable around morning. I could not help but ask my family physician over the phone for any SOS kind of painkiller to take in addition to the Indomethacin. She informed me that Indomethacin might take a few days to start showing its effect and advised me to take TRD-MD (Tramadol) twice a day for the next three days, hoping that by then, the Indomethacin would reduce the swelling and pain on a more permanent basis.

The TRD-MD worked like magic, and I could get some good sleep yesterday afternoon and last night as well. The pain returned late last evening (around 10 hours after the first TRD-MD), but it was not too bad as long as I was sitting or walking slowly. I took the next TRD-MD at night and went to bed after an hour. However, the TRD-MD was yet to take effect, and lying down after sitting on the bed was excruciatingly painful. Thankfully, after lying down for a few minutes, the TRD-MD took effect, and I slept well. Could you please give me your advice on whether I am heading in the right direction with the treatment and should wait for the Indomethacin to work? Or should I try to see a rheumatologist/orthopedic specialist physically and get an X-Ray or MRI done in a day or two? The problem is that visiting a hospital seems very risky given the chances of Covid infection, and most hospitals are hotspots right now.

Apologies for such a long query. I am feeling a little helpless because I am unable to physically show myself to a doctor, and I am apprehensive about the pain and swelling in this area of my body since it is the first time I am experiencing this.

Thank you.

Hello,

Welcome back to icliniq.com.

There is no problem in taking Tramadol; in fact, you could also take a tablet containing Ultracet (Tramadol hydrochloride and Acetaminophen) thrice daily if the pain is excessive. I am not sure if Indomethacin is working; however, let us give it a day or two before deciding. If it does not show any effect by then, the next option would be to switch to something else like a combination of Etoricoxib and Paracetamol twice daily along with Ultracet. As the pain improves, the doses may be reduced. We can probably wait for the X-ray

Thank you.

Patient's Query

Thank you doctor for the reply,

I thought I would update you today as I am completing the seventh day of Indomethacin. So, I had taken two and a half days (five tablets) of TRD-MD. On Sunday evening, (approximately 8 hours after taking the last TRD-MD), I experienced a splitting headache, sweaty hands, and severe dizziness. It was at a scary level, so I spoke to my family physician and asked if I could stop the TRD-MD, to which she permitted me. I slept through the night, and the next morning, the headaches and other symptoms were gone. Surprisingly, the pain did not return to an intolerable level despite not taking the TRD-MD. It remained at a low level, and even the process of lying down, which was extremely painful last week, has become much more tolerable. So, I deduced that Indomethacin was working.

However, the following concerns are still bothering me, while the pain has not returned to the intolerable level of last week, it is still present, especially with certain specific movements, and it increases slightly towards the evening. The swelling has reduced slightly compared to last week, but it seems to have remained unchanged over the last three days. Other parts of my body have started to ache due to constantly sleeping on one side. Today marks exactly one week of taking the 1-0-1 dosage of Indomethacin. A few years back, I had taken Indomethacin for 2 weeks (1-0-1) and then another 2 weeks (1-0-0). Should I follow the same dosage this time? I am once again trying to attach the picture of the exact spot of the swelling and the pain.

Hello,

Welcome back to icliniq.com.

Yes, it will be better to continue with the medication for at least another week, depending on the pain and discomfort, and then the dosage may be reduced. It might not be possible to fully stop Indomethacin after a week, but the dose may be reduced to once daily. Are you also taking Sulfasalazine for arthritis, along with supplements for calcium and vitamin D? Additionally, I hope you have started doing gentle exercises for the back and breathing exercises for the chest.

Thank you.

The Probable causes

Enthesitis.

Treatment plan

Tablet Indomethacin 75 mg bd for seven days.

Preventive measures

Exercise regularly.

Patient's Query

Thank you doctor for the reply,

No, I have not started on Sulfasalazine yet, and I have never taken it before either. The two episodes of ankylosing spondylitis pain that I have had in my life so far were both treated with Indomethacin only, and it took about a month for both episodes to get better. However, both times the pain was in my lower back, specifically on the right side around the sacroiliac joint. Should I start taking Sulfasalazine now? Yes, I am currently taking calcium supplements daily once and a vitamin D3 supplement once a week for the past two weeks. Before this pain started, I used to swim three to four times a week until the Covid lockdown forced swimming pools to close. I also used to do mild exercises, including back stretching and breathing exercises. However, I stopped doing exercises because I was not sure if I should continue while experiencing this pain.

Hello,

Welcome back to icliniq.com.

I think it would be a good idea to start with gentle exercises right away to help you manage this pain. Additionally, sometimes tablet Sulfasalazine can be beneficial. I suggest giving it another week or so, and if the need for painkillers still persists, it is better to start Sulfasalazine 500 mg twice daily along with tablet Folvite (folic acid) acid daily.

Thank you.

Patient's Query

Thank you doctor for the reply,

Until yesterday, the pain and swelling in my upper back had steadily reduced. I would say 90 percent of the pain was gone. However, yesterday, I started experiencing some pain in my right knee, and this morning, I noticed a slight swelling just above my knee. The knee feels tight, and it hurts while walking or folding the knee. This situation brings back a painful memory of when I was 18 years old. At that time, I had a severe pain and swelling in my right knee. I was not aware of my HLA B27+ status. From what I remember, an orthopedic prescribed "Sulfasalazine," and it got cured after about a month. The doctor had mentioned that it was a disease that affected only young adults and usually did not occur after 21-22 years of age.

Now, I am slightly panicked because the pain in my knee is reminiscent of that previous experience. I am feeling extremely tired, especially since my back was just starting to get better, and suddenly the knee is troubling me. Could these two issues be related to the same condition? Should I consider adding or changing any medication immediately, or should I seek physical access to a doctor? Just to reiterate, my current ongoing medications are, Indomethacin 75 mg, twice daily, Pantoprazole twice daily, and calcium and vitamin D3 supplements once daily. I would eagerly await your advice. Thank you.

Hello,

Welcome back to icliniq.com.

Yes, this is related to the back condition, and it seems you have no choice but to restart tablet Sulfasalazine 500 mg twice daily along with tablet Folvite 5 mg. Give your knee some rest, and you can do hot or cold fomentation to help alleviate the discomfort. If the pain and swelling subside with rest and fomentation, that is a positive sign. However, if the pain and swelling persist, the next option will be to consider taking oral or injectable steroids to manage the excess pain and swelling. So, there is no need to panic; this is part of your disease and can be managed accordingly.

Thank you.

Patient's Query

Thank you doctor for the reply,

So, should I discontinue the Indomethacin or Sulfasalazine? Is Folvite in addition to Indomethacin? And should I continue with the other medications?

Hello,

Welcome back to icliniq.com.

Yes, Sulfasalazine and Folvite will be in addition to the previous medicines.

Regards.

Patient's Query

Thank you doctor for the reply,

I have been taking Sulfasalazine 500mg (1-0-1) and Nucoxia-P (Etoricoxib and Paracetamol) 60mg (1-0-1) for the past four days. I understand that Sulfasalazine is a slow-acting medicine and may take over a week before I feel any positive effects. My back and knee both feel slightly better, and the swelling in those areas also seems to be reducing, albeit slowly. However, since Saturday night, I have started experiencing pain in my left elbow, and today the pain is so severe that I can barely move my arm. Additionally, there is swelling right on my elbow joint.

I am guessing this means the disease is still very much active. Do I need to do anything more for the elbow, or should I just tolerate the pain and wait for Sulfasalazine to work overall? I am doing hot and cold fomentation, but it does not seem to be of much use. It has been exactly four weeks since the pain in my left upper back started, and while that spot feels better (not completely cured), I now have pain and swelling in my left elbow, swelling and stiffness in my right knee, and overall body stiffness and slight pain.

Hello,

Welcome back to icliniq.com.

Yes, the disease is definitely still active. I suggest that now you need to switch over to Sulfasalazine DS (double strength) twice daily. It will take some time to take effect. The other option is to consider taking a mild steroid dose if you are willing to do so. Nucoxia needs to continue along with vitamins and calcium supplements.

Regards.

Patient's Query

Thank you doctor for the reply,

I have never had to take steroids before, and yes, I am continuing with Folvite and D3 supplements. Could you please advise on which steroid to take and what should be the dosages for how many days? Also, what can I expect in terms of recovery if I take it? Additionally, what are the side effects that I should be aware of?

Hello,

Welcome back to icliniq.com.

Steroids are sometimes used in SPA (spondyloarthritis) when the arthritis flares up. We typically administer low dosages of tablet Prednisolone 20 mg for five to seven days and then gradually taper it off over the next few days. This approach helps in reducing inflammation faster, leading to a quicker recovery. The plan is to gradually reduce the tablet Prednisolone 20 mg by 5 mg every week until finally stopping it, following the sequence 20-15-10-5. In terms of side effects, short courses of steroids over short periods generally do not cause any significant side effects. However, a mild increase in appetite, reduced sleep, or fatigue may be experienced during the course of treatment.

Regards.

Patient's Query

Thank you doctor for the reply,

As advised, I have been taking Sulfasalazine DS (double strength) and a combination of Etoricoxib and Paracetamol for the last week. While the overall pain level has improved, the swelling in my knee and elbow is still present, and full movement is not possible. I have also noticed slight swelling and pain in my left wrist and palm. As the pain level has decreased, I have not started on steroids yet. Should I continue with the same medication and hope for a slow recovery, perhaps in another couple of weeks or so? Additionally, should I undergo any blood tests or any other examinations at this stage to further assess my condition?

Thank you.

Hello,

Welcome back to icliniq.com.

So now you are on Sulfasalazine DS (double strength) twice daily. If the pain level is low, we can continue with the same medication, and the swelling should gradually reduce. Remember to continue with gentle exercises for the involved joints and back. If fomentation helps, you may also continue doing that. If you have not done it for some time, you can consider doing the following blood tests: CBC (complete blood count), ESR (erythrocyte sedimentation rate), CRP (C-reactive protein), LFT (liver function tests), and serum creatinine. Additionally, I hope you have had your sugar and thyroid tests done within the past year.

Regards.

Investigations to be done

CBC (complete blood count), ESR (erythrocyte sedimentation rate), CRP (C-reactive protein), LFT (liver function tests), and serum creatinine

Treatment plan

Sulfasalazine DS (double strength) twice daily.

Patient's Query

Thank you doctor for the reply,

The test reports have come in. I am attaching them (attachments removed to protect patient's identity). My impression is that the ESR is very high: 76, and the CRP is also very high: 86.9. Could you please let me know your impression and if there should be any change in treatment? I feel better as far as the pains are concerned, but the swelling in my left elbow and right knee, along with overall stiffness, is still very much present.

Hello,

Welcome back to icliniq.com.

Yes, the inflammatory markers are high. I suggest taking a course of steroids along with the other medicines. You can start with the tablet Prednisolone 20 mg and then gradually reduce the dose by 5 mg every five days until you stop it. This will help with the pain and also reduce the inflammation.

Regards.

Same symptoms don't mean you have the same problem. Consult a doctor now!

Dr. Puri Divya Inder
Dr. Puri Divya Inder

Rheumatology

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