What Causes Pain Around the Ribs and Back Symptoms? How Can This be Treated?
The thoracic spine and ribs are like a “no man’s” land for many physicians, including spine experts. While many physicians are comfortable treating and diagnosing neck and low back problems when it comes to things like pain around the ribs and back symptoms, they draw a blank. So today we’ll focus on this problem through the story of a patient we recently treated. Let’s dig in.
Pain Around the Ribs and Back Symptoms?
First, let’s define what we mean by pain around the ribs and back symptoms. Basically, the pain wraps around the back of the rib, generally at least to the side and at times all the way to the front. There is also upper back pain that often accompanies this pain. The pain also is usually made worse with movement or just feels like something is “out of place” and needs to be popped back in place. Sometimes specific motions or activities will make this better or worse.Request a Regenexx Appointment
Understanding the Thoracic Spine
The thoracic spine is between the neck (cervical) and the low back (lumbar). Its bones (vertebrae) are numbered 1-12 and the abbreviation ‘T” is used for “Thoracic”. Hence, “T6” means the sixth thoracic vertebra.
What’s unique is that the ribs attach here to the thoracic vertebrae. These both constrain and define which movements are possible. Also note that because the two are connected, what happens in the thoracic spine often happens in the ribs and vice versa. In addition, the thoracic vertebrae act as a pivot point for the ribs as you breathe in and out. This is often why patients experience pain by taking a deep breath.
There’s an immense amount going on in the thoracic spine. First, there are facets joints where the two vertebrae meet. There is a spinal nerve that exists in this area at each level. As shown to the left, that nerve begins as the thoracic spinal nerve and then continues all the way around to the front of the chest as the intercostal nerve. There’s a disc that acts as a shock absorber as well as a multitude of muscles and ligaments. Then there are two areas where each rib attaches to each vertebra (costotransverse and costovertebral joints). Realize that there can be problems with any one of these structures that can cause pain around the ribs and back symptoms.
The Top 5 Causes of Pain Around the Ribs and Back Symptoms
Our clinic has had a special interest in the thoracic spine for many years. As an example, most spinal interventionalists have only ever performed a handful of thoracic epidural or facet injections. I’ve done hundreds of each. In all of those years helping patients with pain around the ribs and back symptoms recover, these are the top five things that we see day in and out in our clinic:
- Thoracic Disc Bulge-The thoracic spine, just like your neck and lower back, has discs that act as shock absorbers for the spine bones. These can bulge when they get damaged and can irritate spinal nerves. This can lead to pain around the ribs and back symptoms. In particular, this could be just pain or an electrical feeling. There also may be some numbness in the back and ribs.
- Rib Facet Pain-The ribs attach to the vertebrae at two points each with ligaments. Doctors sometimes call these “rib facets”. Technically they’re called the costovertebral and costotransverse joints. These joints can get damaged and cause referred pain around the ribs with back symptoms. This pain is often more localized to one spot and may get worse with a deep breath. This area may also feel “out of place”.
- Thoracic Facet Joint Pain-The vertebral facets are the joints where each vertebra meets up with the next above or below. These can become injured or get arthritis like any joint and can cause referred pain that is usually in one spot but can extend out from the spine as well. This pain isn’t usually influenced by taking a deep breath but can be made worse or better with movement.
- Rib Fascial Injury-The ribs have a tough outer covering called the fascia. This is there to help control motion and when it gets injured, too much individual rib motion can happen which can cause upper back pain that wraps around the ribs. This pain is usually influenced by taking a deep breath. You may also be able to identify a painful rib by palpating the area.
- Muscle Trigger Points or Areas of Tendinopathy-You have muscles in your upper back that can develop areas called “trigger points” which can cause upper back pain and pain that refers around the rib. The muscles also have tendons which can get ripped up and worn out with time, leading to tendinopathy.
How Can This Problem Be Helped? Juan’s Story…
Juan’s pain around the ribs and back symptoms with spasms began in 2007 and he presented to our clinic in 2020. Any movement, rotation, or flexion/extension made the pain worse while rest and medication made the pain better. Previously, he had tried ozone injections, steroid injections, and facet injections which provided temporary relief. Radiofrequency ablation at the T8-11 facet joints provided relief for only about 6-8 months. He had also developed tingling in his right 4th and 5th fingers and pain in his right elbow and weakness in his right hand. This was likely coming from irritation of the brachial plexus by his ribs.
We approached Juan’s problems differently, looking at what was causing all of these issues. In particular, one of the ligaments in the back of his spinal canal (ligamentum flavum) was loose and buckling which was irritating nerves. Hence, we concentrated his own blood platelets (platelet-rich plasma) to inject into that specific ligament to cause some healing and tightening. In addition, those thoracic nerves were irritated, so we used a platelet lysate to inject around the nerves (epidural using x-ray guidance). Finally, his facet joints had previously been treated with radiofrequency, which burns the nerve that takes pain from the joint. Hence, nobody had ever tried helping the joint with substances that can promote healing. So I carefully injected high dose platelet-rich plasma into those joints again using a sophisticated image guidance technology. How did he do? He’s reporting 90% relief with pain only with certain activities.
The upshot? As you can see, there’s quite a bit that can cause pain around the ribs and back symptoms. The first order of business is getting an accurate diagnosis of why you hurt, which is what we did with Juan. So rather than injecting Juan with steroids which can harm tissues or burning the nerves, we focused on what was causing his problems and tried to improve the function of the spine.