Back pain when breathing: it is one of the symptoms that frightens people most, because breathing cannot be put on pause. Every deep breath, every cough, every sneeze reminds you that something is wrong. The good news exists and it is real: the most frequent source of the pain is the chest wall, that is, the muscles, the ribs and the joints between the ribs and the vertebrae. "More frequent", however, does not mean "almost always": in the best study we have, the chest wall explained less than half of the cases, and further on you will find the exact figure.
The less comfortable news should be said straight away, before the exercises. Pain that appears or worsens with breathing belongs to the same family of symptoms produced by the lungs, the pleura and the heart: it is what medicine calls pleuritic pain. For this reason the right order of things is not "I'll do two exercises and see how it goes", but "first I rule out, then I move". This article follows that order, and it also tells you where scientific evidence exists and where it simply does not.
⚠ Important: read this before continuing
The exercises and advice in this article are general guidance and may not suit your situation. Every person has a unique clinical history: what works for others could be counterproductive for you.
Want a professional's opinion? Start with the questionnaire: you register and see who will follow you, a physiotherapist registered with the Albo, chosen for your case, whom you write to in chat. If you would rather hear their voice, the first consultation is free and we look at your situation together.
Warning signs: when you need a doctor, not a physiotherapist
I am putting this part at the top and not at the bottom, because it is the only one that can change your day. If the back pain linked to breathing comes with any of these signs, physiotherapy is not the first step: contact the emergency number or go to the emergency department.
- Sudden shortness of breath, laboured breathing even at rest.
- Oppressive chest pain that radiates to the arm, neck or jaw, with cold sweats, nausea or a sense of fainting.
- Fever, shivering, cough with phlegm.
- Coughing up blood.
- Swelling or pain in one calf, especially after a long period of immobility: a long journey, bed rest, a recent surgical operation, pregnancy or the postpartum period.
- Rapid heartbeat, dizziness, fainting.
- Recent trauma: a fall, an accident, a direct blow to the chest or the back.
- Pain that gets progressively worse, that wakes you at night regardless of position, unexplained weight loss, a history of cancer or immunosuppression.
This is not alarmism, it is numbers. In a clinical review on pleuritic pain, pulmonary embolism is the most frequent potentially fatal cause and is found in 5-20% of patients who present to the emergency department with this type of pain; the same review also lists pericarditis, pneumonia, myocardial infarction and pneumothorax as clinically relevant causes. It should be read for what it is: that 5-20% concerns people who arrive at the emergency department, that is, a population already selected by its symptoms, not everyone who feels a stab behind the shoulder blade. But it explains why the same review recommends history taking, physical examination and a chest X-ray for everyone with pleuritic pain, and an electrocardiogram when there is suspicion of infarction, embolism or pericarditis.
On the spinal side the picture is similar. A systematic review of 22 studies and 41.320 patients with back pain who came to the emergency department found a serious condition that required immediate or urgent treatment in 2,5-5,1% of cases in the prospective studies (vertebral fractures 0-7,2%, spinal tumours 0-2,1%, infections 0-1,9%). Low percentages, which nevertheless stop being theoretical when the signs above are really present.
How often it is "just" the chest wall
Here an honest admission is needed: there are no studies on "back pain when breathing" as an isolated symptom. Nobody has taken a thousand people with exactly this presentation to count the diagnoses. What we have are close data, and they must be used for what they are.
The most useful comes from general practice. A German study of 1.212 consecutive patients aged 35 and over who consulted their GP for chest pain attributed the pain to the chest wall in 46,6% of cases, to stable ischaemic heart disease in 11,1%, to psychogenic disorders in 9,5%, while acute coronary syndrome accounted for 3,6%. It is chest pain, not back pain: but the chest wall is exactly the structure that hurts when you breathe, and the practical message is the same. The most frequent cause is musculoskeletal; the most frequent cause is not the only one.
The second figure concerns the back region. A systematic review of 33 studies measured a prevalence of back pain that varies widely depending on the definition used: for "any back pain" it ranges from 0,5-23,0% over seven days, 15,8-34,8% over one month and 12,0-31,2% over a lifetime. In other words: pain in the middle of the back is common, and the enormous variability of those numbers shows how little this region has been standardised in research compared with the neck and the lower back.
Why the back hurts precisely when you breathe
Breathing is not only a matter for the lungs: it is a movement that involves the spine. The diaphragm, the main engine, anchors through its crura to the first lumbar vertebrae. The intercostal muscles connect one rib to the next. Each rib articulates at the back with the thoracic vertebrae through two small joints, the costovertebral and the costotransverse. When you take a deep breath the rib cage expands and all these joints move.
It follows that something simple: if one of those structures is irritated, sensitised or not very mobile, breathing becomes the movement that provokes it. Not because breathing is wrong, but because it is the one movement you cannot avoid. It is also why this pain seems more intrusive than others: it recurs fifteen or twenty times a minute.
"Asthma and back pain": how they fit together
It is one of the questions that arrive most often on this page, and it deserves a precise answer because it lends itself to two opposite errors.
Asthma does not cause back pain, not directly. What can happen is indirect: when breathing costs effort, you breathe more with the accessory muscles (scalenes, sternocleidomastoid, pectoralis minor, intercostals) and with the chest rather than with the diaphragm. Those muscles are not made to work all day, and prolonged use can leave pain in the upper back and between the shoulder blades. It is the same mechanism I describe further on for people who breathe badly out of habit, not because of illness.
The mistake not to make is the opposite: taking for granted that it is muscular. Back pain that appears together with breathlessness, a cough that does not go away, fever or chest pain is not a matter for exercises, and it is the first section of this page. If you have asthma and the pain appeared while your breathing was getting worse, the thing to do is not to look for an exercise: it is to have it discussed with the doctor who follows your asthma.
Muscular causes: the most frequent
The muscles most often implicated are the quadratus lumborum, the spinal erectors, the intercostals and the posterior serratus. A trapezius strain can also contribute to the picture, especially when the discomfort extends towards the shoulder and shoulder blade. Intercostal pain is the variant that follows the course of a rib, like a line.
Some clues point towards a muscular origin: the pain is localised, you can often find with a finger the spot that reproduces it, it changes with position and with trunk movement, it worsens on a deep breath but remains tolerable on a calm breath. Be careful, however, of a common error, which is worth writing out in full: reproducing the pain by pressing does not rule out an internal cause. It is a clue in favour, not proof. In the general practice study cited above, the diagnosis of chest wall pain came after a complete assessment, not from palpation.
You will not find here a prediction of the "it resolves in one or two weeks" kind, because that figure, repeated widely online, rests on no study dedicated to back pain when breathing. Chest wall pain generally improves, but the timeframes vary from person to person and promising them is dishonest.
An important tip: before trying these exercises, make sure you have received a correct diagnosis. People often think they have one problem, but the real cause of the pain is something else. Doing the wrong exercises can make the situation worse instead of better.
Joint causes: ribs and thoracic vertebrae
When the joints between the ribs and the thoracic vertebrae become painful and not very mobile, deep breathing and trunk rotation become the two movements that pinch. The typical picture is one-sided, with pain that can follow the rib towards the front and a sensation of stiffness or "locking" at a precise point in the mid back. It is a situation often seen after a sudden movement, a violent cough or a period of immobility, and it falls within the broader chapter of dorsalgia.
Here too, the situation needs to be stated plainly. "Joint locking" is a useful clinical description, not something you see on an X-ray. And manual therapy, which is often proposed for this presentation, has fewer specific proofs than is claimed: in the Cochrane review on chronic non-specific low back pain, exercise does not differ from manual therapy for pain (mean difference 1,0; 95% confidence interval from -3,1 to 5,1). Two caveats that matter more than the number: it is a subgroup analysis, not the main comparison of the review, and it was carried out on the lumbar region, not on the ribs and thoracic vertebrae. In other words: hands can give relief, but there is no proof that they are a shortcut able to replace movement, and this specific presentation has never been studied with them.
And what if it is the disc?
A thoracic disc problem can irritate the nerve roots that run along the ribs and cause pain that breathing accentuates, possibly with tingling along the rib itself. It is, however, a rare situation, because the rib cage makes that portion of the spine much more stable than the lumbar tract. In practice a lumbar disc protrusion is seen far more often than a thoracic one.
Two honest points on this. The first: precisely because it is rare, the literature on thoracic disc disease is limited, made up mainly of small case series, and it does not allow recovery percentages to be given. The second: rarity is not a reason to ignore neurological symptoms. Leg weakness, bladder or bowel control problems, a change in sensation that rises upwards are symptoms for rapid medical evaluation, not for exercise.
How a diagnosis is reached
If the pain is clearly linked to breathing, the first step is medical and follows the pathway indicated by the literature on pleuritic pain: history, physical examination and a chest X-ray, with an electrocardiogram when there are elements that suggest a cardiac problem or an embolism. It is not excessive caution, it is the recommended sequence.
Once that side has been ruled out, physiotherapy assessment becomes useful and generally does not need further imaging. It looks at how the rib cage expands on both sides, how mobile the thoracic spine is in rotation and extension, which movements reproduce the pain, and how you are breathing when you are not thinking about it. If there are tests already done, they should be read together with the clinical picture: a report on its own does not explain a symptom.
What helps, and how much we know
For this specific symptom there are no studies. There is, however, solid evidence on neighbouring areas, and it is worth being precise about what it says.
Exercise. The Cochrane review on chronic back pain included 249 studies. Exercise reduced pain compared with no treatment, usual care or placebo by a mean difference of 15,2 points out of 100 (95% confidence interval from 12,2 to 18,3), a difference the authors consider clinically relevant; for function the improvement was there but remained below the threshold of relevance the authors had set themselves. Compared with other conservative treatments the advantage becomes narrower. Note the scope: it concerns non-specific chronic low back pain beyond twelve weeks, not back pain in general nor pain that appears when breathing.
Breathing exercises. A meta-analysis of 13 randomised studies with a total of 677 participants with chronic low back pain found a significant effect on pain measured with the visual analogue scale (standardised mean difference -0,84; 95% confidence interval from -1,24 to -0,45) and on disability measured with the Oswestry Disability Index (-0,74; from -0,95 to -0,54), as well as an improvement in forced vital capacity. The authors conclude that breathing exercises can be considered a potential alternative treatment, not that they are the cure. Here too the population studied is that of chronic low back pain.
The practical and honest conclusion: training the breath and moving the chest are reasonable things to try, with a clear biological rationale and indirect evidence in their favour. They are not a proven protocol for back pain when breathing, and anyone who presents them to you as one is selling you something.
Useful exercises
The doses that follow are clinical practice guidance: no study has validated them for this symptom. The rule that matters is another one and it is always the same: if an exercise increases the pain while you do it, you stop there.
Diaphragmatic breathing. Lie on your back with your knees bent, one hand on the abdomen and one on the sternum. Breathe in through the nose letting the hand on the abdomen rise while the one on the chest stays almost still, then breathe out slowly through the mouth, without forcing. The point is not to "breathe well" in the abstract, but to take work away from the accessory muscles of the neck and shoulders. If you want to go deeper into the technique there is a guide dedicated to diaphragmatic breathing, and it is worth knowing that neck and breathing influence each other more than you might think. A few minutes, a couple of times a day.
Open book (thoracic rotation). Lie on one side with your knees bent to ninety degrees and your arms extended in front of you. Slide the upper arm towards the ceiling and then towards the floor on the other side, following it with your gaze, rotating the chest but keeping the knees still. Return slowly. The movement should be sought slow and accompanied by the out-breath, not pushed to the end of its range. About ten repetitions per side.
Quadratus lumborum stretch. Standing, raise one arm and lean sideways towards the opposite side until you feel a pull along the flank, without rotating the trunk. Breathe normally in the position instead of holding your breath: this is the part almost everyone gets wrong. Hold for about twenty seconds and repeat a couple of times per side.
Bird-dog. On all fours, extend one arm and the opposite leg at the same time, keeping the pelvis still, as if you had to balance a glass on your back. Alternate calmly. The detailed version is in the guide to the bird-dog. If the position on the floor is uncomfortable, you can skip it without regret.
Forearm plank, in a tolerable version. If the pain allows it, hold the position while breathing normally. The criterion is not record duration but quality: as soon as your breath stops or your back arches, you are done. You can start from the variant with the knees resting on the floor. It is part of core strengthening, which makes sense here not because it magically "stabilises" the ribs, but because a trained trunk tolerates daily loads better.
Band pull-down. Seated or standing, with the band anchored in front of you, pull downwards drawing the ribs in and bringing the shoulder blades together without raising the shoulders. It works the muscles between the shoulder blades, which are often under-trained in people who spend the day at a computer. Controlled movements, a few sets.
Posture: what is honest to say
Here a very widespread belief needs correcting, including among professionals. It is read everywhere that correcting posture is "the key" to solving the problem for good. The evidence does not support this. A review of systematic reviews that analysed 41 reviews on spinal postures, physical exposures and back pain concluded that there is no consensus on causality: the association is documented, but it does not provide a causal explanation of back pain, and the reviews that included only prospective studies were even less in agreement.
What remains valid, then? That staying still in the same position for a long time is uncomfortable, and that changing position relieves it. That a decent workstation makes the day more comfortable: the screen at eye level, forearms resting, feet on the floor, as explained in the guide to desk ergonomics. That if you spend hours hunched forward it may be worth working on desk-related kyphosis. All of this is reasonable and gives relief. It is not the cure for back pain when breathing, and presenting it as such leads people to chase a perfect alignment for months that does not exist.
Online physiotherapy: what to really expect
Telerehabilitation makes sense in this scenario, on two conditions: that medical causes have been excluded and that expectations are correct. The most recent systematic review included 37 clinical studies and 5 economic studies, for a total of 4.288 participants with musculoskeletal disorders: telerehabilitation was better than control treatments on all outcomes studied, with effects ranging from 0,24 to 0,91 standardised mean difference. The detail that almost nobody reports, however, is the decisive one: on the main outcome, physical function, the superiority emerged only in people with a hip fracture, while for spinal pain the effects were similar to those of control treatments; and in the direct comparison with in-person rehabilitation the advantage disappeared. The authors also point to signs of publication bias and results that are not very robust, to be read with caution. On the economic side the included studies indicate a saving of 89,55 dollars per person (95% confidence interval from 4,6 to 174,5) compared with conventional treatments. The authors' conclusion is sober, and I share it: telerehabilitation should be considered when optimal in-person rehabilitation is not feasible, and because it reduces costs and waiting times.
With Ri-Hub a session costs 29,90 euros and takes place by video call from home. What a remote assessment can do well is listen to the history, observe the movements that reproduce the pain, recognise the signs that require a step to the doctor, and build a tailored programme. What it cannot do is replace a chest X-ray when one is needed.
When my back hurts when I breathe: what it means
The fact that the pain appears with breathing is already a piece of information, and it narrows the field considerably.
Breathing moves the ribs, and the ribs articulate with the thoracic vertebrae: when that movement is what sets off the pain, the most frequent origin is musculoskeletal, an irritated costovertebral joint, a tensed intercostal muscle, or the consequence of a violent cough. The typical sign is that the pain is localised to a point you can indicate with a finger, changes with position and worsens if you rotate the trunk.
What is not explained this way, and needs to be seen quickly: pain that comes together with breathlessness, fever, a racing heartbeat, or that does not change in any position and does not depend on how you move. There, breathing is not the cause, it is only what makes it evident, and the emergency warning signs are listed at the start of this page.
Prevention and realistic expectations
When the acute phase has calmed down, three habits hold up better than the others: keep moving the thoracic spine in rotation and extension, maintain a minimum of trunk training, and interrupt static positions before they become a nuisance. A few minutes a day are enough, and the most credible benefit is precisely regularity, not the length of a single session.
The last thing to bear in mind is the hardest to accept: back pain when breathing can come back, as almost all musculoskeletal pains do. It is not a failure of the pathway. The difference is made by knowing what to do at the second episode, and above all by knowing how to tell apart the discomfort you already know from a new symptom that deserves a check.
Conclusion
Back pain when breathing has the chest wall as its most frequent cause, and it is generally manageable with movement, breathing and a bit of patience. But "most frequent" is not "always": and in the only study with real numbers, that most frequent cause stopped below half of the cases. This is one of the few symptoms for which the order of things matters more than the exercises: first you exclude the lungs, pleura and heart, then you work.
On the rest it is best to be sincere. Nobody has studied this symptom directly; what we know comes from neighbouring areas and must be used with caution. Exercise and breathing have evidence in their favour for chronic back pain, postural correction has far less than is claimed, and promises of recovery within precise timeframes have nothing behind them. If your pain persists, gets worse or limits you, a well-conducted assessment is worth more than ten protocols copied from the internet.
Sources
- Pleurisy. American Family Physician, 2007
- Chest pain in primary care: epidemiology and pre-work-up probabilities. European Journal of General Practice, 2009
- Low Back Pain in the Emergency Department: Prevalence of Serious Spinal Pathologies and Diagnostic Accuracy of Red Flags. The American Journal of Medicine, 2020
- Thoracic spine pain in the general population: prevalence, incidence and associated factors in children, adolescents and adults. A systematic review. BMC Musculoskeletal Disorders, 2009
- No consensus on causality of spine postures or physical exposure and low back pain: A systematic review of systematic reviews. Journal of Biomechanics, 2020
- Effects of breathing exercises on chronic low back pain: A systematic review and meta-analysis of randomized controlled trials. Journal of Back and Musculoskeletal Rehabilitation, 2024
- Exercise therapy for chronic low back pain. Cochrane Database of Systematic Reviews, 2021
- Effectiveness and cost-effectiveness of telerehabilitation for musculoskeletal disorders: A systematic review and meta-analysis. Annals of Physical and Rehabilitation Medicine, 2024
Ultima verifica delle fonti: agosto 2026.
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