(Also known as an Intercostal Muscle Strain, Intercostal Muscle Tear, Torn Intercostal)
What is an intercostal strain?
An intercostal strain is a condition that is occasionally seen in sports such as cricket (i.e. in fast bowlers) and is characterised by a tear in one of the muscles located between the ribs (known as the “intercostals”).
The chest comprises of 12 rib bones on each side of the body. Each rib attaches to the spine at the back of the body and then travels around to the front of the chest (figure 1). The top 7 ribs attach to the sternum, the 8th to 10 ribs attach to the ribs above via cartilage and the 11th and 12th ribs are known as ‘floating’ ribs as they are unattached at the front of the chest.
Figure 1 – Relevant Anatomy for an Intercostal Strain
Numerous muscles of the abdomen, shoulder girdle and back attach to one or more ribs. The intercostal muscles are a group of muscles that run between the ribs, attaching from the rib above to the rib below and are primarily responsible for elevating the ribs (allowing for inspiration) and forming the chest wall.
During contraction or stretch of the intercostals tension is placed through the muscles. When this tension is excessive due to too much repetition or high force, a tear in one or more of the intercostal muscles may occur. This condition is known as an intercostal strain.
Cause of an intercostal strain
An intercostal strain can occur either suddenly (e.g. from a forceful bowl, particularly if not warmed up properly) or gradually over time from excessive or repetitive activity (e.g. over-training). They most commonly occur due to a sudden contraction of the intercostal muscles when they are in a position of stretch (such as during the fast bowling action) or during other activities involving excessive side bending or twisting forces.
In athletes, intercostal strains are most commonly seen in cricket (fast bowlers), javelin throwers, rowers and ice hockey players. Occasionally they may occur traumatically due to a direct impact to the ribs, forcing the ribs apart such as a collision in contact sports or due to a motor vehicle accident.
Signs and symptoms of an intercostal strain
In cricket fast bowlers, intercostal strains tend to occur on the non-bowling arm side of the body. Patients typically experience a sudden, sharp pain or pulling sensation in the side of the chest (often in the region of the lower ribs) during the provocative activity. Pain typically occurs suddenly (e.g. during a forceful bowl), but can also occur gradually over time (e.g. over the course of a match or training session).
In minor cases, the patient may be able to continue the activity only to have an increase in symptoms upon cooling down. In more severe cases the patient may be unable to continue the activity and will often have to cease sports participation. Patients with an intercostal strain typically experience pain that increases with activities that place strain on the intercostal muscles. These activities may include: bowling, throwing, heavy lifting, rowing, side sit ups, twisting, turning or side bending. It is also common for patients to experience pain or stiffness after these activities with rest, especially upon waking in the morning (or at night).
Patients with this condition may also experience swelling, muscle spasm, weakness and bruising in the side of the chest. Symptoms typically increase on firmly touching the affected region of the muscle or ribs or when performing a side stretch. In more severe cases, deep breathing, laughing, coughing or sneezing may also provoke symptoms.
Diagnosis of an intercostal strain
A thorough subjective and objective examination from a physiotherapist is usually sufficient to diagnose an intercostal strain. Further investigations, such as an X-ray, MRI, CT Scan or ultrasound, are sometimes required to confirm diagnosis, rule out other conditions, determine the severity of injury and monitor healing.
With appropriate physiotherapy management, most patients with an intercostal strain can make a full recovery (i.e. return to sport or normal activities) in a period of 4-6 weeks. In more severe cases, recovery may take longer.
Treatment for an intercostal strain
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Contributing factors to the development of an intercostal strain
There are several factors which may contribute to the development of an intercostal strain. These need to be assessed and, where possible, corrected with direction from the treating physiotherapist. Some of these factors include:
inappropriate warm up
inappropriate or excessive training
inadequate recovery periods from training or activity
exercises to improve strength, flexibility, core stability and posture
a gradual return to activity plan
Other intervention for an intercostal strain
Despite appropriate physiotherapy management, some patients with this condition do not improve and may require other intervention to ensure an optimal outcome. The treating physiotherapist or doctor can advise on the best course of management when this is the case. This may include further investigations such as an ultrasound, MRI, X-ray, CT scan or bone scan, extended periods of rest, pharmaceutical intervention, or referral to appropriate medical authorities who can advise on any intervention that may be appropriate to improve the intercostal strain.
Exercises for an intercostal strain
The following exercises are commonly prescribed to patients with an intercostal strain. You should discuss the suitability of these exercises with your physiotherapist prior to beginning them. Generally, they should be performed 3 times daily once the physiotherapist has indicated it is safe to do so and only provided they do not cause or increase symptoms.
Your physiotherapist can advise when it is appropriate to begin the initial exercises and eventually progress to the intermediate and advanced exercises. As a general rule, addition of exercises or progression to more advanced exercises should take place provided there is no increase in symptoms.
Begin sitting or standing tall with your back and neck straight (figure 2). Breathe in as deeply as possible without increasing symptoms and then relax. Focus on breathing with your lower lungs (instead of elevating your shoulders) and allow your stomach to gently expand. Repeat 5 times.
Figure 2 – Deep Breathing (in standing)
Foam Roller Stretch
Place a foam roller under your upper back as demonstrated (figure 3). Breathe normally keeping your back and neck relaxed. Hold this position for 15 – 90 seconds provided it is comfortable and does not cause pain. This exercise can be progressed by taking your arms overhead.
Figure 3 – Foam Roller Stretch
Rotation in Lying
Begin this exercise lying on your back as demonstrated (figure 4). Slowly take your knees from side to side as far as you can go without pain and provided you feel either nothing, or, no more than a mild to moderate stretch. Repeat 10 times to each side provided the exercise is pain free.
Figure 4 – Rotation in Lying
More Initial Exercises
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<a href=”http://www.physioadvisor.com.au/injuries/upper-back-chest/intercostal-strain/”>Intercostal Strain – PhysioAdvisor.com</a><br/>An intercostal strain is a condition that may be seen in cricket fast bowlers and is characterised by a tear in one of the intercostal muscles located between the ribs. Assessment and treatment by a physiotherapist is vital for an optimal outcome.
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Brukner et al (2012). Brukner & Khan’s clinical sports medicine (4th ed.), 456. Australia: McGraw Hill Education.