Thoracic radiculopathy and intercostal neuralgia are the two main nerve-driven causes of chest wall pain. Both produce a band of burning, electric or aching pain that wraps around one side of the chest along the territory of a single nerve, and both are routinely mistaken for heart, gallbladder or lung disease before anyone thinks about a nerve.
This article is part of a wider guide to chest wall pain that is not your heart, which covers the full differential.
Before you read further: chest pain can be an emergency
Call 911 or go to an emergency department now if your chest pain is sudden and severe, feels like pressure, crushing, squeezing or tightness, or comes with any of the following:
- Pain spreading to the arm, jaw, neck, shoulder or back
- Shortness of breath
- Sweating or clammy skin
- Nausea or vomiting
- Lightheadedness, fainting, or a racing or irregular heartbeat
- Pain that comes on with exertion and eases with rest — this pattern needs urgent assessment even when the pain itself is mild
National guidelines treat acute chest pain as a cardiac emergency until testing proves otherwise.12
A heart attack does not always cause chest pain. In women, in people with diabetes, and in older adults it can present instead as unusual fatigue, indigestion-like discomfort, breathlessness on its own, or pain felt only in the back, jaw or upper abdomen. Do not rule out your heart because the pain is not where you expected it.
How the pain feels cannot settle what is causing it. Chest wall pain is often reproduced by pressing on the chest — but tenderness does not exclude heart disease. Among adults presenting with chest pain who also had chest wall tenderness on examination, 3% to 6% still had coronary artery disease.13 Which side the pain is on does not distinguish the two either.
If you were cleared before, that clearance covered the pain you had then. A normal cardiac workup months ago does not cover a new pain, or a pain that has changed in character, timing or severity. Get a changed pain reassessed.
This article is about chest wall pain in people whose pain has already been evaluated and found not to be cardiac. It is general information, not medical advice, and it is not a substitute for being examined.
What thoracic radiculopathy is
A radiculopathy is pain, numbness or weakness from irritation or compression of a spinal nerve root where it leaves the spinal canal. In the neck the affected root sends symptoms down an arm; in the low back, down a leg. In the mid-back it does neither: the twelve thoracic roots do not supply a limb. They wrap forward around the ribcage.
So a thoracic root problem produces a band. The pain begins near the spine, travels around one side of the ribs, and stops at the midline. It does not cross to the other side. It is often burning or electric rather than dull, and worse with coughing, a deep breath or trunk rotation. Pain that worsens with a deep breath is not by itself reassuring: pulmonary embolism and a collapsed lung do the same thing, which is part of why the cardiac and pulmonary workup comes first. Numbness, hypersensitivity or intolerance of clothing inside that same band is the most useful examination finding, because visceral organs do not produce sensory change in a strip of skin. That is a finding an examiner maps in person, not something to test on yourself in place of an evaluation.
Why it is the rarest radiculopathy
The thoracic spine is splinted. Each vertebra is anchored to a pair of ribs, and the ribs join the sternum in front, so the segment moves very little compared with the neck or the low back. Less motion means less disc shear and less foraminal narrowing over a lifetime. Thoracic disc herniations are uncommon relative to cervical and lumbar herniations13. The causes are a short list: disc herniation, a compression fracture narrowing the foramen, degenerative narrowing, shingles, diabetes, and — less often but important to exclude — tumor. Rarity is why the diagnosis is missed: a clinician who sees thousands of sciatica patients may see this a few times a year.
Why it gets mistaken for cardiac, gallbladder or lung disease
The mistake is anatomical, not careless. The T4 through T6 roots on the left map onto the skin over the heart; T6 through T9 on the right map onto the skin over the gallbladder; T7 through T12 wrap the upper abdomen. A nerve problem at those levels puts pain precisely where visceral disease is expected. The overlap is deeper than skin: the same thoracic segments carry sympathetic supply to the heart and upper abdominal organs, so the nervous system has no clean way to separate a chest wall signal from an organ signal.
The sequence most patients go through is therefore correct — organ first, nerve second. The problem is what happens after a negative workup, when the patient is told nothing is wrong. The testing showed only that the heart and the gallbladder are not the source.
Diabetic thoracic radiculopathy
One variant behaves differently from everything else on the list. Diabetic thoracic radiculopathy — also called diabetic truncal neuropathy — appears in middle-aged and older adults with type 2 diabetes as unilateral pain and hypersensitivity in a thoracic dermatomal pattern5. In one series of six patients it involved three to five adjacent roots between T6 and T12, affected predominantly middle-aged men, favored the right abdominal wall, and was sometimes accompanied by profound weight loss not explained by poor glucose control4. Because the thoracic nerve also supplies the abdominal wall muscles, some patients develop a visible bulge on one side as those muscles weaken4 — often worked up as a hernia.
Two consequences follow. This is not a disc problem, so a spine MRI will not explain it, and treating a coincidental disc bulge will not help; it can be separated from intercostal neuralgia on clinical and electromyographic grounds6. And it usually resolves on its own, over roughly three to twelve months in the reported series46. The goal is pain control and function through an interval expected to end, not a structural fix. Our page on diabetes and neuropathy covers the metabolic picture.
Intercostal neuralgia
Intercostal neuralgia is pain from the intercostal nerve itself, after it has left the spine and entered the groove on the underside of the rib. The distribution looks nearly identical to a thoracic radiculopathy — same band, same side, same burning quality — but the generator is peripheral, not at the root, and that determines where a diagnostic injection goes.
After chest surgery
This is the best-documented cause. Persistent pain after thoracotomy affects roughly 25 to 60 percent of patients7; another review reports up to 65 percent with some pain and about 10 percent with pain severe enough to change their lives8. Intercostal nerve injury appears to be the single most important mechanism7 — the nerve is compressed by the rib retractor, stretched, or divided. Breast surgery has its own version: intercostobrachial nerve injury is a recognized cause of pain after mastectomy9. Intercostal neuralgia is also a listed complication of thoracic disc surgery3.
After rib fracture and blunt trauma
A fractured rib heals. The nerve running underneath it does not always recover with it. Patients describe pain that outlasts the fracture by months, in the same band, often with a tender point where the nerve crosses the rib angle. Imaging shows a healed rib and the patient is told the injury is over. It is over structurally, not neurologically.
After shingles
Thoracic dermatomes are the most common site of herpes zoster: 45 percent of cases in one clinic series, more than any other region, with pain preceding the rash in 41 percent10. That prodrome is a major reason zoster gets admitted as chest pain — for several days there is nothing to see. When pain persists after the rash heals, it is post-herpetic neuralgia, covered in our article on post-herpetic neuralgia.
How the diagnosis is actually made
The imaging trap
MRI of the thoracic spine in ninety people without thoracic symptoms found an abnormality in 73 percent: 37 percent had a disc herniation, 53 percent a disc bulge, and 29 percent deformation of the spinal cord — all symptom-free2. A thoracic disc herniation on an MRI report is therefore not a diagnosis. It becomes one only when its level matches the band the patient describes and the sensory change the examiner can map.
Examination and electrodiagnostic testing
The examination is mapping. Where does the band start and stop? Does it respect the midline? Is sensation altered inside it? Needle electromyography adds objective information: denervation in the thoracic paraspinal muscles at the involved level points to the root rather than the peripheral nerve, and that was the finding used to confirm the diagnosis in the early diabetic truncal neuropathy work56. We perform electrodiagnostic testing in our office.
Diagnostic nerve blocks
The most direct test of where pain comes from is to anesthetize a specific nerve and see whether the pain stops. In the published literature, intercostal nerve blocks are used this way — as a diagnostic test for intercostal neuralgia as well as a short-term therapeutic measure11. If numbing the intercostal nerve abolishes the band, the generator is peripheral. If it does not, and a selective nerve root block at that thoracic level does, the generator is at the root.
The limits are real. Local anesthetic spreads beyond its target, placebo response is substantial, and a single positive block over-calls the diagnosis. A block is evidence, not a verdict.
We perform intercostal nerve blocks, and they are our preferred approach for chest wall and intercostal pain. We also perform thoracic paravertebral blocks, which deposit anesthetic closer to the nerve root where the pain is segmental rather than confined to one intercostal space, or where several adjacent levels are involved. Which one is appropriate depends on where the block is meant to answer the question. Both are described on our nerve blocks page.
What treatment can and cannot do
Treatment follows the generator. Diabetic thoracic radiculopathy is managed through the interval it takes to resolve, because the natural history is recovery46. Root compression may respond to a thoracic epidural steroid injection, which reduces inflammation around the root but does not remove what is pressing on it. Pain generated in the peripheral intercostal nerve calls for treatment aimed at that nerve rather than at the spine, which is a different set of options from root compression. Pain that resists everything reasonable sometimes leads to a discussion of neuromodulation. Nothing here is a cure, and no one should promise you a number. A workup buys the right target. We do not manage this pain with escalating opioids; we work to reduce them. See our pain treatments page.
Being evaluated in St. Louis
Padda Institute, Center for Interventional Pain Management, evaluates thoracic radicular and intercostal chest wall pain at 4477 Woodson Rd, Suite 100, St. Louis, MO 63134 and 12174 Natural Bridge Road, Bridgeton, MO 63044. Dr. Gurpreet Singh Padda, MD, MBA, MHP performs the workup, including electrodiagnostic studies and image-guided injections such as thoracic epidural steroid injection. Call (314) 481-5000, see our locations, or request an appointment.
Frequently asked questions
How do I tell nerve pain from heart pain?
You cannot do this reliably on your own, and you should not try. Chest wall nerve pain tends to be band-like, one-sided, stops at the midline, and comes with altered skin sensation; cardiac pain is more often central, pressure-like and provoked by exertion. Those patterns overlap enough that the separation is made after a cardiac workup, not before one. If you have not had that workup, start in an emergency department, then see a pain physician.
Does a thoracic disc herniation on my MRI explain my chest pain?
Not by itself. Thirty-seven percent of people with no thoracic symptoms have one on MRI2. It explains your pain only if its level matches the band of pain and the sensory change on examination — a correlation a selective nerve root block is used to test.
Will diabetic thoracic radiculopathy go away?
In the published series it typically resolved over three to twelve months46. That is the natural history, not a guarantee for any individual. Because recovery is expected, treatment focuses on pain control and function during the interval, and on the underlying disease — see diabetes and neuropathy.
Why does my chest still hurt years after my surgery?
Because the intercostal nerve was injured during the operation and did not fully recover — the dominant mechanism in persistent post-thoracotomy pain7, which affects a substantial minority of patients8. The pain is neuropathic, so it responds to different treatments than incisional soreness. Identifying which nerve carries the pain comes first; our pain treatments page covers what an evaluation can offer.
Can shingles cause chest pain before the rash appears?
Yes. Pain preceded the rash in 41 percent of patients in one series, and thoracic dermatomes are the most commonly affected site10. That is a recognized reason patients are admitted for cardiac evaluation days before any skin findings appear. If pain persists after the rash heals, read our article on post-herpetic neuralgia.
Is a nerve block a treatment or a test?
Both, and the purposes should be kept separate. As a test, a block tells you whether the nerve you numbed carries the pain11. As a treatment, relief is usually temporary because local anesthetic wears off. To discuss which block would answer your question, contact our office.
Sources
- Kasliwal MK. Evolution and current status of surgical management of thoracic disc herniation – A review. Clin Neurol Neurosurg. 2023. PMID 37992532
- Wood KB, Garvey TA, Gundry C, Heithoff KB. Magnetic resonance imaging of the thoracic spine. Evaluation of asymptomatic individuals. J Bone Joint Surg Am. 1995. PMID 7593072
- Robinson WA, Nassr AN, Sebastian AS. Thoracic disc herniation, avoidance, and management of the surgical complications. Int Orthop. 2019. PMID 30666348
- Chaudhuri KR, Wren DR, Werring D, Watkins PJ. Unilateral abdominal muscle herniation with pain: a distinctive variant of diabetic radiculopathy. Diabet Med. 1997. PMID 9300233
- Massey EW. Diabetic truncal mononeuropathy: electromyographic evaluation. Acta Diabetol Lat. 1980. PMID 7223309
- Brewer R, Bedlack R, Massey E. Diabetic thoracic radiculopathy: an unusual cause of post-thoracotomy pain. Pain. 2003. PMID 12749978
- Wildgaard K, Ravn J, Kehlet H. Chronic post-thoracotomy pain: a critical review of pathogenic mechanisms and strategies for prevention. Eur J Cardiothorac Surg. 2009. PMID 19307137
- Gupta R, Van de Ven T, Pyati S. Post-Thoracotomy Pain: Current Strategies for Prevention and Treatment. Drugs. 2020. PMID 32876936
- Wisotzky EM, Saini V, Kao C. Ultrasound-Guided Intercostobrachial Nerve Block for Intercostobrachial Neuralgia in Breast Cancer Patients: A Case Series. PM R. 2015. PMID 26493855
- Goh CL, Khoo L. A retrospective study of the clinical presentation and outcome of herpes zoster in a tertiary dermatology outpatient referral clinic. Int J Dermatol. 1997. PMID 9352407
- Engel AJ. Utility of intercostal nerve conventional thermal radiofrequency ablations in the injured worker after blunt trauma. Pain Physician. 2012. PMID 22996865
- Gulati M, Levy PD, Mukherjee D, et al. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of chest pain. Circulation. 2021;144(22):e368-e454. PMID 34709879
- Proulx AM, Zryd TW. Costochondritis: diagnosis and treatment. American Family Physician. 2009;80(6):617-620. PMID 19817327
Dr. Gurpreet Singh Padda, MD, MBA, MHP
