Causes of Rib Cage Pain

Everything you need to know about pain in the rib cage

In This Article

There are many possible causes of rib cage pain or pain that seems to come from the area around your ribs. These can range from conditions that are primarily a nuisance to those that are life-threatening.

We will look at common and uncommon causes musculoskeletal causes of this pain, as well as causes that may be felt in the rib cage but instead originates in organs within or outside of the rib cage. When the cause of rib pain is uncertain, a careful history and physical exam can help guide you and your doctor to choose any labs or imaging studies that are needed.

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Rib Cage Anatomy and Structure

When looking at potential causes and how rib cage pain is evaluated, it's helpful to think about the structures in and around the rib cage.

Bony Structure

There are 12 ribs on each side of the chest. The upper seven ribs are attached directly to the breastbone (sternum) via cartilage. These are known as the "true ribs." The remaining five ribs are referred to as the "false ribs."

Of these, ribs eight through 10 are also attached to the sternum, but indirectly (they attach to the cartilage of the rib above which ultimately attaches to the sternum). Ribs 11 and 12 are not attached to the sternum either directly or indirectly and are called the floating ribs.

There can be variations to this pattern, with some people having an extra set of rubs and some have fewer ribs (primarily the floating ribs).

Surrounding Structures

In addition to the bones that make up the ribs, sternum, and spine, as well as the attaching cartilage, there are many other structures associated with the rib cage that could potentially cause pain. This includes the intercostal muscles (the muscles between the ribs) and the diaphragm (the large muscle at the base of the chest cavity), ligaments, nerves, blood vessels, and lymph nodes.

Organs Within the Rib Cage

The rib cage functions to protect several organs while allowing movement so that the lungs can expand with each breath.

Organs protected by the rib cage include the:

  • Heart
  • Great vessels (the thoracic aorta and part of the superior and inferior vena cava)
  • Lungs and pleura (lining of the lungs)
  • Upper digestive tract (esophagus and stomach)
  • Liver (on the right side at the bottom of the rib cage)
  • Spleen (on the left side at the bottom of the rib cage)

The area between the lungs, called the mediastinum, also contains many blood vessels, nerves, lymph nodes, and other structures.

Organs Outside of the Rib Cage

Organs not within the rib cage but that can sometimes cause pain that feels like it comes from the rib cage include the gallbladder, pancreas, and kidneys. The skin overlying the rib cage may also be affected by conditions (such as shingles) which cause rib cage pain.

Anatomical Variations

There are a number of variations that may be found in the rib cage that can, in turn, lead to or affect symptoms in this region.

  • Extra ribs: An extra rib lies above the first rib in 0.5% to 1% of the population and is called a cervical rib or neck rib.
  • Missing ribs, most often one of the floating ribs
  • Bifurcated (bifid) ribs, a condition present from birth in which the rib splits into two parts by the sternum
  • Pigeon chest (pectus carinatum), a deformity in which the ribs and sternum stick out from the body
  • Sunken chest (pectus excavatum), in which abnormal growth of the ribs results in the chest having a sunken appearance

Causes

There are many potential causes of pain that feels like it arises from the rib cage, including injuries, inflammation, infection, cancer, and referred pain from organs such as the heart, lungs, spleen, and liver.

In an outpatient clinic setting (such as a family practice clinic), musculoskeletal conditions are the most common cause of rib cage pain. In the emergency room, however, serious conditions that mimic rib cage pain (such as a pulmonary embolism) are more common.

We will look at some of the common and uncommon musculoskeletal causes or rib cage pain, as well as causes that may arise from organs within or outside of the rib cage.

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. 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 can sometimes mimic a heart attack with the type of pain that occurs.

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 disorder often experience mental fog, fatigue, and other annoying symptoms.

Rheumatoid Conditions

Common rheumatoid conditions that can cause rib cage pain include rheumatoid arthritis, psoriatic 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 under-diagnosed 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

Other relatively common causes can include 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 doctor 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 different 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 the cancer.

These tumors may also grow directly in to 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

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 rib cage itself, or underlying structures. Some potential 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, but pain (which can be severe) often occurs before these other symptoms and can be challenging to diagnosis.

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.

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 the 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 and medical conditions to consider 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 upper rib cage pain, is also 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 Doctor

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

Symptoms that should alert you to call 911 and not wait 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 doctor will take a careful history and may do a number of different tests based on your answers.

History

A careful history is essential in making a diagnosis when the cause of rib cage pain in unknown. The questions noted above may help narrow down potential causes and further guide your work-up. These will include questions to not only understand the characteristics of your pain, but a review of past medical conditions, risk factors, and family history.

To narrow down potential causes, your doctor 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 (PE)?
  • Can your pain be reproduced by pressing on any area of your chest?
  • If you also have neck or shoulder pain, does it radiation to your arms? Do you have any weakness, tingling, or numbness of 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 bony 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 (associated symptoms)? Symptoms such as palpitations, shortness of breath, a cough, a rash, jaundice (a yellowish discoloration of the skin), nausea, vomiting, itchy skin, etc. should be shared with your doctor.

Physical Exam

On physical examination, your doctor will likely begin with an examination of your chest (unless you have symptoms suggesting an emergency condition is present). Palpation (touching) your chest will be done 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 doctor 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 an underlying pneumonia or other lung conditions.

In women, a breast exam may be done to look for any masses (that could 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.

Rib detail exercises 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.

Procedures

Procedures may be needed to diagnosis 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 physician 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 physicians are leaning against only 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 ranging from pain control, to stretching, to physical therapy, to local injections of numbing medication.

A Word From Verywell

Rib cage pain can signal a number of different musculoskeletal conditions as well as non-musculoskeletal conditions within or outside of the chest. Some of these conditions can be challenging to diagnose. Taking a careful history is often the best single "test" in finding an answer so the underlying cause can be treated.

It can be frustrating to be asked a thousand questions (that are sometimes repeated more than once), but in the case of rib cage pain, is worth the time it takes to make sure you doctor has all of the clues possible to diagnose, and subsequently treat, your pain.

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Article Sources
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  3. Wilkerson RG, Ogunbodede AC. Hypertensive Disorders of PregnancyEmerg Med Clin North Am. 2019;37(2):301-316. doi:10.1016/j.emc.2019.01.008

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