Intercostal neuralgia: Causes, symptoms, diagnosis, and treatment

Intercostal neuralgia is a form of neuropathic pain that results from the damage or dysfunction of one or more nerves of the peripheral or central nervous system. Intercostal neuralgia affects the nerves running between the ribs and is seen in an estimated 3–22 percent of patients referred to pain clinics. Prevalence in the general population is about 15 percent.

Damage to intercostal nerves can occur due to a variety of diseases and conditions. This can lead to sporadic episodes of acute pain, often felt as a tearing, sharp, aching or gnawing sensation that wraps around the upper chest. Pain can be exacerbated by sudden movements like when laughing or coughing.

Causes and risk factors for intercostal neuralgia

Nerve damage or dysfunction of the intercostal nerves may occur due to infection, inflammation, direct trauma, or even certain diseases of the lung or chest wall. However, one of the most common causes of intercostal neuralgia is injuries caused during surgery involving the thoracic chest. This usually involves spreading apart the ribs to access the internal organs, possibly damaging the intercostal nerves in the process.

Various intercostal neuralgia causes include:

• Rib infection or osteomyelitis
• Shingles
• Nerve degeneration
• Inflammation of a nerve or group of nerves (neuritis)
• Pregnancy, due to ribcage expansion to make room for the fetus
• Pulled or strained muscle in the chest wall, shoulders, back, or arm
• Direct chest or rib injury
• Intercostal nerve entrapment
• Surgery on organs, bones, and tissues in the thoracic 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 for varicella zoster, especially after the age of 60
• Playing contact sports such as football can put you at risk for a rib injury. Other activities that may lead to injury may also cause the condition
• Unsafe driving that leads to an accident causing injury

Symptoms of intercostal neuralgia

Intercostal neuralgia symptoms are primarily characterized as sharp, spasm-like pain felt around the chest, often in a band-like pattern that wraps around from the back towards the front, with pain presenting on one side of the chest or both (bilaterally). However, some cases may present as a constant dull pain instead. Pain typically intensifies with exertion during activities like lifting heavy objects, twisting the torso, coughing, sneezing, or laughing.

The following are additional symptoms that may also present with intercostal neuralgia pain:

• Pain in your arm, shoulder, or back
• Restricted mobility of your shoulders or back
• Tingling
• Numbness
• Abdominal pain
• Loss of appetite
• Fever

Simply breathing involves the movement of the rib cage, which may exacerbate intercostal neuralgia pain and lead to respiratory problems and difficulty breathing. Additionally, more serious symptoms of intercostal neuralgia that present with serious chest pain symptoms possibly combined with feelings of tightness or pressure should be evaluated at the emergency room to rule out a possible heart attack.

Additional serious symptoms may include:

• Pain radiating to the left arm, shoulder, and back
• A persistent cough producing yellowish-green phlegm
• Increased heart rate and force (palpitations)
• Sudden confusion, dizziness, or loss of consciousness
• Paralysis of muscles
• Severe abdominal pain

Diagnosis of intercostal neuralgia

The physical examination is an important part of an intercostal neuralgia diagnosis once a presentation of intercostal pain appears. This often involves inspection of the area at rest and palpitation of the vertebra and paravertebral structures. Various movement will also be assessed, looking for the production of pain which may point to a possible origin source. Pain produced under pressure from simply pressing down lightly at various areas around the thoracic area will also be assessed. A detailed neurologic examination will also be done to identify the cause of pain.

To rule out any pathological causes of intercostal neuralgia, additional testing will be done. This will help diagnose causes such as lung diseases or cardiovascular conditions. Once the potential cause has been found, additional tests looking for confirmation will be carried out.

Additional diagnostic tests may include:

• Blood test
• Electrocardiogram
• Echocardiogram
• Chest X-ray
• CT/MRI
• Ultrasound

Treatment for intercostal neuralgia

Treatment for intercostal neuralgia will depend on the underlying cause, but in most cases, symptoms tend to resolve on their own. Because nerve pain, in general, can be quite unpredictable and problematic, various methods for dealing with nerve pain can be implemented. Various intercostal neuralgic treatments include:

• Non-steroidal anti-inflammatory medication (NSAIDs): Helps reduce pain and inflammation.
• Epidural injections: Done into the nerve root to reduce pain symptoms.
• Selective radiofrequency or cryo nerve ablation: Offered to patients who experience frequently recurring intercostal pain and involves destroying the specific portion of the nerve causing the symptom.
• Antidepressants: Found to be useful for reducing nerve pain.
• Capsaicin cream: A common item that helps to reduce pain.
• Intercostal nerve block: With the use of a local anesthetic or corticosteroid to black the intercostal nerve causing pain.
• Neuropathic pain medication: Can be used to block the action of nerves that cause pain.

Treatment may also come in other forms, such as complementary medicine or through alternative therapies. These are expected to be used in conjunction with traditional forms of treatment to help manage symptoms.

Home remedies and exercises for intercostal neuralgia

Home remedies may be beneficial in treating and managing intercostal neuralgia. For example, you can apply local hot water compresses to the area as a means of improving blood circulation. Improved blood circulation may aid in improving symptoms.

Physical therapy and massage are other means of boosting circulation, which in turn alleviates pain. Be mindful that this type of therapy should be performed by a trained professional as to not cause more damage.

Some experts have recommended acupuncture and acupressure as they have been shown to offer improvements.

Aromatherapy, particularly with clove oil, may help alleviate symptoms of burning and pain.

Exercise is another great way to treat intercostal neuralgia at home. For starters, you may want to practice stretching, such as raising your arms above your head or to the side to open up the chest. Simply grasp your hands together and raise your arms above your head. Gently lean to one side and hold that stretch for a few seconds and repeat this motion on the other side. Complete this stretch every morning with a few repetitions to obtain relief.

Posture training is also important. This means practicing standing up straight with shoulders back and pelvis tucked slightly under.

With that said, it’s important to see a doctor when you begin to suffer from intercostal neuralgia, as you don’t want to risk any serious complications arising.

Preventing intercostal neuralgia

Lengthening the intercostal muscles is important because it improves the breathing cycle of the body. These muscles are those that connect the ribs. If these muscles are tight, the lungs can’t fully expand, which limits air intake. The main cause for tight intercostal muscles is poor posture.

There are exercises you can complete that will lengthen the intercostal muscles, which are detailed below.

Lengthening of the spine: Yoga positions are good ways to lengthen the spine. An effective yoga position to lengthen the spine is known as cow face. Also known as gomukhasana, this exercise teaches you how to properly stretch the shoulders as well as the arms. Start by sitting up on the floor and crossing your knees over each other. The bottoms of your feet should be facing behind you. Now, extend your arms behind you and grab onto the wrist. Hold for a couple of seconds and then release.

Twisting of torso exercise: Matsyasana twist, or twisting of the torso, is done by sitting on the floor upright. Keep one leg straight out in front and have the other knee bent, foot on the floor. Cross the bent leg over the straight leg. Now bend the straight leg so the heel of your foot comes towards your buttocks. Gently twist your torso in so that you are looking to the side of your outer thigh. Hold this position and switch legs.

Stretching of sides exercise: To complete Parighasana (Gate pose), kneel on both knees and then extend one leg out to the side with your heel on the ground. Inhale, lift the opposite arm of the extended leg, and lean over to your side with your other hand resting on your calf. Hold this for a few breaths, return to center, and switch sides.

Deep breathing for stretching intercostal muscle: Take a quiet moment to concentrate on your breathing—don’t change it, just breathe how you normally would. Do your lungs feel full? Has your belly risen? If you answered “no” to both questions, you’re not breathing deeply enough.

Step 1: If possible, find a spot where it is quiet and you can relax. Feel free to either sit up tall or lie down.

Step 2: Take a normal breath and follow it up with a deep breath. You should feel your lungs expand and fill up with air. Likewise, your belly should rise with each deep breath. To release the breath, expel the air either through your mouth or nose—whatever is most comfortable—ensuring it is all out.
It’s important that you focus not only on your breath but also on how your body feels with each breath. Notice the way your abdomen grows and falls, and feel it getting larger as you take deeper breaths. You will begin to feel a sense of calm. Stressful thoughts will begin slipping away as you count to four and back down to one.

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