Background & Etiology
The spine is composed of three main sections: the cervical (neck) thoracic (middle back) and lumbar (low back). The thoracic spine is the site of least movement when compared to either the cervical or lumbar segments. As a result the incidence of muscle injury to the thoracic spine is lower, however it is still possible to experience strain of the intercostal muscles.
The muscular system of the spine is large and complex, including the deep erector spinae or paraspinal muscle groups that run parallel to the spine. In addition, there are the more superficial muscles that help to move and protect the spine. Each area of the spine has a group of muscles that serve to support, move and stabilize it. The spinal muscles work together with the ligaments to provide movement, stability, and postural support to spine. They can be categorized according to their function. The four basic categories are the flexors, extensors, lateral flexors and rotators.
Muscles can be multisegmental connecting and attaching to more than one vertebra, or muscles can support and move one segment in relation to another. Irritation or injury of the structures of the spine may produce spasm and pain in the muscles of the back. Injury, tightness, or weakness of the muscles of the spine can result in pain, decreased ability to maintain good posture, limit movement and reduce the ability to stabilize the spine during activity.
In the spine there is an intercostal muscle group consisting of the internal and external intercostals, and the subcostal and transverse thoracic muscles, located between the ribs in the thoracic cavity. These muscles can become strained due to rapid movements that bend or twist the upper body suddenly. There are three grades of muscle strain:
- Grade I – A mild strain, where a few muscle fibers have experienced damage.
- Grade II – A moderate strain, where more muscle fibers are damaged, but they have not been ruptured.
- Grade III – A severe strain, where the muscle is ruptured.
Intercostal strains are often caused by sharp increases in physical activity or added stress on the muscles in the back. Additionally, sudden turning or twisting motions with the upper body are a common cause of intercostal muscle strains.
- Back pain or tenderness
- Sharp pain when inhaling or exhaling
- Pain when moving or using the back in daily activities
- Pain or soreness near the ribs
- Pain that worsens with bending or twisting motions
If an individual suspects they have an intercostal strain, the initial treatment should consist of avoiding the positions and activities that produce the pain. A course of conservative treatment is usually recommended that includes rest and immobilization, ice, physical therapy and non-steroidal medications to reduce inflammation. If symptoms persist, treatment by your physician may be necessary. This may include steroidal medication or injections, in conjunction with therapy. In severe cases surgical intervention may be needed to repair the torn muscle.
In mild cases rest, ice and medication may be enough to reduce the pain. Many patients will do well with this regiment. Physical therapy is recommended to develop a series of postural, stretching and strengthening exercises to prevent reoccurrence of the injury. Return to activity should be gradual to prevent a return of symptoms.
Moderate to Severe
If the problem persists, consulting with your health care provider should be the next step. Your physician will perform a thorough evaluation to determine the possible cause of your symptoms, the structures involved, the severity of the condition, and the best course of treatment.
Procedures that your physician may recommend and perform in addition to physical therapy may include:
- REST and ICE
- Splinting or bracing the affected area
- The use of NSAIDS (Non Steroidal Anti-Inflammatory Drugs)
- Steroidal injections to reduce inflammation
- Pain medication to reduce the discomfort and allow the patient to perform the recommended exercises
Physical Therapists are professionals, educated and trained to administer interventions. As defined by The Guide to Physical Therapist Practice, interventions are the skilled and purposeful use of physical therapy methods and techniques to produce changes consistent with the diagnosis, prognosis and the patient or client’s goals.
Your physical therapist will perform a thorough evaluation to assess and determine the following:
- Spinal Examination: where the patient is put through a series of movements and tests to determine the most probable cause of the condition.
- Strength: resisted testing is performed to determine if there is associated weakness or strength imbalances.
- Flexibility: tight muscles can contribute to poor mechanics and weakness creating imbalances and making one more susceptible to disc and back injuries.
- Posture Analysis, ADL’s and technique: discuss and observe the activity that may have started the problem. An examination of the dynamic and static postures that may have caused or contributed to the back problem. A review of your current activities at home and work that may or may not be causing or prolonging your present condition.
Physical therapy for an intercostal strain must remain conservative at the onset to avoid aggravating the condition. Emphasis will be on rest, reducing the inflammation, load and stress on the affected area. Once the initial inflammation has been reduced, a program of stretching and strengthening will be initiated to restore flexibility to the joints and muscles involved, while improving strength and stability to the spine. Your program design will be based on the structure and cause of your symptoms. A program not tailored to your problem could aggravate your symptoms.
Physical Therapy Interventions
Common Physical Therapy interventions in the treatment of an intercostal strain include:
- Manual Therapeutic Technique (MTT): hands on care including soft tissue massage, stretching and joint mobilization by a physical therapist to improve alignment, mobility and range of motion of the thoracic spine. Use of mobilization techniques also helps to modulate pain.
- Therapeutic Exercises (TE) including stretching and strengthening exercises to restore joint mobility, range of motion, and strengthen muscles of the back and abdominals to support, stabilize and decrease the stresses place on the spinal joints, discs, and neck.
- Neuromuscular Re-education (NMR) to improve posture, restore stability, retrain the patient in proper sleeping, sitting and body mechanics to protect the injured spine.
- Modalities including the use of ultrasound, electrical stimulation, ice, cold laser, traction and others to decrease pain and inflammation of spinal structures.
- Home programs including strengthening, stretching and stabilization exercises and instructions to help the person perform daily tasks and advance to the next functional level.
Most people recover full function following a course of conservative care that includes physical therapy, medication and/or injections. It is important that once the pain and inflammation is reduced, and motion and strength are restored, the patient gradually returns to full activities. Instruction in daily activities or sport performance is helpful for reducing a reoccurrence of an intercostal strain.