{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,8,28]],"date-time":"2025-08-28T10:40:04Z","timestamp":1756377604484,"version":"3.44.0"},"reference-count":16,"publisher":"BMJ","issue":"7","content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Case Rep"],"accepted":{"date-parts":[[2025,7,16]]},"published-print":{"date-parts":[[2025,7]]},"abstract":"<jats:p>Chronic back pain is commonly attributed to musculoskeletal or spinal issues, but rarer conditions like twelfth rib syndrome can often be overlooked, leading to ineffective treatments. This case presents a male in his 50s with persistent left-sided flank pain, initially attributed to low back pain and degenerative disc disease. Despite conservative treatments, his symptoms persisted, prompting further investigation. A physical examination revealed localised tenderness over the twelfth rib, and a trigger-point injection provided immediate pain relief, confirming the diagnosis of twelfth rib syndrome. Differential diagnoses, including musculoskeletal pain, slipping rib syndrome, irritable bowel syndrome, pleuritis, renal pathology and costochondritis, were considered but ruled out. The patient\u2019s treatment involved trigger-point injections and physical therapy, resulting in significant symptom improvement. This case emphasises the importance of considering twelfth rib syndrome in patients with unexplained flank pain, especially when standard treatments fail and highlights the role of targeted interventions in improving patient outcomes.<\/jats:p>","DOI":"10.1136\/bcr-2025-266106","type":"journal-article","created":{"date-parts":[[2025,7,28]],"date-time":"2025-07-28T01:10:15Z","timestamp":1753665015000},"page":"e266106","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":0,"title":["Chronic back pain: recognising twelfth rib syndrome"],"prefix":"10.1136","volume":"18","author":[{"given":"Andrew","family":"Chen","sequence":"first","affiliation":[{"name":"Department of Rehabilitation and Physical Medicine, Penn State Health, Hummelstown, Pennsylvania, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jiqing","family":"Shi","sequence":"additional","affiliation":[{"name":"Penn State College of Medicine, Hershey, Pennsylvania, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Hong","family":"Wu","sequence":"additional","affiliation":[{"name":"Physical Medicine and Rehabilitation, Rush Medical College of Rush University, Chicago, Illinois, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8267-2796","authenticated-orcid":false,"given":"Weibin","family":"Shi","sequence":"additional","affiliation":[{"name":"Physical Medicine and Rehabilitation, Penn State Health Milton S Hershey Medical Center, Hershey, Pennsylvania, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"239","published-online":{"date-parts":[[2025,7,27]]},"reference":[{"key":"2025082803152466000_18.7.e266106.1","doi-asserted-by":"crossref","first-page":"52","DOI":"10.1038\/s41572-018-0052-1","article-title":"Low back pain","volume":"4","author":"Vlaeyen","year":"2018","journal-title":"Nat Rev Dis Primers"},{"key":"2025082803152466000_18.7.e266106.2","first-page":"379","article-title":"Musculoskeletal chest wall pain","volume":"133","author":"Fam","year":"1985","journal-title":"CMAJ"},{"key":"2025082803152466000_18.7.e266106.3","doi-asserted-by":"crossref","first-page":"172","DOI":"10.1016\/S0885-3924(96)00271-0","article-title":"The twelfth rib syndrome","volume":"13","author":"Cranfield","year":"1997","journal-title":"J Pain Symptom Manage"},{"key":"2025082803152466000_18.7.e266106.4","doi-asserted-by":"publisher","DOI":"10.1136\/bmj.287.6392.586"},{"key":"2025082803152466000_18.7.e266106.5","first-page":"E45","article-title":"Treatment and Management of Twelfth Rib Syndrome: A Best Practices Comprehensive Review","volume":"24","author":"Urits","year":"2021","journal-title":"Pain Physician"},{"key":"2025082803152466000_18.7.e266106.6","doi-asserted-by":"crossref","first-page":"889","DOI":"10.1002\/mus.28377","article-title":"Myofascial Pain Syndrome: An Update on Clinical Characteristics, Etiopathogenesis, Diagnosis, and Treatment","volume":"71","author":"Steen","year":"2025","journal-title":"Muscle Nerve"},{"key":"2025082803152466000_18.7.e266106.7","doi-asserted-by":"publisher","DOI":"10.1111\/j.1533-2500.2010.00408.x"},{"key":"2025082803152466000_18.7.e266106.8","doi-asserted-by":"publisher","DOI":"10.1136\/rapm-2019-101243"},{"key":"2025082803152466000_18.7.e266106.9","doi-asserted-by":"crossref","first-page":"183","DOI":"10.1053\/j.sempedsurg.2018.05.009","article-title":"Slipping Rib Syndrome: A review of evaluation, diagnosis and treatment","volume":"27","author":"McMahon","year":"2018","journal-title":"Semin Pediatr Surg"},{"key":"2025082803152466000_18.7.e266106.10","unstructured":"Schumann JA , Sood T , Parente JJ , et al . Parente, costochondritis. In: StatPearls. 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