Thoracic Spine & Rib Pain

Written by Dr Steven Hewitt — Chiropractor · AHPRA: CHI0001115420 · Last reviewed: May 2026

The thoracic spine sits between two of the most mobile and load-bearing regions of the body — the cervical spine and the lumbar spine — and connects to the rib cage, which houses the diaphragm and the thoracic outlet. In practice, it is frequently underassessed and undertreated, with clinical attention defaulting to the more symptomatic regions above and below it. The consequence is that thoracic restriction often persists as a background driver of cervical pain, shoulder dysfunction, and breathing impairment — addressed, if at all, only after other treatments have underperformed.

Important note: Chest pain of any kind — including mid-back pain that radiates anteriorly — should be assessed by a medical practitioner to exclude cardiac and pulmonary causes before attributing it to the musculoskeletal system. The conditions described on this page are musculoskeletal in nature. If you have chest pain associated with exertion, shortness of breath, jaw or arm pain, sweating, or nausea, seek urgent medical assessment.

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Thoracic Facet and Costovertebral Dysfunction: The Region That Drives Compensation Elsewhere

The thoracic spine has 12 motion segments, each with a pair of facet joints and — unlike the cervical and lumbar segments — a pair of costovertebral joints connecting the ribs to the vertebral bodies and transverse processes. These joints are richly innervated and capable of generating local and referred pain across the mid-back, around the ribcage, and into the anterior chest wall. [1]

Pain referral from the costovertebral joints has been mapped in detail: stimulation of the costotransverse joints produces local and referred pain that closely mimics intercostal neuralgia, visceral chest pain, and thoracic outlet symptoms. [2] The clinical implication is that mid-thoracic and upper-thoracic joint dysfunction is regularly misattributed to cervical disc disease, shoulder pathology, or cardiac disease — particularly when the referred anterior chest component is prominent.

From a movement perspective, the thoracic spine is responsible for approximately 35 degrees of total spinal rotation — the largest contribution of any region. When thoracic rotation is restricted, the cervical spine and lumbar spine are recruited to compensate. This is one reason why chronic cervical stiffness and recurrent lumbar tension commonly accompany thoracic restriction that has not been specifically addressed. Manual therapy directed at the thoracic spine consistently improves cervical range of motion and reduces cervical pain — a finding replicated across multiple randomised controlled trials. → Thoracic Facet & Costovertebral Joint Dysfunction

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Tietze's Syndrome and Costochondritis: Not the Same Condition

Anterior chest wall pain at the costochondral junctions is common and commonly mismanaged — partly because two distinct conditions, Tietze's syndrome and costochondritis, are frequently conflated. They have different presentations, different demographics, and different implications for management.

Tietze's syndrome involves a visible or palpable swelling at one or more costochondral junctions — most commonly the second or third rib — with localised tenderness and pain. It typically affects a younger demographic and the swelling is a distinguishing feature. Costochondritis is characterised by tenderness at multiple costochondral junctions, most commonly the second to fifth ribs, without swelling. It is more common in middle age and is often bilateral. Both conditions produce chest pain that can be alarming but are benign in nature when cardiac and pulmonary causes have been excluded.

The rib joints and costochondral junctions sit within the same fascial envelope as the thoracic spine — the deep anterior thoracic fascia connects the costal cartilages to the sternum and to the pectoral muscles, and movement restriction in the thoracic spine affects the mechanical environment of the anterior chest wall structures. In practice, anterior rib pain and mid-thoracic restriction commonly co-exist and respond to treatment directed at both. → Tietze's Syndrome & Costochondritis

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Thoracic Outlet Syndrome: Where Posture Meets Anatomy

Thoracic outlet syndrome (TOS) describes compression of the neurovascular structures — the brachial plexus, subclavian artery, and subclavian vein — as they pass through the thoracic outlet between the clavicle, first rib, and scalene muscles. Neurogenic TOS, by far the most common form, produces arm and hand pain, paraesthesia, and weakness patterns that depend on which neural structures are most compressed. It is frequently misdiagnosed as cervical radiculopathy or carpal tunnel syndrome, with which it can co-exist.

The postural and fascial contributors to TOS are well-established. Forward head posture and a depressed or internally rotated shoulder girdle narrow the costoclavicular space and increase tension in the scalenes — the muscles that both elevate the first rib and compress the outlet from above. Pectoralis minor tightness narrows the subcoracoid space through which the brachial plexus passes below the clavicle. [3] These are fascial and postural load problems as much as anatomical ones — and they respond to approaches that address tissue quality and postural mechanics alongside neural mobilisation. [4]

The fascial investments of the thoracic outlet — the anterior and middle scalene fascia, the clavipectoral fascia, and the deep cervical fascia — are structurally continuous with the mediastinal fascia and the cervical fascial sleeve. Densification or restriction in any of these layers can narrow the effective dimensions of the outlet and alter the mechanical behaviour of the structures passing through it. → Thoracic Outlet Syndrome

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The Breathing Connection

The diaphragm attaches to the underside of the lower six ribs and to the first three lumbar vertebrae. The thoracic cage it operates within is directly shaped by the mobility of the thoracic spine and costovertebral joints. When thoracic mobility is restricted — particularly in the lower thoracic segments — the expansion of the lower ribcage during inhalation is reduced, the diaphragm cannot descend fully, and breathing mechanics shift upward into the secondary respiratory muscles: the scalenes, upper trapezius, and sternocleidomastoid. [5]

This secondary muscle recruitment is precisely the same overload pattern that drives chronic upper trapezius tightness and neck fatigue in desk workers — and thoracic spine restriction is frequently an unaddressed contributor to it. Treating the thoracic spine improves both the mechanical capacity of the ribcage for breathing and the load distribution across the cervical structures. A randomised controlled trial by Babina and colleagues demonstrated that adding thoracic mobilisation to a treatment programme for low back pain significantly improved forced vital capacity and chest wall expansion — direct evidence of the thorax-breathing link. [5]

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What Can You Do Right Now?

Exclude cardiac and pulmonary causes first. If chest pain is new, unexplained, or associated with exertion, shortness of breath, or any systemic symptoms, see your GP before attributing it to the musculoskeletal system. This is not cautious overstatement — it is an important clinical step.

Move your thoracic spine daily. The thoracic spine stiffens rapidly with prolonged sitting and limited rotation. Thoracic rotation in a seated or standing position — turning through the mid-back rather than the lower back — is one of the most effective ways to maintain mobility in this region. Ten repetitions each side, twice daily, is a reasonable maintenance dose.

Address your shoulder girdle position. A depressed, internally rotated shoulder girdle narrows the thoracic outlet and increases upper thoracic load. Scapular retraction exercises — rows, face pulls, wall slides — improve shoulder girdle position and reduce the mechanical stress on the costoclavicular and subcoracoid spaces. This matters for both TOS and upper thoracic pain.

Check your breathing mechanics. If your breathing is upper-chest dominant — if your shoulders rise with each breath and your lower ribcage barely moves — your thoracic spine is likely contributing. Diaphragmatic breathing practice, redirecting the breath into the lower ribcage, is directly therapeutic for thoracic restriction as well as for the secondary muscle overload patterns above it.

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