Thoracic radiculopathy and intercostal neuralgia are the two main nerve-driven causes of chest wall pain. Both cause a band of burning, electric or aching pain. The band wraps around one side of the chest along the path of a single nerve. Both are often 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. That guide covers the full list of possible causes.
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. Do the same if it feels like pressure, crushing, squeezing or tightness, or if it comes with any of these:
- 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 effort and eases with rest. This pattern needs an urgent check even when the pain itself is mild.
National guidelines treat acute (new) chest pain as a heart emergency until testing proves otherwise.12
A heart attack does not always cause chest pain. In women, people with diabetes, and older adults, it can show up in other ways. It can be unusual tiredness, discomfort like indigestion, or shortness of breath alone. It can be pain felt only in the back, jaw or upper belly. 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. Pressing on the chest often brings back chest wall pain. But tenderness does not rule out heart disease. Some adults with chest pain also had a tender chest wall on exam. Of those, 3% to 6% still had coronary artery disease.13 Which side the pain is on does not tell the two apart either.
If you were cleared before, that clearance covered the pain you had then. A normal heart workup months ago does not cover a new pain. It does not cover a pain that has changed in feel, timing or strength. Get a changed pain checked again.
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 is thoracic radiculopathy?
A radiculopathy is pain, numbness or weakness from a spinal nerve root that is irritated or squeezed. This happens where the root leaves the spinal canal. In the neck, the root sends symptoms down an arm. In the low back, it sends them 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 makes a band. The pain starts 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, not dull. Coughing, a deep breath or twisting the trunk makes it worse. Pain that gets worse with a deep breath is not, by itself, reassuring. Pulmonary embolism (a blood clot in the lung) and a collapsed lung do the same thing. That is part of why the heart and lung workup comes first. The most useful exam finding is numbness, extra sensitivity, or not being able to stand clothing inside that same band. That is because internal organs do not change feeling in a strip of skin. An examiner maps this in person. It is not something to test on yourself instead of an exam.
Why is thoracic radiculopathy so rare?
The thoracic spine is splinted. Each vertebra is anchored to a pair of ribs. The ribs join the breastbone in front. So this part of the spine moves very little compared with the neck or low back. Less motion means less wear on the discs. It also means less narrowing of the foramen (the opening where the nerve exits) over a lifetime. Thoracic disc herniations are less common than those in the neck and low back13. The causes are a short list. They are disc herniation, a compression fracture narrowing the foramen, wear-and-tear narrowing, shingles, and diabetes. Less often, it is a tumor, which must be ruled out. Because it is rare, the diagnosis gets missed. A doctor who sees thousands of sciatica patients may see this only a few times a year.
Why is thoracic nerve pain mistaken for heart, gallbladder or lung disease?
The mistake comes from anatomy, not carelessness. 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 belly. A nerve problem at those levels puts pain right where organ disease is expected. The overlap goes deeper than skin. The same thoracic levels carry sympathetic nerves to the heart and upper belly organs. So the nervous system has no clean way to tell a chest wall signal from an organ signal.
So the order most patients go through is correct: organ first, nerve second. The problem comes 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 type acts differently from everything else on the list. Diabetic thoracic radiculopathy is also called diabetic truncal neuropathy. It shows up in middle-aged and older adults with type 2 diabetes. It causes one-sided pain and extra sensitivity in a thoracic dermatome pattern (the skin strip one nerve root supplies)5. One series had six patients. It involved three to five roots side by side between T6 and T12. It struck mostly middle-aged men and favored the right belly wall. Sometimes it came with severe weight loss that poor glucose control did not explain4. The thoracic nerve also supplies the belly wall muscles. So as those muscles weaken, some patients get a visible bulge on one side4 that is often worked up as a hernia.
Two things follow. First, this is not a disc problem. A spine MRI will not explain it, and treating a disc bulge that happens to be there will not help. It can be told apart from intercostal neuralgia by exam and by EMG (a needle test of muscle and nerve)6. Second, it usually clears up on its own, over about three to twelve months in the reported series46. The goal is to control pain and help you function through a stretch that is expected to end. It is not a structural fix. Our page on diabetes and neuropathy covers the metabolic picture.
What is intercostal neuralgia?
Intercostal neuralgia is pain from the intercostal nerve itself. This is after the nerve has left the spine and entered the groove under the rib. The pain pattern looks almost the same as a thoracic radiculopathy: same band, same side, same burning. But the source is out along the nerve, not at the root. That determines where a diagnostic injection goes.
After chest surgery
This is the best-documented cause. Lasting pain after thoracotomy (open chest surgery) affects about 25 to 60 percent of patients7. Another review reports up to 65 percent with some pain. About 10 percent have pain bad enough to change their lives8. Injury to the intercostal nerve appears to be the single most important cause7. The rib spreader squeezes the nerve, or the nerve is stretched or cut. Breast surgery has its own version. Intercostobrachial nerve injury is a known cause of pain after mastectomy9. Intercostal neuralgia is also a listed complication of thoracic disc surgery3.
After rib fracture and blunt trauma
A broken rib heals. The nerve running under it does not always recover with it. Patients describe pain that lasts months past the fracture, in the same band. There is often a tender spot where the nerve crosses the bend of the rib. Imaging shows a healed rib, and the patient is told the injury is over. The bone is healed. The nerve is not.
After shingles
Thoracic dermatomes are the most common site of herpes zoster (shingles). In one clinic series they held 45 percent of cases, more than any other region. Pain came before the rash in 41 percent10. That early pain is a major reason shingles gets admitted as chest pain. For several days there is nothing to see. When pain lasts after the rash heals, it is post-herpetic neuralgia. It is covered in our article on post-herpetic neuralgia.
How are thoracic radiculopathy and intercostal neuralgia diagnosed?
The imaging trap
One study took MRIs of the thoracic spine in ninety people with no mid-back symptoms. It found something abnormal in 73 percent. Of them, 37 percent had a disc herniation, 53 percent a disc bulge, and 29 percent a change in the shape of the spinal cord. All had no symptoms2. So a thoracic disc herniation on an MRI report is not a diagnosis. It becomes one only when its level matches the band the patient describes. It must also match the change in feeling the examiner can map.
Examination and electrodiagnostic testing
The exam is mapping. Where does the band start and stop? Does it stop at the midline? Is feeling changed inside it? Needle electromyography (EMG) adds objective facts. Lost nerve supply to the thoracic spine muscles at that level points to the root, not the outer nerve. That finding confirmed 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 numb one nerve and see whether the pain stops. In the published literature, intercostal nerve blocks are used this way. They serve as a test for intercostal neuralgia and as short-term treatment11. If numbing the intercostal nerve wipes out the band, the source is out along the nerve. If it does not, and a selective nerve root block at that thoracic level does, the source is at the root.
The limits are real. Local anesthetic spreads beyond its target. The placebo response is large. 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. We use them when the pain follows a whole spinal level, not one rib space. We also use them when several levels side by side are involved. Which one fits 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 source. Diabetic thoracic radiculopathy is managed until it clears, because it tends to recover on its own46. A squeezed root may respond to a thoracic epidural steroid injection. It reduces inflammation around the root, but it does not remove what is pressing on it. Pain from the intercostal nerve out past the spine calls for treatment aimed at that nerve, not the spine. Those options differ from the ones for a squeezed root. Pain that resists every reasonable step sometimes leads to a talk about 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 rising doses of 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 Rd, St. Louis, 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 a band on one side that stops at the midline. It comes with changed skin feeling. Heart pain is more often in the center, feels like pressure, and comes on with effort. Those patterns overlap enough that the call is made after a heart 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 change in feeling on exam. A selective nerve root block is used to test that match.
Will diabetic thoracic radiculopathy go away?
In the published series it typically resolved over three to twelve months46. That is the usual course, not a promise for any one person. Because recovery is expected, treatment focuses on pain control and function in the meantime. It also targets the disease underneath. 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. That is the main cause of lasting pain after chest surgery7. It affects a large minority of patients8. The pain is nerve pain, so it responds to different treatments than a sore incision. Finding 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 came before the rash in 41 percent of patients in one series. Thoracic dermatomes are the most common site10. That is a known reason patients get admitted for a heart workup days before any skin signs appear. If pain lasts after the rash heals, read our article on post-herpetic neuralgia.
Is a nerve block a treatment or a test?
Both, and the two purposes should be kept apart. 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.
What are the symptoms of a pinched thoracic nerve?
A band of pain that starts near the spine, wraps around one side of the ribs and stops at the midline. It is often burning or electric, not dull. Coughing, a deep breath or twisting makes it worse. The most telling sign is numbness, extra sensitivity, or not being able to stand clothing inside that same band. That is because organs do not change feeling in a strip of skin.
What causes thoracic radiculopathy?
The list is short. It includes a disc herniation, a compression fracture narrowing the opening where the nerve exits, wear-and-tear narrowing, shingles and diabetes. Less often, it is a tumor that has to be ruled out. It is the rarest radiculopathy because the ribs splint the mid-back. So this part of the spine moves far less than the neck or low back. That is why it wears out its discs more slowly.
Does thoracic radiculopathy go away?
It depends on the cause. In the published series, the diabetic form usually cleared on its own over about three to twelve months. So care aims to get you through that stretch. A squeezed root may calm with a thoracic epidural steroid injection. It reduces inflammation around the root but does not remove what presses on it. Nothing here is a cure, and no one should promise you a number.
What is the best treatment for thoracic radiculopathy?
The one aimed at the actual source. Diabetic radiculopathy is managed until it recovers. A squeezed root may respond to a thoracic epidural steroid injection. Pain from the intercostal nerve itself calls for treatment aimed at that nerve, not the spine. Pain that resists every reasonable step can lead to a talk about neuromodulation. What we do not do is manage this pain with rising doses of opioids. We work to reduce them.
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
