Getting to the Bottom of Rib Cage Pain

Getting to the Bottom of Rib Cage Pain

Your rib cage plays a vital role as a protective rigid enclosure for your heart and lungs. It also functions as an attachment site for your respiratory muscles, including your diaphragm, and provides structural support for your upper body.

Because your rib cage interacts with your thoracic spine during movement and expands during respiration, injuries to the rib cage can be quite painful and debilitating, causing pain during physical activity and interfering with breathing. Physical therapy can help you get to the bottom of your rib cage pain and resolve it.

Anatomical Structures of the Rib Cage

Your rib cage is made up of 12 sets of ribs:

Anatomical Structures of the Rib Cage

Ribs 1-7: The uppermost sets of ribs are often called “true ribs” because they attach to both the front and back sides of your body. On the posterior side, your true ribs join with your thoracic vertebrae at the costovertebral and costotransverse joints. On the anterior (front) side, they attach to your sternum by way of the costal cartilage.

Ribs 8-10: Beneath the “true ribs” lie the “false ribs.” Ribs 8-10 attach to the thoracic spine in the same manner as ribs 1-7, but they do not attach directly to the sternum. Instead, each false rib attaches to the cartilage of the rib above it.

Ribs 11 and 12: The lower ribs are called “floating ribs” because they only attach to their corresponding vertebra on the posterior side; in front, they are not attached, so they simply float.

Each rib has a costal groove on the inside of the rib along the lower border to allow for the passage of intercostal veins, arteries and nerves.

The spaces between the ribs are occupied by two thin layers of intercostal muscles that run at right angles to one another. The external intercostals are the top layer and act at the rib cage as you breathe in. The internal muscles are the inside layer and they contract as you exhale.

Role of the Diaphragm in Rib Cage Stability

Role of the Diaphragm in Rib Cage Stability

The diaphragm is most often thought of as a respiratory muscle, but it also plays an important role in spinal stability. The left side of the diaphragm especially contributes to maintenance and regulation of posture, while the right side plays a larger role in respiration. The entire diaphragm provides rib cage stability and spinal support by regulating intrathoracic and intra abdominal pressure.

Role of Fascia in Rib Cage Pain

Fascia is a thin, dense sheet of connective tissue that holds bundles of muscle fibers together so they can glide independently of other muscles and move freely among your bones, nerves and vital organs. Fascia has multiple sensory neurons that help your body’s systems communicate with one another.

Role of Fascia in Rib Cage Pain

To function at its best, fascia needs to remain supple and elastic. Repetitive motion activities and overtraining can cause overuse injuries to the fascia that make it stiff and tight. Stiff fascia can often be the root cause of rib fascia pain, interfering with your breathing apparatus and limiting your trunk range of motion.

Sometimes adhesions can develop in your fascia, causing it to stick rather than glide. Fascial adhesions in one area of your body can affect structures in other areas. Thoracic fascia adhesions can affect mobility and stability throughout your upper body.

Left Side Rib Pain

Costochondritis is a condition that causes left side rib pain, most often in ribs 2 to 5, accounting for up to 30% of emergency chest pain visits. It occurs most often in adults over 40, and more frequently in women. Prior to diagnosing costochondritis, a thorough exam and chest x-ray should be done to rule out cardiac issues.

Costochondritis is caused by inflammation of the cartilage that connects the ribs to the sternum. It is associated with repetitive trunk and arm movements, chest wall trauma, and chronic coughing. Its symptoms are tenderness in the joints and cartilage of the affected ribs.

Left Side Rib Pain

Common Causes of Rib Cage Pain

Rib cage pain can arise from injury to any of the muscles, bones, nerves or joints within the thoracic cage region. Some of the most common causes of rib cage pain stem from sports and physical activity. In a recent peer-reviewed article (Gundersen et al., 2021), the authors describe multiple potential causes of rib cage pain.

Stress Injuries to the Rib Bones

Rib bone stress injuries most commonly occur in athletes who play sports like golf, swimming, running, rowing and throwing sports. They are especially common in elite rowers, with female rowers at greater risk. Rib stress injuries most frequently occur in ribs 4 to 8.


Costochondritis is a condition most often seen in ribs 2 to 5 that manifests as chest pain, accounting for up to 30% of emergency chest pain visits. It occurs most often in adults over 40, and more frequently in women. Costochondritis is associated with repetitive trunk and arm movements, chest wall trauma, and chronic coughing. Its symptoms are tenderness in the joints and cartilage of the affected ribs.

Tietze Syndrome

Tietze syndrome (TS) is a rare condition that mostly affects adults between the ages of 20-40. TS is similar to costochondritis in that it involves joint tenderness, but it most often affects joints 2 and 3 and is marked by inflammation.

Slipping Rib Syndrome

Slipping rib syndrome (SRS) is a somewhat uncommon condition that affects the cartilaginous attachments of the false ribs. The cartilage may become subluxated, causing pain and possible nerve impingement. The syndrome is more common in female athletes in sports like running, rowing, swimming and lacrosse, and often manifests as debilitating lower rib cage pain.

Common Causes of Rib Cage Pain

Posterior Rib Joint Dysfunction

This condition is frequently described as “subluxation,” but there is little evidence to support that notion. Thoracic pain at the back of the rib cage is most commonly seen in rowers and swimmers. The condition responds well to manual therapy.

Serratus Anterior Strain

Athletic strain of the serratus anterior muscle is most commonly seen in rowers and athletes who play overhead sports like golf, tennis and baseball. Symptoms are pain on the side of the ribcage.

Intercostal Muscle Strain

Up to 50% of rib cage pain is caused by strain of the intercostal muscles that run between the ribs. Sports that require repetitive upper body movements like tennis, rowing and baseball increase the risk of intercostal strain.

Transient Upper Abdominal Pain

Pain at the lower side of the rib cage, often called a side stitch, occurs most often in young athletes during sports like swimming and running. Pain can sometimes radiate from the lower rib cage to the shoulder.

Oblique Muscle Strain

The internal and external oblique muscles are responsible for trunk rotation, and they can become strained during explosive rotation activities like pitching a baseball or swinging a bat. Oblique strains are most often felt as side rib pain in lower ribs 9 through 12, and may increase with deep breathing or coughing.

Myofascial Trigger Points

Trigger points are tight nodules of contracted fascia or muscle tissue that can cause both local and referred pain. They often occur from overtraining, and can affect both superficial and deep tissues. Superficial trigger points can be palpated from the skin’s surface and are easily treated with manual therapy or dry needling. Deep tissue trigger points can only be detected with imaging, and can be treated with ultrasound guided dry needling. Trigger points can affect the muscles that surround and support the rib cage, causing pain and limiting range of motion.

Referred Visceral Pain

Pain that stems from the visceral organs such as the liver, pancreas, GI tract, heart or lungs can sometimes manifest as rib cage pain. Unlike musculoskeletal pain, visceral pain does not diminish or increase with movement, change in position or palpation.

Diagnosis of Rib Cage Pain

Because there are so many things that can cause rib cage pain, a thorough exam is needed to rule out visceral sources of pain. A thorough health history and physical exam can help determine the underlying cause of rib cage pain.


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At NYDNRehab, we use diagnostic ultrasonography to view the structures of the thorax and rib cage in motion, in real time. When combined with feedback from the patient, ultrasound imaging can help us pinpoint the exact location and source of pain, enabling us to decide on the most effective treatment solutions.

Rib Cage Pain Treatment Options

Physical therapy can help you get to the source of your rib cage pain and restore healthy pain-free function. Treatment options may include:

Rib Cage Pain Treatment Options
  • Ultrasound guided dry needling to eliminate myofascial trigger points
  • Upper body stability and mobility training that targets the thoracic region
  • Athletic skills retraining to correct deficient movement mechanics
  • Postural restoration therapy to restore optimal alignment
  • Myofascial release therapy to stretch and soften the fascia and release adhesions

Rib Cage Pain Treatment in NYC

Rib cage pain requires specialized treatment from a skilled practitioner. At NYDNRehab, we work with thoracic cage pain using specialized soft tissue manipulation of the myofascial structures of the rib cage, to release adhesions and increase mobility of the ribs and thoracic spine.

You don’t have to live with rib cage pain. Contact NYDNRehab today, and get rid of your rib cage pain so you can get back to doing the things you love.


  • Gundersen, Alexandra, Haylee Borgstrom, and Kelly C. McInnis. “Trunk injuries in athletes.” Current sports medicine reports 20.3 (2021): 150-156.

About the Author

Dr. Lev Kalika is clinical director of NYDNRehab, located in Manhattan. Lev Kalika is the author of multiple medical publications and research, and an international expert in the field of rehabilitative sonography, ultrasound guided dry needling and sports medicine Dr. Kalika works with athletes, runners, dancers and mainstream clients to relieve pain, rehabilitate injuries, enhance performance and minimize the risk of injuries. His clinic features some of the most technologically advanced equipment in the world, rarely found in a private clinic.


In this instance, an athlete was originally diagnosed with minor quadriceps muscle strain and was treated for four weeks, with unsatisfactory results. When he came to our clinic, the muscle was not healing, and the patients’ muscle tissue had already begun to atrophy.

Upon examination using MSUS, we discovered that he had a full muscle thickness tear that had been overlooked by his previous provider. To mitigate damage and promote healing, surgery should have been performed immediately after the injury occurred. Because of misdiagnosis and inappropriate treatment, the patient now has permanent damage that cannot be corrected.

The most important advantage of Ultrasound over MRI imaging is its ability to zero in on the symptomatic region and obtain imaging, with active participation and feedback from the patient. Using dynamic MSUS, we can see what happens when patients contract their muscles, something that cannot be done with MRI. From a diagnostic perspective, this interaction is invaluable.

Dynamic ultrasonography examination demonstrating
the full thickness tear and already occurring muscle atrophy
due to misdiagnosis and not referring the patient
to proper diagnostic workup

Demonstration of how very small muscle defect is made and revealed
to be a complete tear with muscle contraction
under diagnostic sonography (not possible with MRI)


Complete tear of rectus femoris
with large hematoma (blood)


Separation of muscle ends due to tear elicited
on dynamic sonography examination

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