Puri, B K, Gunatilake, K D R, Fernando, K A C et al. · The Journal of international medical research · 2011 · DOI
Researchers examined the chests of 42 people with ME/CFS and 20 healthy people to look for physical signs. They found that 81% of people with ME/CFS had tenderness (pain when touched) in a specific area on the left side of their rib cage, while none of the healthy people had this tenderness. This suggests there may be a consistent physical finding that doctors could potentially use to help identify ME/CFS.
This study identifies a potential objective physical sign associated with ME/CFS, which is valuable given the disease's lack of established biomarkers. If confirmed in larger, blinded studies, such a finding could aid clinical diagnosis and potentially provide insights into underlying pathophysiology, particularly regarding lymphatic or cardiovascular dysfunction.
This study does not prove that left intercostal space tenderness causes ME/CFS or is specific to the disease. The finding is observational and correlational; the proposed mechanism involving lymphatic dysfunction is speculative and requires confirmation through imaging and mechanistic studies. A single positive finding in one small study requires replication before clinical adoption.
About the PEM badge: “PEM required” means post-exertional malaise was an explicit required diagnostic criterion for participant inclusion in this study — not that PEM was studied, observed, or discussed. Studies using criteria that do not require PEM (e.g. Fukuda, Oxford) are tagged “PEM not required”. How the atlas works →
The first block is for the primary paper and is the citation you should use in research work. The atlas-snapshot line only applies if you are specifically referring to this atlas’s reading of the paper on the date shown.
Primary citation
Puri, B K, Gunatilake, K D R, Fernando, K A C, Gurusinghe, A I, Agour, M, & Treasaden, I H (2011). Increased tenderness in the left third intercostal space in adult patients with myalgic encephalomyelitis: a controlled study.. The Journal of international medical research. https://doi.org/10.1177/147323001103900122
BibTeX
@article{mecfsatlas-puri-2011-increased-tenderness,
author = {Puri, B K and Gunatilake, K D R and Fernando, K A C and Gurusinghe, A I and Agour, M and Treasaden, I H},
title = {Increased tenderness in the left third intercostal space in adult patients with myalgic encephalomyelitis: a controlled study.},
journal = {The Journal of international medical research},
year = {2011},
doi = {10.1177/147323001103900122},
note = {PubMed: 21672323},
url = {https://www.mecfsatlas.com/evidence/puri-2011-increased-tenderness},
}Atlas snapshot reference
ME/CFS Atlas. Generator v1 / Scanner v1.4 / policy v0.1. Accessed 2026-05-30. https://www.mecfsatlas.com/evidence/puri-2011-increased-tenderness
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