Upper back pain when breathing in is most often caused by an irritated rib joint or a strained muscle, which tends to hurt at one spot, catch on a deep breath or twist, and leave breathing otherwise easy. But the lungs, the heart and a blood clot in the lung can also cause it. Sudden breathlessness, chest pressure, a fast heartbeat, coughing blood, sweating or fainting with the pain needs emergency care. Fever with a cough needs a doctor today.
The safe order is to rule out the urgent causes first. If you have any of these right now, stop reading and call your local emergency number:
- Blood clot in the lung (pulmonary embolism): sudden sharp pain on breathing in, with breathlessness, a fast heartbeat, coughing blood or lightheadedness. A swollen or painful calf, recent surgery, a long flight or drive, pregnancy, hormone medicine or cancer raise the concern.
- Heart attack or heart lining problems: chest pressure or tightness, pain spreading to the arm, jaw or back, sweating, nausea or breathlessness.
- Collapsed lung (pneumothorax): sudden one-sided chest or upper back pain with breathlessness, often in tall, thin young adults, smokers or people with lung disease.
- Aortic dissection: sudden, severe, tearing pain through to the back.
Key takeaways
- Common benign cause: an irritated rib joint or strained muscle, usually tender at one spot and worse with twisting as well as breathing.
- Emergency causes: a blood clot in the lung, a heart attack, a collapsed lung and aortic dissection can all cause pain on breathing.
- Emergency signs: breathlessness, chest pressure, a fast heartbeat, coughing blood, sweating or fainting alongside the pain.
- Infection signs: fever, chills or a cough with pain on breathing suggest pleurisy or pneumonia and need a doctor today.
- Typical course for rib joint pain: often eases within 1 to 6 weeks.
Where are you right now?
- It has just started: check the emergency signs above and the safety sections near the end. If none fit, read “Where else this could be coming from”.
- Weeks in and still catching on a breath: go to “If it isn’t going to plan”.
- After an injection, surgery or an illness: pain on breathing after chest, heart, shoulder or spine surgery, or after a chest infection, should be reported to your surgeon or doctor, as some causes are more likely in this period.
- Getting back to work or sport: the “When can I…” table gives typical ranges for musculoskeletal causes once others have been ruled out.
Where else this could be coming from
Muscles, joints and nerves
- Rib joint irritation: sharp, pinpoint pain beside the spine that catches at the top of a deep breath, a cough or a sneeze, and also with twisting or reaching. Breathing is otherwise easy.
- Muscle strain: an ache or sharp pull along a muscle that is tender to press, often after lifting, reaching or a bout of coughing.
- Rib fracture: very tender at one point on a rib after a fall, a blow or severe coughing. More likely with osteoporosis.
- Irritated nerve between the ribs or shingles: burning or shooting pain following a rib around the chest. Shingles adds a rash in that band within a few days.
- Spinal compression fracture: sudden central spine pain that can wrap around the ribs, often after a minor fall or lift in someone with thin bones.
Lungs, heart and other organs
- Inflamed lining of the lung (pleurisy): sharp, stabbing pain on breathing in, often after a viral illness, sometimes with fever. It is usually not tender to press and does not change much with twisting.
- Pneumonia: pain on breathing with fever, chills, a cough with phlegm and feeling unwell.
- Inflamed lining of the heart (pericarditis): sharp chest pain that can reach the back or shoulder, worse lying flat and eased by leaning forward.
- Gallbladder: pain under the right ribs that can reach the right shoulder blade and catch on a deep breath, often after fatty meals.
Pain on breathing is usually a rib joint. Pain on breathing with breathlessness is a different conversation.
Week by week
This timeline is for rib joint or muscle pain, once lung, heart and other causes have been ruled out.
- Days 1 to 3: deep breaths, coughing and turning in bed catch sharply. Slow, full breaths every hour help keep the lungs clear, even if they pinch a little. Gentle movement within comfort usually helps more than staying still.
- Days 4 to 14: the catch usually becomes less frequent and less sharp. Gentle upper back rotation and side bending can be added.
- Weeks 2 to 6: most people settle within this window. Upper back mobility and shoulder blade strength are built up.
- After 6 weeks: pain on breathing that is still present needs a medical review, if it has not already had one.
Is this normal?
- It only hurts at the very top of a deep breath: common with rib joint irritation, as long as normal breathing is comfortable and you are not short of breath.
- I can press on the spot and it hurts: tenderness at one point beside the spine is typical of a rib joint or muscle. It does not by itself rule out other causes if other symptoms are present.
- I have been taking shallow breaths to avoid the pain: common, but it can leave the lungs less well ventilated. A few slow, full breaths each hour are usually advised.
- It started after a cold or a coughing fit: common. Heavy coughing can strain rib joints and muscles. Fever, a worsening cough or breathlessness need a doctor.
If it isn’t going to plan
It is week three. You have stopped taking deep breaths because each one catches beside your spine, and getting the shopping bags out of the car still makes you wince. The thought in your head is that if you keep your breathing shallow and stay still, it will settle on its own.
Shallow breathing and stillness tend to stiffen the upper back and rib joints further, so each deep breath keeps catching. A rib joint usually settles with regular gentle movement of the upper back, slow full breaths through the day, and gradual strengthening of the muscles around the shoulder blades.
If the pain has not clearly eased after about 2 weeks, get assessed by a doctor or physical therapist. Questions worth asking:
- Have the lungs and heart been checked as causes?
- Is this a rib joint, a muscle, a fracture or a nerve?
- Which movements and breathing exercises should I do now?
- What change would mean I should come back sooner?
When can I…
These ranges apply to rib joint and muscle causes only.
| Activity | Typical range |
|---|---|
| Sleep on that side | Often within 1 to 2 weeks; your back or the other side is usually easier at first |
| Drive | Once you can turn to check blind spots and brake without a sharp catch, often within 1 week |
| Reach overhead | Often within 1 to 3 weeks |
| Lift | Light loads close to the body within days; heavier lifting, especially with a twist, often 2 to 6 weeks |
| Desk work | Often within a few days, with a change of position every 20 to 30 minutes |
| Manual work or sport | Running, swimming and twisting sports often 2 to 6 weeks, once deep breaths no longer catch |
If you have had surgery, your surgeon’s protocol comes first.
Call your local emergency number or go to the emergency department if
- Breathlessness: sudden shortness of breath, or breathing that is getting harder.
- Possible clot: pain on breathing with a fast heartbeat, coughing blood, lightheadedness, or a swollen, painful calf.
- Heart signs: chest pressure or tightness, sweating, nausea, or pain spreading to the arm or jaw.
- Fainting or tearing pain: collapse, near-fainting, or sudden severe tearing pain through to the back.
- Chest injury: pain on breathing after a fall, car accident or blow to the chest, especially with breathlessness.
See a doctor today if
- Fever or cough: pain on breathing with fever, chills, or a cough with phlegm.
- Worse lying flat: sharp chest or back pain that is worse lying down and eased by leaning forward.
- Possible shingles: a burning band of pain on one side, with or without a new rash.
- Possible fracture: very tender point on a rib or the spine after a minor fall or coughing, especially with osteoporosis.
Get it checked soon if
- Slow progress: the pain has not clearly eased after about 2 weeks.
- Ongoing cough: a cough that has lasted more than 3 weeks.
- Pain after meals: pain under the right ribs or shoulder blade linked to eating.
- Wider health: unexplained weight loss, night sweats, or a history of cancer.
More on this area: upper and mid back conditions.
Rule out the lungs and heart first, and most upper back pain on breathing turns out to be a joint that settles with movement.
Written by Louise Yow, Neck & Shoulder Physio.