Rib Cage Pain: Why Medical Imaging Provides No Answers

My friend is adding onto her house, a project that requires careful planning at every step. First, the architect considers the type of space needed and its use, creating a broad design that integrates with the existing house and yard. Once foundational needs are determined, the focus shifts to details like plumbing, electrical, and windows. Only after these essentials are set does the fun part—interior design—begin.

A physical therapy (PT) evaluation for rib pain is much the same. We use a whole-body approach, starting with a broad assessment of your movement to identify what is functioning optimally and what is not. Next, we conduct a more specific evaluation, examining things like strength, joint range of motion, balance, and palpation (touch). This comprehensive assessment allows us to develop a targeted plan to reduce or eliminate your symptoms and help you return to doing what you love. Remember, everything is connected. So, sometimes what’s causing your rib cage pain isn’t the same place you’re experiencing that pain. 

By the way, you’ll see several ways of describing rib pain throughout this post, such as thorax pain, thoracic pain, and rib cage pain. While these terms are mostly interchangeable, here are their respective descriptions:

Thorax: The upper part of the trunk between the neck and the abdomen, enclosed by the rib cage, housing the heart, lungs, and major blood vessels.

Thoracic Cage: The bony framework of the thorax, composed of the ribs, sternum, thoracic vertebrae, and costal cartilages, providing protection to the chest organs.

Rib Cage: The arrangement of ribs attached to the spine and sternum, forming the chest’s protective structure and supporting respiration.

Understanding Rib Cage Pain and Its Symptoms

Rib cage pain can be a puzzling and frustrating experience. For many, the discomfort begins subtly—a twinge on your side or an ache in the mid-back area. Yet, over time, it can become disruptive.   Symptoms can vary, but people may report sharp pain with deep breaths, a dull ache after a day’s activities, discomfort when sitting or standing for long periods, pain with twisting, or even during simple tasks like lifting a bag or reaching overhead. As the pain persists, it’s natural to seek answers from medical imaging like MRIs, CT scans, and X-rays. However, these scans often come back “normal,” leaving patients feeling confused and still in pain.  For some, this pain has been present for years, undiagnosed and unresolved, despite numerous tests.

So, why doesn’t imaging provide answers? The answer lies in the nature of rib cage pain. Often, this pain originates from the muscles between the ribs, called intercostal muscles, or from restricted joint movement around the thorax (rib cage area). When these muscles become tense, inflamed, or strained, they can create intense, pinpointed pain that doesn’t show up on imaging. Since MRI and X-rays are designed to capture structural issues like fractures or significant tissue damage, they won’t detect the movement limitations or muscle dysfunctions responsible for rib cage pain.

This is where a whole-body evaluation with a physical therapist can make a difference. PTs assess the way your rib cage, spine, and surrounding muscles move together, identifying any restrictions or weaknesses that contribute to your pain. By addressing these root causes through targeted movement therapy, many people find lasting relief from pain that imaging simply couldn’t explain.

Real Solutions Through Movement and Manual Therapy

Recently, I’ve seen five patients with pain in the thorax or rib cage, specifically in the side and mid-back areas. During a physical examination, including palpation at rest and while taking deep breaths, I found that specific intercostal muscles were tender and painful. This tenderness limited normal rib cage movement during both breathing and other motions.

• Two of the patients were dentists who sat very still while doing their work.  They needed to be taught how to use their lower body both when working while sitting and functionally while standing so as not to overuse their intercostal muscles when using their arms to work and with daily functions.
• One patient had done repetitive rotation movements while installing a wood floor—straining his deep upper back (thoracic) muscles which then caused him to strain the intercostal muscle. 
• Two of the patients needed total hip replacements as they lacked significant hip mobility from the extensive degeneration.  When using their arms they strained their intercostal muscles because their hips didn’t allow them to move optimally when reaching or twisting.
• One patient had 2 total knee replacements a few years ago and still walked with a side-bending gait because of hip weakness.  The patient’s excessive sidebending led to significant restrictions in her rib cage limiting rib cage expansion during breathing and poor arm swing when walking.

By the time these patients came to see me, each had experienced intercostal pain for two to five years. Their symptoms varied, from pain at the end of the day, tingling in their arm, and episodes of severe/sharp upper back pain to random discomfort while walking. Each had undergone extensive medical testing—MRI, CT scan, ultrasound, X-rays, blood work—and consulted multiple doctors, chiropractors, and even some physical therapists. One patient had even had their gallbladder removed. 

After just four or five sessions at The Manual Touch, all five patients were pain and symptom-free!! What did I do differently? 

I listened to the patient’s story and medical history of how their symptoms began.  I asked if specific activities, positions or movements increased their symptoms.  Then, I began their whole body approach evaluation, starting with a global assessment of their movement, much like the initial broad view taken when planning an addition to a house. Based on the patient’s responses and our objective findings, we identified that their symptoms were musculoskeletal, movement-related, and reproducible. These kinds of issues will never show up on imaging, which often leads to frustration for both patients and their medical providers.

10 Tips to Avoid Rib Cage Pain:

• Maintain Good Posture: Keep your shoulders relaxed and avoid slouching, especially when sitting for long periods. Poor posture can strain the thoracic spine and rib cage muscles, leading to pain.
• Strengthen Core and Back Muscles: A strong core and back can better support your upper body and reduce strain on the rib cage area.  Try this entry-level core exercise: https://vimeo.com/856462940
• Practice Deep, Controlled, diaphragm Breathing: Deep breathing engages the intercostal muscles (muscles between the ribs) and helps maintain flexibility in the rib cage. Breathe into your belly and then your chest expanding throughout your sides and back to fully expand your rib cage.
• Avoid Overreaching and Twisting Abruptly: Activities that involve sudden, forceful twisting or reaching, especially when lifting objects, can strain the rib cage muscles. Try these exercises to improve your ankle and hip mobility to avoid overusing your intercostal muscles
• Gradually Increase Intensity in Physical Activities: Whether exercising or performing daily activities, avoid sudden increases in activity intensity. Gradually build up your strength and flexibility, especially when lifting weights or engaging in sports.
• Take Breaks When Sitting for Long Periods: Prolonged sitting can tighten the thoracic spine and rib cage muscles. Stand up, stretch, and move around every hour to release tension in the upper body.
• Warm Up and Stretch Regularly: Before any physical activity, a good warm-up and gentle stretches for the chest, back, and shoulders can help prepare the muscles and reduce the risk of injury.
• Sleep in a Comfortable Position: Sleeping in positions that put pressure on your rib cage or twist your spine can contribute to discomfort. Try sleeping on your back or side with support, and avoid sleeping on your stomach.
• Manage Stress: Stress can cause muscle tension throughout the body, including the thoracic area. Incorporate relaxation techniques like meditation, yoga, or breathing exercises to reduce stress and muscle tightness.

Our Approach to Heal Naturally From Rib Pain

Physical therapists are trained to understand how every joint and muscle in the body should work together to create smooth and optimal movement. During our evaluation, we observe how you move in everyday activities to assess whether everything is functioning optimally. By the time pain arises, there are usually limitations or poor interactions within the body that contribute to these symptoms.

I understand that having pain in your rib cage or abdomen can be unsettling, especially when the cause isn’t clear. When you visit a doctor or PT, sharing specific details about your symptoms is essential to help determine whether the issue is medical or musculoskeletal. The sooner we identify it as musculoskeletal, the sooner we can address the pain and prevent it from becoming chronic. Here’s a list of information to share with your medical professional:

• When do you experience pain? (e.g., in the morning, at the end of the day, when taking a deep breath or during a specific activity)
• Are there any movements that make the pain better or worse?
• Is the pain constant, or does it come and go?
• Does the pain wake you up at night?
• Did the pain begin after a particular activity, like playing tennis, a fall, or installing a wood floor?

If you can answer these questions clearly and specifically, the pain is likely musculoskeletal, and a PT appointment may be the best next step—even before seeing an MD.  However, if your answers are unclear, your pain is constant, and nothing seems to make it better or worse, further medical testing may be needed.