Pain under the ribs
Pain under the ribs is a very common problem, but initially not threatening. The pain can be traced back to a variety of causes. Serious organic diseases are only in the rarest of cases.
Pain under the ribs can be immediate or transmitted. If the pain is unbearably severe or does not improve within a short time, a doctor must clarify the exact cause. The clinical pictures that are behind this should be clarified below.
The reasons
The 12 ribs pull from the spine as a curved bone towards the sternum. In this way they cover the entire thorax and parts of the upper abdominal area. Between the individual ribs there are various muscle strands that play a role as auxiliary breathing muscles, among other things. Blood vessels and small so-called "intercostal nerves" are also located under the respective ribs. Due to their superficial position and constant movements in the chest, all of these structures are predestined for injuries, tension and pain.
Broken ribs are a common injury that leads to movement-dependent pain. Severe bruises in the ribs can also be painful. The muscles can also be affected. Tension in the small muscles between the ribs is the most common cause of stabbing rib pain, particularly when breathing. Sports activities, monotonous sitting, cold air and jerky movements promote tension.
Involvement of the nerves under the ribs, the intercostal nerves, is less common, but often very painful. Intercostal neuralgia is not a rare sight. This is an entrapment of the nerve between the muscles and ribs. Here, too, movements caused by breathing are particularly painful.
Projections from other organs can also cause pain under the ribs. In the chest itself, the lungs, heart and thymus can cause pain of this type. Heart attacks and angina pectoris are often described as pain in the ribs. Inflammation of the pericardium also causes pain. On the lungs, only the lungs are sensitive to pain. If this is injured or affected, for example in the case of inflammation, pain occurs under the ribs. Even with injuries to the ribs, under unfavorable circumstances the lung membrane immediately below can be pierced and injured.
More rarely, upper abdominal organs also project pain onto the ribs. Frequently affected are the diaphragm, stomach, esophagus, liver and gallbladder. If these organs are injured or enlarged, pain may affect the lower costal arch. A rare cause for this is the “HELLP syndrome” of pregnancy. This organic damage must urgently be clarified by a doctor.
The side pain
The pain under the ribs, which only occurs from the side, is typical of bone or nerve complaints. With blunt pressure on the chest from the front or back, the side rupture of the ribs is most likely. Due to the pressure distribution, the ribs on the side edge are most likely to burst. This is very typical in patients who have suffered cardiac arrest and are being resuscitated. A rib fracture can hardly be avoided in these cases, especially in older, osteoporotic patients. In the case of broken ribs, care must be taken to ensure that the broken ends do not pierce the chest and injure the lung membrane there. This is also a cause of side pain. This can lead to life-threatening complications of the lungs with shortness of breath.
Nerve entrapment can also cause side pain under the ribs. This pain can be triggered and made worse by breathing and movement in particular.
The broken rib as the cause
Broken ribs are caused by falls and blunt violence. The rib cage is mobile due to its cartilaginous connections with the breastbone and absorbs many shocks, but it can also break quickly. Broken ribs are particularly common in older people who already have osteoporosis. Bruised ribs represent the preliminary stage to breakage.
Broken ribs can occur on the left as well as on the right side. In rare cases, the ribs on either side can break. Series ruptures in ribs can also occur, with several superimposed ribs breaking at corresponding points due to the action of force.
The pain that occurs is sharp and is heavily dependent on the breath. The pain can also be triggered by external pressure and touch. A break can sometimes be felt externally. The breakpoints can be precisely identified in an X-ray or CT image of the chest. If the fractures lie on top of one another, therapy does not necessarily have to be carried out. Bandages around the chest do not make sense as they additionally restrict breathing. Care must also be taken to ensure that the broken ends do not penetrate the rib cage and possibly sever the lung membrane. Acutely life-threatening lung problems can be a complication.
In the case of severe symptoms, pain medication from the group of NSAIDs or opiates can be given to cure them. Depending on the severity of the fracture, healing takes several weeks.
Find out all about the topic here: The broken rib.
The pleurisy as the cause
With pleurisy, the thin skin that covers the lungs and the inside of the chest becomes inflamed. First and foremost, pain occurs when breathing. Therefore, those affected tend to breathe shallowly and adopt a relieving posture. Often only one side is affected.
When you breathe in, your lungs come close to your costal arch. Therefore, pleurisy can be felt in this area as well. Inflammation of the pleura can vary in severity from person to person.
Read more about the topic here: The pleurisy.
The pain on the right side
A one-sided occurrence of the symptoms on the right side can limit the causes. On the one hand, symptoms of the bones, muscles and nerves on one side can occur. Fractures are rarely found symmetrically on both sides. A broken bone on the right side thus indicates a fall on that side or a weakness of the bones on the right side compared to the left side.
Intercostal neuralgia, i.e. the pinching of a nerve between the ribs, is almost always one-sided. Muscle problems can also occur on the right side, for example from sporting activities and jerky movements and turning to the right side.
In the case of organic causes, however, the sole appearance on the right side can provide an indication of the affected organs. In addition to the lungs in the chest, the stomach, liver, gall bladder, large intestine or the right kidney in particular can be affected in the abdomen. In the case of complaints caused by gallstones and congestion of the gallbladder, the pain occurs colic-like (interval-like) and can radiate into the shoulder. In addition, yellowing of the eyes and skin can often be noticed.
After large meals, the stomach can also be the cause of the pain. If it is full, the pressure alone can cause pain in the lower costal arch. In rare cases, diaphragmatic defects can occur that allow the stomach to enter the chest. This, in turn, leads to severe pain that can be projected onto the ribs.
Pleurisy can also occur in isolation on the right side. Since the cavities on the right and left sides of the lungs are separated, inflammation often appears one-sided. The liver itself rarely causes isolated, right-sided pain under the ribs. During pregnancy, however, it can be an indication of dangerous, pathological metabolic processes. The "HELLP syndrome" is a possible disease.
Liver enlargement as the cause
The liver is located under the right costal arch.The liver can become enlarged as part of various diseases. Often this only creates a feeling of pressure. Real pain is more likely to occur with acute inflammation of the liver, hepatitis. However, liver enlargement also occurs in the context of hepatitis. There are different types of hepatitis, each of which causes additional symptoms.
Pfeiffer's glandular fever can - among other infectious diseases - spread to the liver. The liver becomes swollen and painful.
Find out more about the topic here: The hepatitis.
The left side pain
Left, unilateral pain under the ribs is also musculoskeletal in most cases. Bone fractures, muscle soreness, tears, tension, neuralgia (nerve pain) and other superficial injuries provoke pain that can be aggravated by pressure or movement.
The left lung, heart, stomach and spleen are the main organic causes. In coronary artery disease, pain under the ribs is not a rare symptom. Depending on the degree of blockage of the artery, the pain occurs as pressure and tightness with more or less stress. In the case of an acute heart attack, severe chest pain usually occurs even at rest, which can radiate into the head, neck and arm. If the symptoms are less pronounced, such a pain can be mistaken for pain in the ribs.
Diseases of the spleen can also rarely be the cause of left-sided pain under the ribs.
You can read more information here: Rib pain on the left.
The spleen as the cause
In rare cases, an organic cause of pain under the ribs on the left side lies in the spleen. The spleen is an upper abdominal organ that filters and sorts the blood. With certain blood diseases, for example severe blood poisoning or leukemia, the spleen does not do its job and the organ swells up considerably.
The spleen is usually below the ribs and extends to the lower left costal arch. If it swells, it also puts pressure on the diaphragm and ribs, causing pain. The spleen can also rupture as a result of the swelling or injury.
Read more on this topic at: Pain in the spleen
The central pain
Central pain only rarely affects the ribs themselves. The first 8 ribs are connected to the sternum via cartilage, which extends in the middle to above the stomach. This can also break in blunt injuries and lead to severe pain. Damage to muscles and nerves is very atypical for central pain.
With diffuse, dull or burning pain behind the breastbone, an organic cause is obvious. Mainly the trachea and esophagus are to be found in the middle. The windpipe can be irritated by inflammatory processes. Bronchitis of viral or bacterial origin can be responsible. Foreign bodies can also get into the windpipe if swallowed and cause pain. More often, however, the esophagus is affected. In the case of badly chewed large bites, it can happen that food residues get stuck in the esophagus. This leads to acute, sharp pain. Acidification of the mucous membrane can also cause pain. The typical heartburn is mainly caused by fatty food in combination with risk factors such as smoking, obesity and medication.
If the stomach gets into the chest through a hole in the diaphragm, this too can lead to central pain in the ribs. The stomach can press on the surrounding chest organs, which is aggravated by ingesting food. Read more on this topic at: Diaphragmatic hernia
Heartburn as the cause
Heartburn affects many adults. It is an irritation of the lining of the esophagus from too much acid. In particular, high-energy foods such as alcohol and fatty foods provoke heartburn. In addition, some risk factors promote the occurrence. These include being overweight, smoking, lying down frequently, consuming coffee and certain medications. Heartburn is a diffuse, burning pain in the middle behind the breastbone. In some cases, the stomach is also affected, which can lead to an ulcer. This may show up as a sharp pain under the ribs.
The gastric mucosal inflammation as the cause
The stomach is located centrally to left under the costal arch. In the case of an inflammation of the gastric mucosa, among other things, pain occurs, which is perceived in this area.
Inflammation of the gastric mucosa occurs when the mucous layer that protects the stomach wall is weakened. Then the stomach acid attacks the stomach lining. The pain often decreases for a short time after eating. The stomach acid is somewhat neutralized by the food, which leads to the alleviation of the symptoms.
In addition to the stomach pain, there is also nausea and in some cases vomiting. Those affected also have less appetite and a feeling of fullness. With the right foods and medication, stomach acid can be neutralized and its production reduced, thereby improving the symptoms.
The diaphragmatic hernia as the cause
A diaphragmatic hernia is a congenital or acquired defect in the diaphragm muscle. This results in gaps in the muscle and thus an incomplete separation of the abdomen and chest. This can cause the stomach to move into the chest and come to rest next to the heart and lungs. Especially after eating, when the stomach fills up and increases in volume, pain and various ailments can occur. Pain under the ribs is also typical. The so-called “thoracic stomach” can be easily determined by an X-ray examination.
The sore muscles as the cause
As with any muscle, the small strands of muscle between the ribs can be affected by sore muscles. These are tiny muscle fiber tears that result from excessive stress. In the context of infections that are accompanied by a strong cough, muscle soreness can occur. It makes deep breathing and coughing all the more painful.
In the case of particularly pronounced symptoms, the pain can be alleviated with a pain medication until it has healed.
The pain in the back
On the back, the ribs are directly connected to the spine and are fixed by ligaments and muscles. This is where many of the muscles and tendons of the spine attach to the individual ribs to ensure the stability of the back. In the event of tension, overload and injuries to these muscles, the pain also manifests itself under the back ribs. Rapid turns in the upper body, monotonous movements or heavy weight loads can damage the muscles. The pain can be provoked by deep breathing and coughing.
The spine can also be the cause. The thoracic spine is a potential location for herniated discs and pain. A herniated disc in the thoracic spine is much less common than in the deep back. In certain circumstances, nerve cords can be affected, causing pain under the ribs and radiating from the spine.
With dull pain in the ribs on the back, a kidney problem must also be considered. The renal pelvis is sensitive to pain, which is why injuries and inflammation lead to pain. The pain can be provoked by thudding on the back. In most cases, inflammation of the kidneys is accompanied by a strong feeling of illness and general symptoms.
The pain when breathing
Most of the breathing is carried out through the diaphragm. However, some muscles of the chest support this process, which is why they are referred to as "auxiliary breathing muscles". These include some muscle groups that attach to the ribs and, when contracted, raise the ribs and expand the chest for breathing. Between the individual ribs run transversely small muscle strands that help with deep inhalation and forced exhalation. With tension, sore muscles or tears in these muscles, stabbing pain under the ribs occurs with every breath.
If the intercostal nerves (nerves under the ribs) are irritated or damaged, the pain is aggravated or triggered by deep breathing. Unconsciously, patients breathe more slowly and particularly severe pain can lead to shortness of breath. Even with broken ribs, the pain is made worse by the deep breathing, which causes the chest to move and thus shift the breakpoints. In the case of breathlessness or unbearable pain, strong pain relievers such as morphine may have to be given to ensure breathing and make it bearable.
Some organic diseases also cause shortness of breath. However, the pain under the ribs does not necessarily depend on the breath. Inflammation of the lungs or heart attacks, but also heart failure, lead to chest pain with shortness of breath. Immediate measures in the event of an acute heart attack include propping yourself up with your hands behind you while sitting. This supports the auxiliary breathing muscles of the chest and makes breathing easier.
The pain when coughing
Coughing is a reflex-like forced exhalation, for example to clear the airways of foreign bodies. In order to be able to implement the rapid exhalation, many muscles of the chest are tensed, which exert great tension on the ribs. If you already have bone or muscle problems, coughing is a very painful, stinging process. Patients who have had thoracic surgery that severed the sternum or ribs will need to learn new coughing techniques as they heal. Targeted pressure on the chest while coughing can partially reduce the tensile load.
Inflammation of the airways and lungs can cause pain under the ribs in several ways. If the lung is involved in the inflammation, every breathing movement is painful. Frequent coughing can also overstrain the auxiliary breathing muscles of the ribs, making coughing a doubly painful process. In such cases, so-called "antitussive" drugs, such as codeine, can alleviate the symptoms.
The pain when sitting
Often, pain under the ribs can be triggered or worsened while sitting. On the one hand, this is due to the displacement of the abdominal organs while sitting; on the other hand, muscle parts that are important for standing are neglected in long, monotonous sitting. Often the muscles of the thoracic spine and shoulders slacken when sitting for a long time, causing the upper body to sag slightly. Movement-dependent pain in the ribs also increases. Breathing is also made difficult by the slump of the shoulders. This in turn makes existing breathing-dependent complaints more difficult.
Pain under the ribs that worsens when sitting is common, especially in pregnant women. Often there are harmless causes behind it. Due to the large uterus and the increased pressure in the abdomen, the pressure on the peritoneum, diaphragm, rib cage and ribs from the inside also increases. Especially when sitting, the abdominal organs shift and the pressure increases. Even in non-pregnant women, parts of the intestine can press on the ribs and diaphragm while sitting and cause pain under the ribs.
The pain of pregnancy
Pregnancy is a burden for the female body in several ways. Through hormonal changes, certain muscle parts in the entire body relax, including the back and upper body. In the abdomen, the growing uterus increases the pressure on the abdominal organs, the diaphragm and the ribs. Pain in the abdomen and chest is unfortunately not uncommon, but rarely has a dangerous cause. In particular, pressure on the upper abdominal organs such as the stomach, liver and gall bladder can be painful under the ribs.
A rare but very serious illness that can lead to rib pain is HELLP syndrome. It occurs in about 1 in 300 pregnant women and is associated with diseases of the blood cells and the liver. Typical symptoms are upper abdominal pain and rib pain on the right side due to enlarged liver, and other severe symptoms.
However, since in most cases it is a question of muscle complaints due to overload, it is primarily advisable to rest until the pain subsides on its own after a short period.
The pain after eating
When you eat, some digestive processes start which, in addition to moving the esophagus, stomach and intestines, also release enzymes and bile acids. Too large portions and bites can cause stabbing pains in the esophagus that appear at chest level. The filling stomach creates additional pressure on the surrounding upper abdominal organs and the diaphragm. Pain can result from it.
Colic-like pain (pain that swells in and out in the interval) that occurs a few minutes after eating can be typical of a gallbladder problem. In general, the upper abdominal organs, which are concerned with digestion, have a close neighborly relationship with the diaphragm, chest, and ribs. In the case of irritation, injury, stretching and other discomfort, the discomfort can express itself as pain under the ribs.
The pain after biliary surgery
The gallbladder is usually operated on with minimally invasive methods and rarely leads to complications. Sometimes, however, some patients may experience digestive discomfort and pain, which can vary in severity.
In severe cases one speaks of a "postcholecystectomy syndrome". Translated, this simply means: discomfort after removing the gallbladder. Typical for this are digestive problems such as diarrhea, nausea, colic (interval-like pain), fatty stools, flatulence and intolerance. However, there is usually pain under the ribs. For therapy, means or herbs can be used that support digestion and partially take over the work of the bile acids.
Pain after biliary surgery? Read more about this here.
The pain after exercise
In sport there is a high risk of rapid, abrupt movements but also of injuries. Muscle parts in the upper body can be pulled or torn through strong twists and movements. This can be very painful under the ribs.
Blunt violence is also found more frequently in sport. The risk of chest bruises and broken ribs increases significantly in some sports. The spleen can also be damaged and swollen in the event of an adverse impact, which in turn leads to pain under the ribs.
The accompanying symptoms
The main symptom is chest pain. It is important to differentiate between whether the pain occurs punctually or diffusely. In the case of diffuse pain, the pain can often be narrowed down to the lower costal arch or a specific side. The pain can be acute and sudden or worsen over days to weeks. The form of the pain can be sharp or dull, or even burning. With most musculoskeletal complaints (complaints of muscles, tendons, ligaments or bones), the pain can be consciously triggered or worsened by deep breathing.
In the case of underlying organic diseases, a large number of different accompanying symptoms can provide information on the diagnosis. Heart disease can lead to stress-dependent chest pain, for example after climbing stairs. In acute emergencies, circulatory collapse and severe shortness of breath can be associated with pain under the ribs. In diseases of the lungs, shortness of breath is in the foreground. If there is inflammation, severe symptoms of infection with fever and cough can also occur.
With causes that are in the gastrointestinal tract, nausea, diarrhea and vomiting can occur as accompanying symptoms. Further organ-specific complaints occur depending on the disease.
When the liver is affected, symptoms can vary widely. They range from itching and clotting disorders to headaches and visual disturbances. Bile congestion (jaundice) is a not uncommon clinical picture. It is accompanied by severe, stabbing pain after eating. Yellowing of the eyes and skin is a clear indication of this cause. The pain is often mistakenly described as pain under the ribs.
The diarrhea as an accompanying symptom
Diarrhea is a symptom that indicates organic complaints of the digestive tract. Often it occurs with gas, vomiting, and nausea. The gallbladder or liver can also be the cause. If it is accompanied by rib pain, the cause is almost always to be found in the upper abdomen. Digestive problems, intolerance and large meals can also cause pain in the ribs and provoke diarrhea. With the help of an ultrasound examination, pathological changes in the upper abdominal organs can be narrowed down.
The rare HELLP syndrome of pregnancy also leads to nausea, vomiting and diarrhea in addition to the pain under the ribs. If the symptoms persist for a long time or are very pronounced, possible diseases should be diagnosed by a doctor.
The diagnosis
In order to make a diagnosis, it is primarily important to differentiate and limit the pain through targeted questioning. In the majority of cases, there are musculoskeletal diseases (diseases of the muscles, tendons, ligaments or bones). There is often an underlying cause, for example a broken rib as a result of a fall. Often times, pressure, movement, or breathing make the pain worse.
In the event of a break, a break point can be felt on the outside. A chest x-ray is useful for further clarification. Organic damage can sometimes also be seen on this. An injury to the lung membrane with collapse of the lungs can be detected, as can problems of the large pulmonary and heart vessels. Individual diseases such as diaphragmatic hernias (penetration points of the diaphragm) and other diseases of the gastrointestinal tract can also be seen on the x-ray. These can be examined more closely using endoscopic examinations, for example a gastroscopy. For special organic diseases, CT and MRT images can also be used. Coronary artery diseases, which often lead to pain under the ribs, can be diagnosed using a so-called "cardiac catheter".
In the case of mild, initial complaints, potential causes should first be narrowed down on the basis of the pain and the precise anamnesis. If an underlying illness is suspected, the doctor will refer the patient to an appropriate specialist. Numerous further diagnostic steps are available to these.
The therapy
Treatment for pain under the ribs varies widely with underlying causes. Ailments of the ribs, muscles and nerves can be easily remedied in most cases, in the case of organic complaints the treatment depends heavily on the disease.
Rib fractures are among those fractures that can hardly be treated. If the break points are straight to each other, there is no need for intervention, plaster of paris or a bandage. As with bruises, treatment is based on waiting for the healing process and, if necessary, on medication to relieve pain. Drugs from the group of NSAIDs (non-steroidal anti-inflammatory drugs), for example diclofenac and ibuprofen, can be used. For severe pain that even makes breathing difficult, morphine-like drugs can be used to relieve pain. Tension and pinching of the muscles and nerves between the ribs heal themselves in most cases. Here, too, the symptoms can be alleviated with NSAIDs or opiates. Means to relax the muscles or anesthetics for the nerves may also be administered.
If there is an organic disease, comprehensive, causal therapies must be carried out. In acute cases, intensive medical measures consisting of ventilation and circulatory stabilization may be necessary. Endoscopic and surgical interventions are not infrequently used for diseases of the upper abdomen.
Prognosis
There is no general prognosis for pain under the ribs. Tension and nerve entrapment can get better within a few hours to days. Other irritations and overloading of the muscles usually do not need more than a few days for the muscle to recover and regenerate.
Bruised bones and fractures require longer recovery time. The stronger the bruise, the longer it will take to heal. When broken, the bone needs time to grow together. The duration can be several weeks.
In the case of organic causes of the pain under the ribs, the diseases can sometimes be remedied immediately through targeted interventions, but the focus is often on protracted therapy, the duration of which is often not foreseeable.
