Why Do My Ribs Hurt? Causes of Rib Cage Pain

There are many possible explanations for why your ribs hurt. Injuries, inflammation, infection, cancer, and referred pain from organs such as the heart, lungs, spleen, and liver are all capable of causing pain in the rib cage area.

This article will discuss the various causes of rib cage pain, from those that are temporary or merely uncomfortable to those that can be life-threatening. It will also cover how a diagnosis is made, treatment options, and when to call a healthcare provider.

Common Musculoskeletal Causes

Some of the more common musculoskeletal causes of rib cage pain include:

Injuries

Muscle strains may occur with an injury or even coughing or bending. Rib fractures are relatively common and can sometimes cause intense pain. Ribs can also be bruised (bone bruise) without a fracture.

The sternum is infrequently fractured, but chest trauma can result in a number of abnormalities ranging from single fractures to flail chest, in which two adjacent ribs have two or more fractures each. With osteoporosis, rib fractures can sometimes occur with very little trauma.

Inflammation

Costochondritis is an inflammatory condition that involves the cartilage that connects the ribs to the sternum. The condition is common and the pain can sometimes mimic the pain felt in a heart attack.

Fibromyalgia

Fibromyalgia is a relatively common cause of rib cage pain and can be challenging to both diagnose and treat (it's primarily a diagnosis of exclusion). Along with pain and morning stiffness, people with the condition often experience mental fog, fatigue, and other symptoms.

Rheumatoid Conditions

Common rheumatoid conditions that can cause rib cage pain include rheumatoid arthritis and psoriatic arthritis.

Intercostal Neuralgia

Intercostal neuralgia is a condition in which nerve pain (neuropathic pain) arises from an injury, shingles, nerve impingement, and more. It can be challenging both to diagnose and treat.

Slipping Rib Syndrome

Slipping rib syndrome (also called lower rib pain syndrome, rib tip syndrome, or 12th rib syndrome) is thought to be underdiagnosed and can cause significant pain in the lower ribs (the floating ribs). In the condition, it's thought that overly mobile floating ribs slip under the ribs above and pinch the intercostal nerves, nerves that supply the muscles that run between the ribs.

Other Causes

Other relatively common musculoskeletal causes can include those that are pain-related to conditions involving the thoracic spine (which not uncommonly causes chest pain in the front of the rib cage), Sternalis syndrome, and painful xiphoid syndrome (the xiphoid is the pointy bony growth at the bottom of the sternum).

Less Common Musculoskeletal Causes

Less common, but significant, musculoskeletal causes of rib cage pain can include:

Rib Stress Fractures

Rib stress fractures are an overuse injury commonly seen with activities such as rowing or backpacking. They can be challenging to diagnose, so it is important to let your healthcare provider know what type of exercises and sports you participate in.

Tietze Syndrome

Tietze syndrome is similar to costochondritis but less common. Unlike costochondritis, there is swelling that accompanies the inflammation of the cartilage connecting the ribs to the sternum.

Malignancies

A number of cancers can lead to rib cage pain. Both lung cancer and breast cancer commonly spread (metastasize) to bones, including those of the rib cage. This can occur with a number of other cancers as well.

Pain may be due to the presence of the tumor in bone (bone metastases) or due to fractures that result in weakened bones (pathologic fractures). In some cases, rib cage pain may be the first symptom of cancer.

These tumors may also grow directly into the rib cage and cause pain. Multiple myeloma is a blood-related cancer that may occur in the bone marrow of the rib cage and other bones and can also cause rib cage pain.

Other Less Common Musculoskeletal Causes

A sickle cell crisis (bone infarct or essentially a death of bone) is an uncommon cause of rib cage pain. Rheumatoid causes such as lupus are less commonly associated with rib cage pain.

Some other potential but infrequent causes include infections in joints in the rib cage (septic arthritis), polychondritis, and sternoclavicular hyperostosis.

Non-Musculoskeletal Causes

It can sometimes be very difficult to know whether pain that is felt in the rib cage is related to the rib cage itself, or to underlying structures. Some potential non-musculoskeletal causes of rib cage pain include the following:

Shingles

Shingles is a condition in which the chickenpox virus (which remains in the body after the initial infection) reactivates. Symptoms include fever, chills, and rash distributed on one side of the body. However, pain, sometimes around the rib cage (which can be severe), often occurs before these other symptoms, making shingles difficult to diagnose.

Heart Disease

Heart disease not uncommonly causes pain that is felt as rib cage pain, and women especially, tend to have atypical symptoms such as these. The possibility of a heart attack should always be considered in a person who has any form of chest-related pain. Pericarditis, an inflammation of the membrane that lines the heart, is also a potential cause.

Enlargement of the Aorta

Enlargement of the large artery (aorta) in the chest may cause rib cage pain. Risk factors include the condition Marfan's syndrome as well as cardiovascular disease.

Lung Conditions

Lung conditions such as pneumonia or lung cancer may cause rib cage pain. Lung cancer, in particular, may irritate nerves that lead to pain that feels like it originates in the rib cage. Pulmonary emboli, or blood clots in the legs (deep venous thromboses) that break off and travel to the lungs are a serious cause of rib cage pain.

Pleural Conditions

Inflammation of the pleura (pleurisy) or the build-up of fluid between the two layers of pleura can cause rib cage pain. This may cause pain with a deep breath and in some positions more than others.

Enlargement of the Spleen

Spleen enlargement, such as with some blood-related conditions or cancers, may cause rib cage pain. The spleen may also become enlarged (and sometimes rupture with mild trauma) with infectious mononucleosis.

Liver Conditions

Inflammation or scarring of the liver, such as with hepatitis or cirrhosis, may cause rib cage pain.

Digestive System Conditions

Gastroesophageal reflux disease (GERD) often causes heartburn, but can also cause other types of pain. Peptic ulcer disease or gastritis are other potential causes.

Referred Pain From Outside of the Rib Cage

Organs outside of the rib cage may also cause pain that feels like it arises in the rib cage. Some of the organs that can be associated with rib cage pain include:

• Gallbladder: Gallstones or cholecystitis (infection of the gallbladder)
• Pancreas: Pancreatitis or pancreatic tumors
• Kidneys and ureters: Kidney stones may sometimes cause referred pain that's felt in the rib cage (and is often severe).

Rib Cage Pain in Pregnancy

Rib cage pain, especially in the upper ribs, is relatively common in pregnancy. Most of the time it's thought that the pain is due to the positioning of the baby or related to the round ligament.

Much less commonly, and after the 20th week of gestation, pain on the right side felt under the lower ribs is sometimes a sign of preeclampsia or HELLP syndrome, a medical emergency.

When to See a Healthcare Provider

If you are experiencing rib cage pain that does not have an obvious explanation, it's important to make an appointment to see your healthcare provider.

Symptoms that should alert you to call 911 include:

• Chest pressure or tightening
• Pain in the rib cage that radiates into your arm, back, or jaw
• Heart palpitations
• Shortness of breath, especially of sudden onset
• Pain that is severe
• Sudden onset of sweating
• Lightheadedness
• New onset confusion or change in consciousness
• Coughing up blood, even if only a very small amount
• Difficulty swallowing
• Numbness or tingling in your arms or legs

Diagnosis

In order to determine the cause or causes of rib cage pain, your healthcare provider will take a careful medical history and may do a number of different tests.

History

A careful history is essential in making a diagnosis when the cause of rib cage pain in unknown.

To narrow down potential causes, your healthcare provider may ask a number of questions. Some of these include:

• What is the quality of your pain? Is the pain sharp or dull?
• How long have you had the pain? Did it start gradually or abruptly?
• Have you ever experienced pain like this in the past?
• Where is the location of your pain? Is it localized or diffuse? Does it affect both sides of your chest or is it isolated to the left side or right side?
• Is there anything that makes your pain better or worse? For example, pain with a deep breath (pleuritic chest pain) may suggest pleurisy or other lung conditions. Movement may worsen musculoskeletal pain.
• Is the pain present at rest or only with movement?
• Is the pain worse during the day or at night? Pain that is worse at night may suggest serious causes such as an infection, fracture, or cancer.
• Is the pain worse in one particular position?
• Does pain occur when you press on any area of your chest?
• If you also have neck or shoulder pain, does it radiate to your arms? Do you have any weakness, tingling, or numbness in your fingers?
• What medical conditions do you have and have you had? For example, a history of early stage breast cancer in the past might raise concern over a recurrence in the rib cage.
• What illnesses have your family members experienced (family history)?
• Do you or have you ever smoked?
• What other symptoms have you experienced? Symptoms such as palpitations, shortness of breath, a cough, a rash, jaundice (a yellowish discoloration of the skin), nausea, vomiting, and itchy skin, should be shared with your healthcare provider.

Physical Exam

On physical examination, your healthcare provider will likely begin with an examination of your chest. They will palpate (touch) your chest to look for any localized areas of tenderness, such as over a fracture or inflammation.

With costochondritis, pain is most commonly noted with palpation to the left of the sternum in a very localized region. Swelling may be related can occur if Tietze syndrome is present or with an injury such as a fracture.

With fractures, tenderness is usually very localized. With sternalis syndrome, pain is often felt over the front of the rib cage, and palpation can cause the pain to radiate to both sides of the chest. With intercostal neuralgia, pain may be felt over the whole chest or along one rib, but can not usually be reproduced with palpation.

Range of motion tests, such as having you lean forward (flexion), stand up straight (extension), and turn to the right and left are done to see if any of these movements can reproduce the pain.

An examination of your skin will be done to look for any evidence of shingles rash, and an examination of your extremities might show signs of a rheumatoid condition such as any swelling or deformity of joints.

In addition to examining your chest, your healthcare provider will likely listen to your heart and lungs and palpate your abdomen for any tenderness. A pleural friction rub is a breath sound that may be heard with inflammation of the lining of the lungs (the pleura). Other breath sounds might suggest underlying pneumonia or other lung conditions.

In women, a breast exam may be done to look for any masses (that may have spread to the ribs).

Labs and Tests

A number of laboratory tests may be considered depending on your history and physical exam. This may include markers for rheumatoid conditions and more. Blood chemistry including a liver panel, as well as a complete blood count may give important clues.

Imaging

Imaging tests are often needed if trauma has occurred, or if there are any signs to suggest an underlying cancer or lung disease. A regular X-ray may be helpful if something is seen, but cannot rule out either a fracture or lung cancer.

X-rays are better for visualizing the ribs, but can still easily miss rib fractures. In order to diagnose many rib fractures or stress fractures, an MRI may be needed. A bone scan is another good option both for detecting fractures and looking for potential bone metastases.

A chest computed tomography scan (CT scan) is often done if there is concern over lung cancer or pleural effusion. With cancer, a positron emission tomography (PET) scan can be good both for looking at bony abnormalities and other soft tissue spread, such as tumors in the mediastinum.

Since abdominal conditions (such as gallbladder or pancreatic conditions) may cause rib cage pain, an ultrasound or CT scan of the abdomen may be done.

Diagnostic Procedures

Other procedures may be needed to diagnose some conditions that can cause referred pain to the rib cage.

An electrocardiogram (ECG) may be done to look for any evidence of heart damage (such as a heart attack) and to detect abnormal heart rhythms. An echocardiogram (ultrasound of the heart) can give further information about the heart and also detect a pericardial effusion (fluid between the membranes lining the heart) if present.

If a person has had a choking episode or has risk factors for lung cancer, a bronchoscopy may be done. In this procedure, a tube is inserted through the mouth (after sedation) and threaded down into the large airways. A camera at the end of the scope allows a healthcare provider to directly visualize the area inside the bronchi.

Endoscopy may be done to visualize the esophagus or stomach for conditions involving these organs.

Treatment

The treatment of rib cage pain will depend on the underlying cause. Sometimes this simply requires reassurance and advice to avoid activities and movements that aggravate the pain.

Rib fractures are difficult to treat, and many healthcare providers opt for conservative treatments such as wrapping the rib cage due to the potential for complications.

For musculoskeletal causes of rib cage pain, a number of options may be considered including pain control, stretching, physical therapy, or local injections of numbing medication.

For non-musculoskeletal causes, the underlying problem or disease will need to be addressed in order to treat the rib pain.

Summary

Rib cage pain can signal a number of different musculoskeletal conditions as well as non-musculoskeletal conditions within or outside of the chest. A diagnosis is usually based on your history and symptoms, a physical exam, and sometimes imaging scans or other tests. Depending on the cause, healthcare providers have a wide array of options that should ultimately be able to identify the cause of the pain and lead to an appropriate treatment plan.