It is a form of neuropathic pain that results from damage or dysfunction of one or more nerves of the peripheral or central nervous system.
It is described as a discomfort in the front and back of the chest with the hips as the lower limit. The etiology can vary from cardiac, vascular, infectious, related to the spine, rib, metastasis, carcinoma, lung, pleural, visceral, and tissue scars.
Intercostal neuralgia is a painful disorder of the nerves that run between the ribs and is caused by damage to one of those nerves and loss of function of that nerve.
In intercostal neuralgia, severe, sharp, stabbing pain occurs in the area of the intercostal nerve. This pain is independent of posture and segmental manipulation.
Intercostal neuralgia affects the nerves that run between the ribs and is seen in an estimated 3-22 percent of patients referred to pain clinics. The prevalence in the general population is around 15 percent.
Damage to the intercostal nerves can occur due to various diseases and conditions.
This can lead to sporadic episodes of sharp pain, which often feels like a tearing, sharp, aching, or rodent sensation enveloping the upper chest. The pain can be exacerbated by sudden movements, such as laughing or coughing.
Chest pain is relatively rare and is only seen in an estimated 3-22% of patients referred to pain clinics. The prevalence of chest pain in the general population is around 15%.
Chronic post-thoracotomy and post-thoracoscopy pain have a prevalence of 40%, and half of these cases are neuropathic. Intercostal neuralgia is the most common form.
Causes and risk factors of intercostal neuralgia
Nerve damage or intercostal nerve dysfunction can occur due to infection, inflammation, direct trauma, or even certain lung or chest wall diseases. However, one of the most common causes of intercostal neuralgia is injuries caused during surgery involving the chest.
This generally involves separating the ribs to access internal organs, possibly damaging the intercostal nerves. Several causes of intercostal neuralgia include:
Rib infection or osteomyelitis, herpes, nerve degeneration, inflammation of a nerve or group of nerves (neuritis), pregnancy, due to the expansion of the rib cage to make room for the fetus.
A stretched or tight muscle in the chest wall, shoulders, back, or arm, direct damage to the chest or ribs, intercostal nerve entrapment, surgery of organs, bones, and tissues in the chest cavity. Tumors in the chest and abdomen (can press on the intercostal nerves).
Risk factors that can lead to the development of intercostal neuralgia include:
Varicella-zoster infection, not vaccinated against varicella-zoster, especially after age 60.
Playing contact sports like soccer can put you at risk for a rib injury. Other activities that can lead to damage can also cause the condition, unsafe driving that leads to an injury-causing accident.
Signs and symptoms
A sharp, spasm-like pain mainly characterizes symptoms of intercostal neuralgia felt around the chest, often in a band that wraps from the back to the front, with pain on one or both sides of the chest (bilaterally ).
However, some cases may present as a constant dull ache instead. The pain usually intensifies with exertion during lifting heavy objects, twisting the torso, coughing, sneezing, or laughing. The following are additional symptoms that can also present with intercostal neuralgia pain:
Pain in your arm, shoulder, or back, restricted mobility of your shoulders or back, shaking, numbness, abdominal pain, loss of appetite, and fever.
Simply breathing involves movement of the rib cage, which can exacerbate intercostal neuralgia pain and lead to breathing problems and shortness of breath.
Also, the more severe symptoms of intercostal neuralgia that present with severe symptoms of chest pain, possibly combined with feelings of tightness or pressure, should be evaluated in the emergency room to rule out a possible heart attack.
Additional severe symptoms may include:
- Pain radiating to the left arm, shoulder, and back.
- A persistent cough that produces yellowish-green phlegm.
- Increased heart rate and strength (palpitations).
- Sudden confusion, dizziness, or loss of consciousness.
- Paralysis of the muscles.
- Severe abdominal pain
Diagnosis of intercostal neuralgia
An extensive history is essential in all chest pain, particularly in patients with a history of carcinomas. General issues such as weight loss, (chronic) cough, past trauma, chest surgery, and infections should also be explored.
In addition, it is important to ask patients if they have any complaints in the thoracic spine and any pain related to breathing or if it worsens when coughing.
The precise location of the pain and its radiation has to be explored. The character of the pain and the provoking conditions (static and dynamic load) can provide information on the etiology and nature of the pain (neuropathic versus nociceptive).
Physical examination is an integral part of the diagnosis of intercostal neuralgia once a presentation of intercostal pain appears. This often involves inspecting the resting area and palpitating the vertebra and paravertebral structures.
Extensive general physical and neurological examinations are always indicated in chest pain, mainly when there are thoracic spine disorders. The sensitivity of the chest and stomach should also be examined. Loss of sensation means whether the pain is neuropathic pain or not.
Examination of the thoracic spine is preferably performed with the patient seated and comprises inspection at rest and palpation of the vertebra and paravertebral structures, such as the costovertebral joints.
The provocation of pain by performing passive rotations, forward bending, back bending, and lateral bending, in particular, may indicate that the pain has a spinal etiology.
In paramedical upper and middle thoracic unilateral pain, shoulder function should also be examined on the same side.
Pressure pain in the sternum, sternocostal, and costovertebral junctions is usually accompanied by a local pattern (e.g., Tietze syndrome ) but is sometimes associated with segmental pain.
Pressure pain of the rib (s) can indicate which thoracic level (s) is (are) involved. Segmental translation of the thoracic vertebra (Federung test) in the prone position can display the status of the affected segment.
Various movements will also be evaluated, looking for pain production that may point to a possible source of origin.
Pain produced by the pressure of simply pressing down lightly on various areas around the thoracic area will also be evaluated. A detailed neurological exam will also be done to identify the cause of the pain.
Additional tests will be performed to rule out any pathological cause of intercostal neuralgia. Since chest pain is not a clinical entity and the reason cannot always be determined by history and physical examination, additional diagnoses are always needed.
This will help diagnose causes such as lung disease or cardiovascular disease. Once the potential cause has been found, further tests will be carried out for confirmation. Additional diagnostic tests may include:
- Blood test.
- Electrocardiogram .
- Chest x-ray
- Computed tomography scan.
- MRI scan.
In uncomplicated intercostal neuralgia, no additional diagnoses are needed. In trauma with or without osteoporosis, X-rays are indicated to exclude an impression fracture.
When there is a suspicion of malignancy, an MRI scan and referral to a specialist are mandatory. Additional diagnoses are essential, particularly in patients with a history of malignancy with acute chest pain. The same is true in the case of neurological deficits.
When there is suspicion of chest wall pathology, and there are pulmonary complaints, X-rays may be helpful, along with possible referral to a pulmonary specialist.
If there is any doubt or a visceral pathology is suspected, ultrasound scans, CT scans, or referral to a specialist should be considered.
Treatment for intercostal neuralgia will depend on the underlying cause, but the symptoms tend to resolve independently in most cases.
Because nerve pain, in general, can be pretty unpredictable and troublesome, several methods can be implemented to treat nerve pain. Several intercostal neuralgic treatments include:
Non-steroidal anti-inflammatory drug (NSAID): Helps reduce pain and inflammation.
Epidural injections: done in the nerve root to reduce pain symptoms.
Selective radiofrequency or cryo-nerve ablation: offered to patients who experience frequent recurrent intercostal pain and involves the destruction of the specific portion of the nerve causing the symptom.
Antidepressants: found to help reduce nerve pain.
Capsaicin Cream – An everyday item that helps reduce pain.
Intercostal Nerve Block: With the use of a local anesthetic or corticosteroid to blackout the pain-causing intercostal nerve.
Neuropathic pain medicine: can be used to block the action of nerves that cause pain.
Treatment can also come in other forms, such as complementary medicine or alternative therapies. They are expected to be used in conjunction with traditional forms of treatment to help manage symptoms.
RAND-36 (quality of life): touches on eight health concepts; physical functioning, body pain, role limitations due to physical health problems, role limitations due to personal or emotional issues, general mental health, social functioning, energy/fatigue, and general health perceptions.
It also includes a single item that indicates the perceived change in health.
Visual Analog Scale (VAS) -Pain (Maximum, Minimum, Actual, Average / Week): This measuring instrument attempts to measure a characteristic or attitude that is believed to encompass a continuum of values and cannot be easily measured.
It is often used in epidemiological and clinical investigations to measure the intensity or frequency of various symptoms. For example, the amount of pain a patient feels ranges on a continuum from none to extreme pain.
From the patient’s perspective, this spectrum appears continuous – their pain does not take discrete jumps, as a categorization of none, mild, moderate, and severe would suggest. It was to capture this idea of an underlying continuum that the visual analog scale (VAS) was devised.
Pain Catastrophization Scale (PCS): This is a 13-item scale, with each item rated on a 5-point scale: 0 (not at all) to 4 (all the time).
The catastrophizing pain scale is divided into three subscales; increase, rumination and impotence. The scale was developed as a self-report measurement tool that provided a valid index of catastrophizing in clinical and non-clinical populations.
Anxiety and Depression Scale (HADS) (fear and depression) is a widely used questionnaire to detect stress and depressive disorders. It comprises 14 articles, seven related to anxiety symptoms and seven to depressive symptoms. Each item is coded from 0 to 3.
Scores for anxiety and depression can range from 0 to 21, depending on the presence and severity of symptoms. The authors have proposed cut-off points or thresholds; a score between 0 and 7 does not indicate the presence of symptoms of anxiety or depression.
A score between 8 and 10 indicates the presence of symptoms but to a moderate degree, therefore, doubtful cases; a score greater than or equal to 11 indicates a significant number of symptoms of anxiety or depression corresponding to confirmed cases.
Multidisciplinary treatment: means the use of 2 or more therapies together. A team of healthcare professionals will treat you.
Whether somatic treatment is indicated or not is based on the diagnosis of pain. Based on the findings of the pain questionnaires, additional diagnoses and multidisciplinary treatment comprising several non-somatic therapies may be necessary.
If known, doctors and nurses try to reduce the intensity of pain and control any underlying causes. They assess patients, establish treatment plans, counsel and educate patients about their condition, prescribe and review medications, and perform injections and acupuncture for pain relief.
Physical therapists treat musculoskeletal conditions that cause or result from pain. The goal is to maintain or improve joint mobility and strengthen weakened muscles. Some specially trained physical therapists also provide acupuncture.
Psychologists address mood, coping, and behavior changes related to pain. Most patients with ongoing pain are frustrated and depressed by pain, suffering from reduced mobility and not being able to carry on with their profession or life in general.
The amount of depression is much more significant for most patients. And in turn, depression and anger make pain feel worse and lower the pain threshold even more.
Behavior “learned” while in pain, such as avoidance, resignation, and passivity, results in an increasing inability to handle life with pain and increased dependence on others and the healthcare system.
Psychologists can successfully interrupt these interaction cycles, which are essential in most cases to achieve acceptable long-term treatment results.
Home remedies and exercises for intercostal neuralgia
Home remedies can be beneficial in treating intercostal neuralgia. For example, you can apply local hot water compresses to the area to improve blood circulation. Improved blood circulation can help improve symptoms.
Physical therapy and massage are other means of increasing circulation and relieving pain. Keep in mind that a trained professional must perform this type of therapy not to cause further harm.
Some experts have recommended acupuncture and acupressure as they have been shown to offer improvements. Aromatherapy, particularly with clove oil, can help relieve burning symptoms and pain.
Exercise is another excellent way to treat intercostal neuralgia at home. You may want to practice stretching, such as raising your arms above your head or to the side to open your chest.
Just take your hands together and raise your arms above your head. Lean gently to one side and hold that stretch for a few seconds, and repeat this movement on the other side. Complete this stretch every morning with a few repetitions to get relief.
Postural training is also essential. This means practicing standing with your shoulders back, and your pelvis tucked slightly below.
That said, it’s essential to see a doctor when you start to suffer from intercostal neuralgia, as you don’t want to risk serious complications.
Prevention of intercostal neuralgia
Lengthening the intercostal muscles is important because it improves the body’s breathing cycle. These muscles are what connect the ribs. If these muscles are tight, the lungs cannot fully expand, limiting air intake.
The leading cause of tight intercostal muscles is poor posture. There are exercises that you can complete that will lengthen the intercostal muscles, which are detailed below.
Spine Lengthening – Yoga positions are good ways to lengthen the spine. An influential yoga position to lengthen the spine is the cow face.
Also known as gomukhasana, this exercise teaches you to correctly stretch your shoulders and arms. Begin by sitting on the floor and crossing your knees over each other. The bottom of your feet should be facing backward. Now, extend your arms behind you and hold onto the wrist. Hold for a couple of seconds and then release.
Torso Exercise: Sitting on the floor upright is performed with a Matsyasana twist or torso twist. Keep one leg straight in front, and the other knee bent, with your feet on the floor. Cross your bent leg over your straight leg.
Now bend your leg straight so that the heel of your foot reaches toward your buttocks. Gently turn your torso to face the side of your outer thigh. Hold this position and switch legs.
Side Stretch Exercise: To complete Parighasana (door pose), kneel on both knees and extend one leg to the side with the heel on the floor. Inhale, lift the opposite arm of the extended leg and lean to the side with the other hand resting on the calf.
Hold this for a few breaths, come back to center, and switch sides.
Deep breathing to stretch the intercostal muscles:
- Take a quiet moment to focus on your breathing.
- Don’t change it.
- Breathe like you usually would.
Do your lungs feel full? Has your belly lifted? You are not living deeply enough if you answer “no” to both questions.
Step 1: If possible, find a quiet place and relax. Feel free to sit up or lie down.
Step 2: Breathe normally and continue with a deep breath. You should feel your lungs expand and fill with air. Similarly, your belly should increase with each deep breath.
To release your breath, blow the air out through your mouth or nose, whichever is most comfortable, making sure you are done.
It would help if you focused not only on your breath but also on how your body feels with each breath. Watch how your abdomen grows and falls, and feel it more extensive as you take deeper breaths.