Your rib cage is supported by a number of complex structures, ligaments, and muscles, including the muscles between the ribs – the intercostal muscles. “Inner” means within and “costal” means ribs, so the intercostal muscles are the muscles that lie in between your 12 ribs and help form the chest wall. Your intercostal muscles are made up of three layers, which are:
- External intercostal muscles – These are the outermost intercostals, responsible for expanding the chest during breathing to help inhale air and allow for full, deep breaths. The external intercostals originate at the lower edge of one rib and run diagonally forwards to attach to the upper edge of the rib below, and are found in the back, sides, and most of the front of the rib cage.
- Internal intercostal muscles – These muscles sit directly underneath the external intercostals and help collapse the chest during breathing to exhale. The intercostal muscle fibers run perpendicular to the external intercostals, moving diagonally from front to back along the ribs, and are found in the entire rib cage.
- Innermost intercostal muscles – These sit directly underneath and run parallel to the internal intercostal muscles, running from the back of the rib cage to each side. The intercostal veins, arteries, and nerves are typically found between the internal and innermost intercostal muscles.
Your intercostal muscles can be strained by any kind of activity that involves extreme or forceful twisting of the body or swinging of arms, for example in golf or tennis. It can also occur as a result of a direct blow to the rib cage, such as from a fall or car accident, in which the ribs are forced apart suddenly and the intercostal muscles stretch or tear. Blows that occur from contact sports, such as rugby, may cause an intercostal muscle strain from one-time or repeated hits to the area.
Causes & Symptoms
An intercostal muscle strain can occur from any number of injuries, such as the following:
- A direct hit to the rib cage – such as from a fall or car accident, in which the ribs are forced apart suddenly and the intercostal muscles stretch or tear. Blows that occur from contact sports, such as football or hockey, may cause an intercostal muscle strain from repeated jolts to the torso.
- Twisting the torso – can pull the ribs farther apart than normal and cause the intercostals to overstretch or tear. Excessive twisting may occur from sports such as tennis or golf, or from twisting whilst lifting weights. Less forceful twisting can also strain the intercostal muscles, such as retain yoga postures or dance positions.
- Reaching overhead – as when painting a ceiling or lifting above the shoulders. Prolonged overhead reaching can cause the intercostals to remain extended longer than is typical, putting undue stress on the muscles and causing injury.
- Repetitive and forceful motions – as one will experience during rowing, tennis, or batting, or pitching. These motions and repeated stressors may gradually overstretch and tear the intercostal muscles.
Simply performing the above actions does not always lead to intercostal muscle strain. The likelihood of an intercostal strain increases when the muscles are weakened, either from overusing the muscles, leading to burnout, from atrophy due to lack of exercise, or from chronic poor posture. Other symptoms of intercostal muscle strain may vary, and can include:
Severe upper back / rib pain – Upper back pain or pain in the rib cage can be significant and come on suddenly, especially if the injury was caused by sudden impact or a blow to the chest or back. Additionally, a sudden increase in physical activity can strain an intercostal muscle and lead to sudden, intense pain.
Worsening pain – Upper back pain may develop progressively over several days or weeks if repetitive, gradual stress is placed on the intercostal muscles. This type of muscle strain is most common after participating in sports such as swimming or baseball.
Tension and stiffness – Muscles may react to an injury by tensing up, causing upper back pain and stiffness with everyday movements, such as bending or twisting the upper body. Tension in the intercostal muscles may also lead to muscle spasms, increasing pain.
Tenderness – The affected muscles and adjacent ribs may be sensitive to the touch. Additionally, wearing tight clothing, or carrying a backpack or purse over the strained muscles, can worsen the pain.
Difficulty breathing – Taking a full breath can be very painful with an intercostal muscle strain, causing breathing to become difficult to do. Breathing in shorter, shallower breaths to avoid pain can ultimately lead to less oxygen traveling through the body, undermining the healing process.
Inflammation – The strained intercostal muscles may swell, increasing sensitivity in the affected area. In rare cases, this swelling can cause blood to pool or clot around the strained muscles, called a hematoma.
Who Gets an Intercostal Muscle Strain?
Generally, anyone can develop this condition. However, these certain risk factors may increase the risk of straining an intercostal muscle strain, including the following:
- Physical workers – physical labour typically requires movements that can injure the intercostals, including frequent heavy lifting, repeated bending or reaching, and / or excessive twisting of the torso.
- People playing contact sports – in which the upper body is hit with sudden, direct force, including but not limited to football or hockey.
- People playing “thrusting” sports – such as baseball and tennis, in which high force in the arm, shoulder and upper back muscles are used repeatedly, putting undue pressure on these muscles, and increasing the risk for strain. These certain motions may include pitching, batting, or swinging a tennis racket.
How Does It Affect You? How Serious Is It?
In the spine, there is an intercostal muscle group consisting of the internal and external intercostals, and the transverse thoracic muscles, located between the ribs in the thoracic cavity. These muscles can become strained due to rapid movements that bend or twist the upper body suddenly. There are also three grades of muscle strain, as described below:
- Grade 1 – A mild strain, where a few muscle fibers have experienced damage.
- Grade 2 – A moderate strain, where more muscle fibers are damaged, but they have not been ruptured.
- Grade 3 – A severe strain, where the muscle is ruptured.
Recommended Treatment & Rehabilitation
Your doctor will diagnose your intercostal muscle strain by asking you a few questions and performing a physical exam. They will want to know if you remember falling or twisting when the pain began. They will also ask about any sports you play. They will then touch the tender area and test your range of motion and pain level during motion. Your doctor may order a chest X-ray to make sure your lungs were not bruised or punctured when you were previously injured.
Generally, recovery relies on the severity of the injury. The time varies from a couple of days to 8 weeks in the majority of cases. However, in some cases, it lasts longer and causes upper back pain. Initial advice from a doctor is likely to be relaxation for a few days, as well as applying an ice pack in the early days of discomfort to remove the initial swelling. Another treatment method includes pain-relieving medications which include acetaminophen, to disrupt discomfort as well as reduce swelling and inflammation.
Physiotherapy treatment for an intercostal strain is vital to maximize healing, prevent injury recurrence, and ensure an optimal long-term outcome. A physiotherapist will take an in-depth history and work together with you to find what caused the injury. Because this is an injury to your chest, he / she will also perform a screening to rule out any other causes of your pain.
Gentle physiotherapy may be advised to stretch tender muscles after an intercostal muscle injury. Depending on the severity of the injury, exercises can include:
Breathing exercise methods
These slowly fill the lungs and expand the chest to work the intercostal muscles. To perform this exercise, it is typically recommended to sit or stand with your back straight, then take a full breath from the bottom of your lungs. It can help to think of breathing from the diaphragm, by slowly expanding the abdominal muscles whilst inhaling, then pushing air from the lungs using these same muscles. It is necessary to repeat this exercise 5-10 times.
A common yoga position that stretches the intercostals at the side of the torso. On comfortable padding, rise up on both knees and extend the right leg straight to the side, with the kneecap facing up and the sole of the foot on the ground as much as possible. Extend both arms to the sides. Afterwards, bend the upper body towards the right, so the right arm rests on the extended leg. Continue to reach the left arm overhead so a stretch is felt in the left ribs. Finally, hold the stretch 15-30 seconds before repeating on the opposite side.
This exercise is used to stretch the intercostals towards the back of the torso. Sit on the floor with the left leg straight in front of the body and the right bent so the sole of the foot touches the knee. Then, lean forward as far as is comfortable over the right leg, rotating the torso slightly and touching both palms to the floor, if possible. A stretch should be felt in the back intercostal muscles on the left side. Lastly, hold the stretch for 15-30 seconds; then repeat on the opposite side.
Alternative & Homeopathic Treatment
At-home treatments can be very useful in order to reduce symptoms that are linked to further developing intercostal muscle strains, such as the following:
You can take over-the-counter anti-inflammatory medications like ibuprofen (Advil) or naproxen (Aleve), or simple pain relievers like acetaminophen. You should also be sure that you are not overmedicating by taking several products that contain pain relievers, including medicines for colds or menstrual cramps.
Hot and cold application
Cold therapy can help ease your pain and reduce inflammation of the muscle. Apply a cold pack to the injured area for 20 minutes at a time, several times a day for the first two days. You can use an ice bag, a gel cold pack, or a plastic bag filled with ice and wrapped in a towel. After the first 48 hours, you may want to start using heat pads on the injured ribs. Heat can help loosen and relax the muscles so you can do your physiotherapy. You can apply heat for 20 minutes at a time with a heating pad or a warm damp towel.
Epsom salt soaking
As part of heat therapy, you can take a warm bath with Epsom salts added. The dissolved minerals absorb through your skin and may slightly increase your blood levels of magnesium.