What we are talking about
The thoracic spine is the part the ribs attach to. It is built to be stable rather than mobile, which makes it less prone to serious problems — but also prone to stiffening, especially in people who spend the day sitting.
Intercostal pain, the kind that follows a rib and flares when you breathe or twist, frightens people a great deal because it is in the chest area. In the great majority of cases it is musculoskeletal: irritated costovertebral joints, tight muscles. But it is also the area where it is worth ruling other things out first.
Pain under the shoulder blade deserves a separate note: often it does not start there. It is a place where pain referred from the neck arrives, and treating it locally without looking higher up is the most common way of resolving nothing.
When it makes sense to get seen
What we hear most often:
- Pain between the shoulder blades that gets worse after hours at a desk
- A spot under the shoulder blade that feels like a knot and will not go
- Pain along a rib that flares when you breathe deeply or twist
- Stiffness in the upper back in the morning
- Difficulty rotating your trunk, for example reversing a car
- A pain that has come and gone for months and that you have got used to
What can be done remotely, and what cannot
Most of the work here is mobility, strength and organising your day: all things that can be programmed and checked on a video call.
What can be done remotely
- Working out whether the pain starts there or comes from the neck, which changes the whole programme
- Watching you rotate, breathe, move your arms overhead
- Setting up thoracic mobility work and strength for the scapular muscles
- Reviewing your workstation and above all how often you get up
- Teaching you rib breathing, which in this area helps more than it sounds
What cannot
- Spinal manipulations and mobilisations
- Manual trigger point treatment
- Auscultation and medical assessment of the chest
Chest pain with breathlessness, sweating, pain radiating to the arm or the jaw is not a physiotherapy matter: it is A&E, immediately.
Frequently asked questions
Can rib pain come from the back?
Yes, and it is the most common explanation. Every rib articulates with the thoracic vertebrae: when those joints get irritated, the pain is felt along the rib, even well round the front. Breathing deeply lights it up, and that is exactly what frightens people.
Does pain between the shoulder blades come from posture?
Posture matters less than how long you spend in the same position. What usually changes things is not sitting up straighter, it is getting up more often and strengthening the muscles that hold that area.
I have a knot under my shoulder blade that will not go: what is it?
Often it is an area of referred pain, not a problem with the muscle you feel as tight. That is why massaging it brings relief for a few hours and then it all comes back: the cause is elsewhere, usually higher up.
Should I worry if it hurts when I breathe?
If the pain appears when you twist or press a precise spot, it is almost always musculoskeletal. If instead it comes with breathlessness, fever or feeling generally unwell, the first stop is the doctor, not physiotherapy.
