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This article deliberately sticks to pain you can pin down to the ribs themselves: on a rib, in the space between two ribs, along the lower edge of the ribcage or at the side of the chest. Pressing, burning or widespread discomfort in the middle of the chest is covered in the article on chest pain; brief, pinpoint stabbing in the heart area and irritation of the rib cartilage at the breastbone are described in detail in the article on stabbing chest pain. Pain deep in the back below the ribs is covered in the article on flank pain.
A knock against the edge of a table, a fall onto your side, an elbow during football or unaccustomed lifting when moving house: the chest wall, with its ribs, intercostal muscles and the lining of the bone (periosteum), responds with pain. Typically, the pain can be pointed to precisely with one finger and gets worse when you breathe in deeply, cough, sneeze, laugh or twist your upper body. Lying on the affected side is often hardly possible. A bruised rib can hurt for about as long and as badly as a fracture — often for several weeks.
First step: cool the area during the first few days and take it easy, but do not immobilise it. It is important to keep breathing in deeply at regular intervals despite the pain and to cough up mucus, so that the lungs stay well ventilated. A pillow pressed against the painful spot while you cough takes some of the strain off.
Ribs usually break as a result of a direct impact: a fall, a cycling accident, a car accident. With osteoporosis, even small forces are enough — a fall from standing height, a hearty hug or a severe coughing fit. Signs of a fracture are a crack at the moment of the accident, a step or grinding you can feel, and pain at the injured rib when the chest is squeezed somewhere else.
A single rib fracture that has not shifted out of place usually heals by itself within a few weeks. The main purpose of an X-ray is to rule out complications: air in the chest cavity (pneumothorax), bleeding (haemothorax) or a bruised lung. With fractures of the lower ribs after an accident, the practice will also check the liver and spleen. Several broken ribs, older age, pre-existing lung disease and blood thinners considerably increase the risk of complications such as pneumonia — closer medical supervision, sometimes in hospital, then makes sense. A tight bandage or rib belt is generally no longer recommended today, because it restricts breathing.
Ribs can also break without an accident if they are put under strain again and again over weeks. Classic examples are a persistent cough, for instance with whooping cough, bronchitis or COPD, and sports with strong rotation of the trunk such as rowing or golf. The pain starts gradually, usually at the side of the chest, and gets worse with every coughing fit. A stress fracture is often not visible on an early X-ray. First step: have the cause of the cough treated and pause the strain. A stress fracture after only minor strain can point to reduced bone density.
A nerve runs beneath each rib. If it is irritated (intercostal neuralgia), there is a burning, stabbing or electric pain in a strip that runs on one side from the back towards the front; the skin above it can be numb or oversensitive, so that even a T-shirt feels unpleasant. A common cause is shingles (herpes zoster): the pain often starts a few days before the clusters of blisters appear on reddened skin. Other triggers are chest surgery, scars and irritated nerve roots in the thoracic spine, and less often diabetes.
First step: as soon as blisters appear, see your practice promptly. According to the guideline, antiviral medicines such as valaciclovir work best if they are started within 72 hours of the rash appearing if possible, especially in people over 50. If the nerve pain persists after the rash has healed (postherpetic neuralgia), special medicines for nerve pain may be an option.
At the back, each rib is connected to the thoracic spine by small joints. After a sudden movement, long periods of sitting or an awkward sleeping position, one of these joints can become painfully irritated — often called a “blocked rib”. Typically, the pain sits next to the spine and can radiate forwards along the rib when you breathe in or twist. Warmth, movement and physiotherapy usually help; the evidence for individual manipulation techniques is limited. At the front, at the junctions between cartilage and bone next to the breastbone, is where costochondritis occurs — more on this in the article on stabbing chest pain. In younger people with back pain at night and stiffness that improves with movement, ankylosing spondylitis can also affect the rib joints.
At the front, the lower ribs are only loosely connected by cartilage and ligaments. If these connections are too lax, the tip of one rib can slide under the one above it and irritate the intercostal nerve (slipping rib syndrome). Typical signs are pain at the lower edge of the ribcage when bending, twisting or doing sport, a clicking or popping sensation and sometimes a dull pain in the upper abdomen. The condition is often missed and investigated as a stomach or gallbladder problem. The practice usually makes the diagnosis with a simple manoeuvre at the edge of the ribcage; treatment is generally physiotherapy, with severe symptoms a nerve block, and rarely surgery.
The pleura lines the inside of the chest and is very sensitive to pain. If it is inflamed (pleurisy), it stabs with every breath — often as part of pneumonia with fever and cough, sometimes after a viral infection. A sudden, one-sided stabbing pain with breathlessness can point to a collapsed lung (pneumothorax), which mainly affects young, slim men and smokers or occurs after a rib fracture. Sudden pain on breathing with shortness of breath and a racing heart can be a pulmonary embolism, especially after surgery, a long journey, bed rest or with a swollen leg. Both are emergencies.
Some “rib pain” comes from organs that lie directly beneath the lower ribs. On the right, these are mainly the gallbladder and liver: cramping pain after fatty food that pulls into the right shoulder suggests gallstones. On the left are the stomach and spleen; in glandular fever, the spleen can swell and rupture after a knock. Band-like pain in the upper abdomen that pulls into the back can fit with inflammation of the pancreas. At the back, below the ribs, the kidneys can make themselves felt, for example with a kidney infection and fever.
In the second half of pregnancy, the growing womb presses up against the ribs from below, and the baby sometimes kicks right there — uncomfortable, but usually harmless. A new, persistent pain under the right ribs in late pregnancy, especially with headache, visual disturbances or nausea, on the other hand, can point to a serious pregnancy complication (HELLP syndrome) and needs to be seen in hospital immediately. In fibromyalgia, tenderness of the chest wall is often part of a widespread pain picture. Rarely, bone metastases or multiple myeloma are behind it — signs are persistent bone pain even at rest and at night, unintended weight loss, night sweats or fractures without a matching accident.
These tests only make sense if there are no warning signs and there has been no serious accident. They do not replace a diagnosis and cannot rule out either a fracture or a disease of the lungs or heart — they help you describe the pattern at your doctor's appointment.
Medicines can encourage rib pain in three ways: they weaken the bones, they trigger a cough that strains the ribs, or they make an injury more dangerous. If rib pain begins without a clear reason, it is worth taking a look at your medication plan.
Cortisone taken long term, such as prednisolone, is the most common drug-related cause of osteoporosis; rib and vertebral fractures can then occur after only minor strain. According to the summary of product characteristics, aromatase inhibitors such as anastrozole lower bone density, which is why it is checked before and during treatment. For proton pump inhibitors such as omeprazole, the summaries of product characteristics mention a slightly increased risk of bone fractures, especially at high doses and when taken for more than a year. Which other medicines put a strain on the bones is summarised in the guide medications and osteoporosis risk.
Blood pressure medicines from the ACE inhibitor group, such as ramipril or enalapril, trigger a dry, tickly cough in some of the people taking them — often weeks to months after starting treatment. Weeks of coughing can strain the intercostal muscles and, with weak bones, even break a rib. If you have been coughing since starting an ACE inhibitor, talk to your practice: switching to another medicine is often possible. More on coughing at night in the article on dry cough at night.
With anticoagulants such as apixaban, rivaroxaban or phenprocoumon, a rib fracture can bleed more heavily into the chest cavity or the chest wall. After a fall onto your chest, you should therefore have a doctor examine you the same day, even if the pain seems bearable at first. Do not stop the blood thinner itself on your own. More on this in the guide living with blood thinners.
For fluoroquinolone antibiotics such as levofloxacin or ciprofloxacin, the BfArM (German Federal Institute for Drugs and Medical Devices) has warned in a Direct Healthcare Professional Communication (Rote-Hand-Brief) of an increased risk of widening and tearing of the main artery (aorta). Sudden, severe pain in the chest, abdomen or back while taking a fluoroquinolone is therefore an emergency. Preparations containing oestrogen, such as the pill, increase the risk of thrombosis — stabbing pain on breathing with breathlessness or a swollen leg then needs to be checked immediately.
For bruises and uncomplicated fractures, medicines such as ibuprofen, diclofenac or paracetamol may be used for a short time. Without medical advice, the package leaflet usually says: no longer than three to four days in a row. Anti-inflammatories put a strain on the stomach, kidneys and cardiovascular system and increase the risk of bleeding if you take blood thinners; paracetamol must not exceed the maximum daily dose, otherwise the liver can be damaged. Metamizole can, very rarely, cause a dangerous drop in white blood cells — fever or a sore throat while taking metamizole needs to be checked by a doctor immediately. Stronger, prescription painkillers from the opioid group can suppress breathing; this needs particular attention with rib injuries and lung diseases. The painkiller comparison gives an overview; which treatment is right for you is always decided by the practice treating you.
Your medication plan shows your practice at a glance what affects your bones, cough and bleeding risk.
Doses logged so that the maximum duration without medical advice is not exceeded without you noticing.
This article is for general information and does not replace medical advice, diagnosis or treatment. The self-tests described are a guide and not a diagnosis; they cannot rule out a rib fracture or a disease of the lungs or heart. If you have shortness of breath, are coughing up blood, have a racing heart or chest pressure lasting more than five minutes, or after a serious accident or a fall while taking blood thinners, please contact a doctor or the emergency services on 112 without delay.
