Back Rib Pain: Causes Explored, Solutions Revealed

The Relationship Between the Back and the Ribs

The relationship between the back and the ribs is a close one. The thoracic spine, otherwise known as the mid back, runs along the posterior (back) side of the body and provides support for the rib cage. It is that portion of the spine that is below the neck and above the lower back.

The ribs, in turn, wrap around the front and sides of the chest, creating a protective cage for the internal organs and providing attachment points for various muscles involved in breathing and movement.

The thoracic spine has the following key components:

1. Vertebral bodies: The bony building blocks that stack one upon another.
2. Discs: Shock absorbers that are sandwiched between each pair of vertebral bodies.
3. Facet joints: Paired joints that occur at every level of the spine and provide spinal stability and alignment and absorb some of the forces of daily living.
4. Muscles: Multiple muscles play an important role in movement, posture, and support of the spine.
5. Nerves: At each level of the spine, nerves exit the spinal cord. These nerves transmit signals that control movement and sensation. 
6. Costotransverse joint: This is a cartilage-lined joint that is unique to the thoracic spine. It occurs at each level of the thoracic spine and is formed by the union of the rib and the transverse process of the spine. 

The ribs have the following key components:

1. Rib cage: 12 paired ribs surround and protect vital organs in the chest, such as the heart and lungs.
2. Sternum: The flat bone in the front of the chest. It is often referred to as the breastbone. The true ribs connect anteriorly to the sternum through costal cartilage.
3. Costal cartilage: Connects the true ribs to the sternum. It is flexible and allows for expansion and contraction of the rib cage during breathing. It is susceptible to inflammation and injury.

What Can Back and Rib Pain Feel Like?

Persistent pain in the ribs that does not respond to conservative therapy can be an indication that there are problems within the musculoskeletal system. Consider it a warning sign that warrants further attention. Patients with back rib pain and dysfunction can have several different symptoms that include:

• Pain: Pain may be abrupt in onset or insidious. It can feel like a sharp, stabbing pain or a dull aching pain in the upper back. It can be localized or diffuse in character. 
• Swelling: Swelling associated with back pain in the ribs can vary in severity depending on the underlying condition or injury. In general, swelling in the back ribs may present as a noticeable bulge or bump on the affected area, or as an area of redness or inflammation around the injured site.
• Bruising: Bruising associated with back pain in the ribs can occur due to trauma or injury to the area, such as a fall or direct blow to the rib cage. The bruising may appear as a discoloration of the skin around the affected area, ranging from red or purple to yellow or green as it begins to heal.
  
  Bruising associated with other conditions, such as inflammation of the rib cartilage (costochondritis) or a herniated disc, may also cause discomfort or tenderness around the affected area and may limit movement or cause difficulty breathing.
• Difficulty breathing: Difficulty breathing associated with back pain in the ribs can be a serious symptom and may indicate a potentially life-threatening condition. In some cases, the pain and swelling associated with rib injuries can make it difficult to expand the lungs and take deep breaths, leading to a feeling of shortness of breath or difficulty breathing.
• Tenderness: The affected area may be tender to the touch.
• Muscle spasm: The muscles around the back rib area may be painful and go into spasm. Patients often describe cramping or muscle tightness.
• Radiating pain: In some cases, back rib pain may radiate to other areas, such as the chest wall, shoulder blade, or abdomen.

Causes of Back and Rib Cage Pain

Understanding the causes of back and rib cage pain is the first step toward seeking appropriate treatment. The pain one experiences can be attributed to a variety of factors, some of which are outlined below:

1. Rib injury: bruised, fractured, or broken ribs are common causes of back rib pain.

2. Costochondritis: Also known as Tietze’s syndrome, costochondritis is a painful medical condition characterized by inflammation of the cartilage that connects the ribs to the sternum (breastbone). The term is derived from “costo,” which refers to the ribs and “chondro,” which refers to cartilage. 
   
   Back rib pain from costochondritis can range from mild to severe. Symptoms can include tenderness and pain with palpation or when taking deep breaths.

3. Lung infections: bronchitis or upper respiratory infection. The pain may be caused by the infection itself, a pulled muscle, or irritation of the lung lining. 

4. Cancer: Lung cancer is the second most common cancer in the United States and is a leading cause of mortality in the United States.(1) 

5. Pulmonary embolism: Pulmonary embolism is a blockage in one of the pulmonary arteries in the lungs. In most cases, a pulmonary embolism is caused by a blood clot that travels to the lungs from deep veins in the legs or, rarely, from veins elsewhere in the body. 
6. Thoracic disc injury: The thoracic discs in the thoracic spine act as shock absorbers. They are vulnerable to injury, including disc protrusion, herniation, and extrusion, which can cause back rib pain.

Poor Posture

Poor posture is increasingly common due to excessive screen time on cell phones and computers. This can lead to several complications, including rib, thoracic spine, joint and disc degeneration, and head forward posture. Head forward posture can lead to kyphosis, also known as hunchback.

Muscle Strains

The thoracic spine and ribs have many small and large muscles that provide support and movement. Examples include the intercostals, trapezius, rhomboids, and latissimus dorsi. A muscle strain is commonly called a pulled muscle and occurs when the muscle is injured through direct or indirect trauma.(2) Back rib pain, swelling, and restricted movement can be common symptoms of a muscle sprain.

Ligament Sprains

Ligaments are thick pieces of connective tissue that connect bone to bone. They provide important stability for the ribs and thoracic spine. A sprain involves the overstretching or tearing of the ligaments. Ligament injuries are common, occurring at the rate of approximately 17 million injuries per year in the United States.(3)

Joint Injury or Dysfunction

Three important joints can cause thoracic spine and rib pain. Injury can occur to these joints and is most commonly due to trauma, degenerative changes, and ligament laxity. The three joints are:

• Thoracic facet joint: A facet joint is a small paired joint on the backside of the spine that provides important stability, facilitates the transfer of loads, and supports spinal motion.(4) Thoracic facet joints are susceptible to injury and degeneration, which can cause back rib pain. 
• Costotransverse joint: This is an important joint in the thoracic spine that is formed by the rib head and the thoracic spine. It is important in the bucket handle and pump-handle motion of the ribs, which facilitate respiration. 
  
  The joint is surrounded by a capsule and supporting ligaments, all of which are prone to injury and can cause back pain in the ribs. The referral pains of the different costotransverse joints have been established.(5)
• Costovertebral joint: The costovertebral joint is formed by the rib head as it joins the vertebral body, forming a joint. Like the costotransverse joint, it is surrounded by a capsule and supporting ligaments, all of which are susceptible to injury.

Organ Dysfunction

The thoracic cavity is full of structures that can become injured, degenerative, or diseased and  are capable of creating thoracic spine and rib pain. Examples include the heart, lungs, liver, spleen, and kidneys. Heart attacks, GI reflux, and pneumonia can all cause back pain in the ribs.

Shingles

Herpes zoster, aka shingles, is a viral infection that can cause severe, unrelenting burning pain in the thoracic spine, back rib, and chest wall. It is typically associated with a red rash that can progress to painful, fluid-filled blisters.

Thoracic Degenerative Disc Disease

Degenerative disc disease is a clinical condition that refers to the gradual deterioration of the discs located in the thoracic spine and the associated symptoms. Pain, weakness, muscle spasms, and restriction in range of motion are common. Degenerative disc disease can occur at each level of the spine: cervical, thoracic, and lumbar. Studies have demonstrated that degenerative disc disease in the thoracic spine most commonly occurs in the third to fourth decades (1) and occurs most frequently in the lower thoracic segments from T7-T12. Thoracic degenerative disc…

Read More About Thoracic Degenerative Disc Disease

Slipping Rib Syndrome

Slipping Rib Syndrome can be incredibly painful and is often misdiagnosed. It is also known as rib dislocation, rib subluxation, Tietze syndrome, Davies–Colley’s syndrome, rib-tip syndrome, painful rib syndrome, costochondral separation, and clicking or moving rib syndrome. It is very common for athletes involved in contact sports to get a slipped rib. Trauma causes stretching and sometimes tearing of the ligament attachments of the rib, creating instability. We also see this in many of our motor vehicle accident patients, caused by the seat belt and/or airbag. Once damaged, it can take several weeks to resolve (4-12 weeks). After 3 months, if the rib continues to…

Read More About Slipping Rib Syndrome

Degenerative Scoliosis

Degenerative Scoliosis, also known as Adult-onset Scoliosis, is a medical condition that involves a side bending in the spine. The bending can be mild, moderate, or severe with side-bending to either the right or the left. The term degenerative means generalized wear and tear and is common as we get older. Degenerative scoliosis is the curvature of the spine that occurs as a result of degeneration of the discs, small joints, and building blocks. The Degenerative Scoliosis curve is often located in the low back and forms a ‘C” shape. There is a convex and a concave side. The convex side is the open side where it curves outward.

Read More About Degenerative Scoliosis

Other Medical Conditions Associated with Back and Rib Pain

While the sources of back and rib pain can be numerous and varied, it’s important to note that certain underlying medical conditions can directly contribute to this discomfort. Understanding these conditions and their impact on the body can help in identifying the root cause of back and rib pain, and guide appropriate treatment strategies.

Here are some of the medical conditions that are known to be associated with back and rib pain.

Osteoarthritis

Osteoarthritis is the most common form of arthritis and can occur in the thoracic discs, facets, costotransverse, and costovertebral joints, causing back pain in the ribs.

Fibromyalgia

Fibromyalgia is a chronic condition characterized by pain, stiffness, and tenderness in the muscles, tendons, and joints of the body. The pain is typically widespread and can involve the thoracic spine and ribs.

Who Is at Risk of Back and Rib Discomfort?

Back rib pain can affect people of all ages and backgrounds. Factors or groups of individuals that may be at an increased risk for back rib pain include the following:

• Age: Older adults may be at a higher risk of developing back rib pain due to age-related changes in the spine, such as decreased bone density (osteoporosis) and changes in the cartilage that connects the ribs to the sternum.
• Trauma: Individuals who have experienced trauma or injury to the chest are at risk for back rib pain.
• Hypermobility: Ligaments are thick pieces of connective tissue that provide important support to the spine, facet, costotransverse, and costovertebral joints. Some patients have genetic conditions such as Ehlers-Danlos such that their ligaments are lax, putting them at risk for back rib pain. 
• Poor posture: Head forward compromised posture can injure the discs, joints, ligaments, and muscles, leading to pain, limited range of motion and dysfunction in the ribs and thoracic spine.
• Medical conditions: Patients with underlying medical conditions such as osteoporosis, fibromyalgia, and some types of arthritis are at risk for developing back rib pain. 
• Respiratory conditions: Chronic respiratory conditions that cause frequent coughing, such as chronic obstructive pulmonary disease (COPD) or bronchitis, can lead to muscle strain in the ribcage area and potentially contribute to back rib pain.
• Scoliosis: An abnormal side curve in the spine can put abnormal stress on thoracic discs, joints, ligaments, and muscles predisposing them to back rib pain. 
• Pregnancy: Pregnant women may be at risk of back rib pain, particularly in the later stages of pregnancy, due to the changes in posture and the increased pressure on the ribcage caused by the growing fetus.

How Are Symptoms Diagnosed in Professional Care?

Persistent back rib pain, limited range of motion, and swelling that does not respond to conservative care warrants further evaluation, which involves multiple steps. 

• Medical history: Important information to share with your medical provider includes past medical history, current medications, surgical history, and recent injuries.
• Pain history: Detailed information to share with your medical provider about your pain includes onset, duration, pain location, severity, the character of the pain, aggravating and alleviating factors, and whether it is localized or radiates. 
• Physical examination: This includes inspection of back and ribs, range of motion, identification of areas of tenderness, swelling, or signs of injury, motor strength and neurologic testing. 
• Radiographic tests: Imaging studies may be requested that include X-rays, CT scans, and MRI to better evaluate the spine, facets, discs, ligaments, muscles, and nerves. These tests can help identify fractures, dislocations, or other structural issues.
• Lab tests: Blood tests may be ordered to check for signs of inflammation or infection that may be causing the pain.
• Lung assessment: In some cases, back rib pain may be related to lung or respiratory issues. Your doctor may order chest X-rays or pulmonary function tests. 
• Ultrasound: Ultrasound is a powerful in-office imaging modality that can evaluate muscle, tendon, and ligament injuries. At the Centeno-Schultz Clinic, an ultrasound evaluation is often conducted during evaluations and follow-up visits. Ultrasound offers dynamic evaluations, whereas CT scans and MRI are static and cannot accurately evaluate joint instability.

What You Can Do for the Pain

Treatment options for back pain in the ribs vary depending on the underlying cause and severity. That is why securing an accurate diagnosis is so important. For example, the treatment of thoracic spine and rib pain arising from scoliosis is different from pain due to an infection. When appropriate, conservative therapy should always be the first line of treatment. Treatment options include the following:

Rest and Supportive Measures

Conservative treatment options for back rib pain include: 

• Rest: Rest is essential in allowing the affected area to heal, including avoiding certain activities that may cause pain or aggravate the condition.
• Heat: Applying heat can reduce inflammation, increase blood flow, and reduce pain.

Medications

When pain or dysfunction persists despite rest and heat, medications are often utilized. 

• NSAIDs (nonsteroidal anti-inflammatory drugs): Over-the-counter medications such as Ibuprofen, Advil, and Naproxen can effectively relieve rib pain. These medications should be avoided as they have significant side effects.
• Oral steroids: Steroids are powerful anti-inflammatory agents that reduce swelling and pain. Common examples include Medrol dosepak, cortisone, and prednisone. Steroids have significant side effects and may make the underlying condition worse, and for these reasons should be avoided.

Therapeutic Interventions

Effective therapies to address and treat back rib pain include:

• Posture improvement: Improving posture and spinal alignment can reduce thoracic spine pain and rib pain.
• Physical therapy: Physical therapy can help to strengthen the muscles around the affected area, improve flexibility, and alleviate pain.
• Chiropractic care: Chiropractic adjustments can help to realign the rib and surrounding structures, which may help alleviate pain.

Invasive Interventions

When conservative care and oral medications fail, patients are often referred for injections. Unfortunately, not all injections are the same. The most common injections are steroids, which are offered by pain clinics. 

• Steroid injections: Steroids are powerful anti-inflammatory agents that reduce inflammation. They are utilized in an attempt to reduce pain and improve function. Steroid injections for back rib pain commonly involve the thoracic spine or facet joints. Steroids have significant risks that include injuring the ligaments, joints, muscles, and discs in the spine and should be avoided. Steroids have been demonstrated to injure joint cartilage.(6)
• Orthobiologics: Orthobiologics are substances that can help damaged musculoskeletal tissues heal or mitigate degeneration. These include many categories, but PRP (platelet-rich plasma) and BMC (bone marrow concentrate) are the two most popular orthobiologics in use today. 
  
  To learn more about orthobiologics please click on the video below.

Injections in the thoracic region cannot be performed by your PCP or local orthopedic doctor as these are complex injections with significant risks including the collapse of a lung. Physicians must have a thorough understanding of the anatomy and be experts in the use of X-rays and ultrasound.

It is important to understand that not all PRP is the same. PRP is made by concentrating platelets, which are then injected. It would make sense that knowing how concentrated those platelets are or are not is a critical piece of information.

Most PRP is created by bedside centrifuges, which cannot adjust the PRP concentration. Some centrifuges produce low concentration (low dose) PRP and others create mid-range dose PRP.

Does PRP dose matter? Absolutely. We performed lab experiments in 2019, utilizing tendon cells.(7) Tendon cells were utilized as inflammation and injury of tendons (tendinopathy) is a common issue we evaluate and treat. Young tendon cells did fine with lower concentration (dose) PRP, whereas the older cells are stimulated to grow more with higher concentrations of platelets.

The bottom line is that PRP concentration matters. At the Centeno-Schultz Clinic, we have a university-level cell laboratory that can create a wide range of PRP concentrations. This is critical to achieve the best clinical outcomes in patients over 30 years of age.

If you have PRP treatment elsewhere or are considering PRP injections, please ask about the concentration of the PRP. If you get a blank stare, don’t be surprised!

Getting the proper diagnosis is crucial in treating back pain in the ribs because different underlying conditions or injuries can cause similar symptoms of pain in the back, making it difficult to determine the specific cause of the pain without a proper diagnosis.

For example, pain in the back ribs could be caused by muscle strain, a rib fracture, a herniated disc, or a pinched nerve.

Each of these conditions may require different treatment approaches, and treating the wrong condition may result in the worsening of symptoms or further injury.

At the Centeno-Schultz Clinic, we are experts in the evaluation and treatment of thoracic spine and rib pain. Board-certified, fellowship-trained physicians review your symptoms, aggravating and alleviating factors, past medical history, past surgical history, and current medications to determine the best regenerative treatment option.

PRP has concentrated platelets that are rich in growth factors that are vital to initiate and accelerate tissue repair and regeneration. Bone marrow concentrate which contains stem cells can potentially accelerate tissue repair, thereby reducing pain and increasing function.

Not all regenerative medicine clinics are the same. Important questions to ask include:

1. Who is performing the injections? At Centeno-Schultz Clinic all injections are performed by board-certified, fellowship-trained physicians.
2. What is the concentration of the PRP?
3. How are the injections performed? Injections without guidance (blind injections) are below the standard of care. At the Centeno-Schultz Clinic, all injections are performed with X-ray and/or ultrasound guidance to ensure accurate placement of the PRP or bone marrow concentrate.
4. Is the clinic prepared to manage an adverse event? Complications can and do occur, and it is essential to be prepared. At the Centeno-Schultz Clinic, we have a full resuscitation cart and equipment in each procedure room.

Get the Best Treatment for Your Rib and Back Pain

Thoracic spine and rib pain can be a common and debilitating condition. If thoracic spine or back rib pain persists despite conservative care, it is important to have the condition evaluated by an expert.

Back rib pain can be caused by several underlying conditions that include poor posture, muscle strain, ligament sprain, joint injury, organ dysfunction, infections, osteoarthritis, scoliosis, thoracic disc, thoracic joint, and fibromyalgia.

Symptoms may include pain, swelling, bruising, and difficulty with breathing. Securing an accurate diagnosis is critical for the best clinical outcomes. Treating the symptoms is NOT the answer. Rather, identifying the underlying cause of the pain is key.

At the Centeno-Schultz Clinic we are experts in the evaluation and treatment of rib and thoracic spine injuries and the use of orthobiologics. We are committed to securing an accurate diagnosis so that an effective treatment plan can be created.

 To learn more, please click the video below.

If you or a loved one continue to have back pain in your ribs that has not responded to conservative therapy, oral medications, or physical therapy, please schedule an appointment to learn about regenerative options. Find a lasting solution for your thoracic and rib pain. Make an appointment today.

Are you struggling with persistent back pain? Find out how our treatments address the root of your pain.

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References:

1. Chinmay T. Jani et al. Trends in Lung Cancer Incidence and Mortality (1990-2019) in the United States: A Comprehensive Analysis of Gender and State-Level Disparities. JCO Glob Oncol 9, e2300255(2023) 
2. Maffulli, N., Buono, A. D., Oliva, F., Via, A. G., Frizziero, A., Barazzuol, M., Brancaccio, P., Freschi, M., Galletti, S., Lisitano, G., Melegati, G., Nanni, G., Pasta, G., Ramponi, C., Rizzo, D., Testa, V., & Valent, A. Muscle Injuries: A Brief Guide to Classification and Management. Translational Medicine @ UniSa, 12, 14-18. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4592039/
3. Leong, N. L., Kator, J. L., Clemens, T. L., James, A., Enomoto-Iwamoto, M., & Jiang, J. (2019). Tendon and Ligament Healing and Current Approaches to Tendon and Ligament Regeneration. Journal of Orthopaedic Research: Official Publication of the Orthopaedic Research Society, 38(1), 7. https://doi.org/10.1002/jor.24475
4. Paschos, N. K., Link, J. M., Klineberg, E. O., Hu, J. C., & Athanasiou, K. A. (2018). Facet Joints of the Spine: Structure–Function Relationships, Problems and Treatments, and the Potential for Regeneration. Annual Review of Biomedical Engineering. https://doi.org/10.1146/annurev-bioeng-062117-120924
5. Young, B.A., Gill, H.E., Wainner, R.S. et al. Thoracic costotransverse joint pain patterns: a study in normal volunteers. BMC Musculoskelet Disord 9, 140 (2008). https://doi.org/10.1186/1471-2474-9-140
6. Wernecke C, Braun HJ, Dragoo JL. The Effect of Intra-articular Corticosteroids on Articular Cartilage: A Systematic Review. Orthop J Sports Med. 2015 Apr 27;3(5):2325967115581163. doi: 10.1177/2325967115581163. PMID: 26674652; PMCID: PMC4622344.
7. Berger DR, Centeno CJ, Steinmetz NJ. Platelet lysates from aged donors promote human tenocyte proliferation and migration in a concentration-dependent manner. Bone Joint Res. 2019 Feb 2;8(1):32-40. doi: 10.1302/2046-3758.81.BJR-2018-0164.R1. PMID: 30800297; PMCID: PMC6359887