SaveYourself.ca •Sensible advice for aches, pains & injuries
 
[Picture of a man with a respirator, illustrating difficulty breathing.]

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There are many causes for shortness of breath. Some are complex & serious, but there are also surprisingly simple & non-scary possibilities.

When To Worry About Shortness of Breath … and When Not To

Some common, minor & treatable causes of a scary symptom explained

3,000 words, published 2007, updated 2012
by Paul Ingraham, Vancouver, Canada bio
I am a science writer, a former massage therapist, and the Assistant Editor of Science-Based Medicine since 2009. I am nearly done with a long-procrastinated Bachelor of Health Sciences degree. I am a middle-aged runner and ultimate player with plenty of personal experience with athletic injury and chronic pain. Readers often want to know more about me and my qualifications, because my style and subject matter is controversial. Most importantly, yes, I used to actually believe and practice almost everything that I now debunk and criticize. I live by the ocean with my wife in beautiful downtown Vancouver.

SHOW SUMMARY Difficulty breathing is a common complaint and a tough diagnostic challenge, and there are some serious causes to be aware of. However, many cases are probably caused by minor and treatable muscle knots, respiratory dysfunction and/or weakness. Relief may be relatively easy for some patients. It’s safe and cheap to experiment with self-massage for muscular trigger points. And, although changing bad habits is always tricky, increasing your respiratory strength is definitely effective and a worthwhile fitness goal in any case.

Difficulty breathing is a common complaint… and a tough diagnostic challenge. Like abdominal pain, dizziness, or fatigue,1 minor breathing difficulties have several possible causes. You should certainly discuss breathing troubles with a doctor, especially if you have any other worrisome symptoms, like pain or trouble remaining upright. Fortunately, there at least two causes of breathing trouble that are quite minor, common, and at least somewhat treatable:

If you are short of breath for one of these two reasons, easy relief is possible. It’s safe, cheap, and almost fun to experiment with self-massage for trigger points. Results are hardly guaranteed, but it’s a sensible thing to experiment with. And although changing bad habits is always tricky, it’s a more certain path to relief, and increasing your respiratory strength is possible with a little oomph234 — and it’s a worthwhile fitness goal in any case. Also, these two issues may be intertwined, each one causing the other. Some simple and interesting ideas for self-treatment are provided in this short article, with plenty of links to other information and resources for those who want to delve.

Safety first! A checklist of warning signs of more serious breathing problems

It’s nice that some people may be able to find an easy solution to their shortness of breath, or at least be reassured that it’s mostly harmless. Unfortunately, more ominous causes of shortness of breath are also common, so please always alert your doctor about any difficult breathing. If your doctor cannot find any explanation, and you have none of these “red flags,” then you can pursue the possibility of muscle knots and weak breathing muscles. Safety first! And second.

Any of these factors could be associated with a slow, sneaky onset of a serious condition. For more help self-diagnosing, please see this page about breathing difficulties at FamilyDoctor.org:

A quick success story about sore breathing muscles

Recently I developed a sharp pain in the side of my neck when I coughed or sneezed. It was clearly a muscular pain,5 specifically of the scalenes muscle group that kick in when you breathe hard. If I took a really deep breath, I could feel it a little too — but it was mostly only clear when I coughed or sneezed.

Until I went for a run.

After a few minutes of huffing and puffing, that pain started up. I also felt distinctly short of breath, despite being generally quite fit. The pain was like a stitch in my side, but in my neck, and I was not getting full breaths. I realized I was barely using my diaphragm to breathe, and so my scalenes were working overtime to make up the difference — and hurting and failing. (More about this below.) I started using my diaphragm again … and the pain steadily eased even though I kept running.

Not only was the pain clearly caused by over-using my scalenes while breathing, but I was able to fix a fairly significant pain problem without stopping my workout — just by breathing differently. That’s a good, clear example of the easiest kind of breathing trouble to fix. What was going on?

The effects of trigger points (muscle knots) on breathing

Trigger points — better known as muscle knots — can cause shortness of breath. They are small patches of sensitive muscle tissue, maybe caused by a localized spasm, or “just” neurological hypersensitivity. Trigger points are a big topic.

Trigger points may form in the muscles we use to breathe, making it difficult or even painful to move the ribs and expand the chest. Even the diaphragm itself might develop trigger points that make it feel weak and tired, and limit its range of contraction.6

Trigger points in the muscles of the throat, neck, chest, and back may also interfere with the nervous system’s control of respiration.7

Trigger points may afflict the respiratory musculature for reasons unrelated to breathing, such as postural strain. Or they can arise in response to bad breathing habits: a chicken and egg problem. Do you get breathing trouble because you have trigger points? Or do you get trigger points as a symptom of breathing trouble? The answer is surely both. If there is an obvious problem in the area, such as an old shoulder injury, then it’s a good bet that the shoulder was the “chicken” that started it all, and it may remain the primary source of discomfort and muscular dysfunction in the area.8 In such a straightforward case, treating the trigger points caused by the old shoulder injury might just solve the problem.

On the other hand, if there is no obvious cause of discomfort in the area, but you are out of shape and sit slumped in a chair all day long, a better guess is that respiratory dysfunction was the “egg” that started it all, and the real challenge is to learn to breathe and sit better.

What can you do about trigger points that might be interfering with respiration?

Muscle trigger points are unpredictable and a bit mysterious. Exactly what they are and how to treat them is controversial. Sometimes they melt as easily as ice cream in the sun. The first thing to try is just a little simple self-massage. Or a warm bath. Or a holiday. The problem could be solved by a self-treatment as simple as digging with your thumbs into some aching muscles between your ribs. Voila — no more shortness of breath! I’ve seen that happen many times, and even experienced it myself, in a big way.

My story: I am generally prone to muscle pain, and one of the most persistent specific challenges I’ve had is with breathing pain — not “shortness of breath” in my case, but “breathing limited by pain.” For about twenty years, I had routine episodes of strong pain that choked off my breath. The pain would ease when I relaxed for long enough … but it’s hard to relax when you can’t breathe.Once every few days, I would be nearly paralyzed by it for several minutes, and sometimes nightmarish episodes of an hour or more. The pain would ease when I relaxed for long enough … but it’s hard to relax when you can’t breathe.

I recovered! During my first year of massage college in 1997, I experimented with self-massage of my intercostals, discovered that I could easily stop any “attack” of this pain within a minute just by rubbing between the ribs near the pain.9 It was a revelation. I’ve probably never been so happy to learn anything! Over a year or two, I massaged my intercostals regularly until I stopped having these episodes at all.

Unfortunately, it’s not always that easy. Trigger points can be so stubborn they become a major source of grief. Self-massage is definitely no miracle cure, and trying to treat tougher trigger points can become an epic journey of rehabilitation. You might have a complex array of trigger points, both causing and caused by many factors, including really tricky ones like seriously dysfunctional breathing behaviour and intractable emotional factors.

Again, if you want to learn a lot more about trigger points and how to manage them, please see my advanced tutorial.

Where exactly to massage (muscles of respiration)

The main muscles of respiration are:

It is also well worthwhile to massage other muscles throughout the neck, shoulders, and chest. Even the upper back! Soothing them may indirectly help the actual respiration muscles. And even if they don’t control breathing themselves, they often produce sensations that feel related to breathing in a way that is hard to describe. After professional massage in the upper back, patients often say something like, “I feel like I can breathe again!” Even if they didn’t feel short of breath to begin with!Feeling “stiff” in the upper back often has a lot of sensory overlap with shortness of breath — they are similar and probably related sensations.

For instance, it’s startling how much trigger points between the shoulder blades can feel related to breathing (and indeed there are some actual minor muscles of respiration back there). After professional massage of this area, patients often say something like, “I feel like I can breathe again!” Even if they didn’t feel short of breath to begin with!

Just what is a “bad breathing habit” anyway?

The most common form of respiratory dysfunction is usually just chronic shallow breathing, eventually leading to an inability to breathe deeply due to weakness and stiffness — you don’t use deep breathing, so you lose deep breathing. A lifelong habit of breathing shallowly is only a short hop away from feeling short of breath. Shallow, weak breathing is mostly a result of trying to breathe with the upper chest muscles instead of the belly and diaphragm. Such habits can easily become reinforced by the trigger points they cause — you get “locked in.” For instance, if you chronically try to breathe with the neck muscles, which are too weak to do the job on their own, they get exhausted and then cranky and full of trigger points … and then they really can’t handle it.

But why would we breathe shallowly and “badly” in the first place? It’s not like anyone is conscious of trying to breathe with their scalenes instead of their diaphragm! Respiratory dysfunction is usually driven by postural, psychological, and emotional factors…

ZOOM

Hydraulics!

Water pressure resists expansion of the rib cage and abdomen uniformly on all sides — and therefore it resists diaphragm contraction. Simply deep breathing while submerged to your chin is a simple way to challenge and exercise your respiratory musculature, and much greater resistance is possible with snorkels and breathing tubes. This and other breathing exercises are described in The Respiration Connection.

ZOOM

Hydraulics!

Water pressure resists expansion of the rib cage and abdomen uniformly on all sides — and therefore it resists diaphragm contraction. Simply deep breathing while submerged to your chin is a simple way to challenge and exercise your respiratory musculature, and much greater resistance is possible with snorkels and breathing tubes. This and other breathing exercises are described in The Respiration Connection.

Head games: psychological factors in breathing

The way we breathe is a powerful aspect of self-expression. “Emotional constipation,” anxiety, and other habits of mind and dysfunctional and self-limiting behavioural patterns are common causes of minor breathing difficulties, and perhaps even some serious cases. The connection might be obvious: you may already know (or suspect) that you have a problem with anxiety, or serious chronic stress, or a deep-seated lack of self-confidence that you know makes you breathe shallowly.

However, it’s more likely that it will not be obvious. Shortness of breath usually sneaks up on you slowly. The symptom can be subtle and so slow to develop that we don’t even realize there’s a problem until all the contributing factors and bad habits and vicious cycles are too deeply entrenched to break free — a “boiling frog” kind of problem.

There’s also a basic Catch-22 in life — a basic problem with being human — that keeps us from perceiving and correcting our own worst habits and their consequences: the kinds of trouble we get into are always, to some degree, a consequence of the lack of the very same awareness and skills we needed to avoid the trouble in the first place, or to deal with it. The kinds of trouble we get into are always, to some degree, a consequence of the lack of the very same awareness and skills we needed to avoid that trouble in the first place … or to deal with it. Since habitually shallow breathing is often also an avoidance mechanism — part of the way that we avoid dealing with certain stresses — the shallow breather is often naturally and strongly inclined to avoid coming to grips with the real issues. It’s a trap!

So these kinds of problems tend to be identified later in life, if ever, and often go hand-in-glove with a lack of self awareness and denial — it just goes with the territory, and there’s certainly no shame in it. Who isn’t “emotionally constipated” about something? Most of us are. Sometimes we get the “wake up call” in the form of being short of breath enough to get nervous about it, at which point we may or may not realize that there’s a connection with lifelong mental habits.

Maybe you feel so stressed that it’s obvious that the stress is “squeezing” the breath out of you … or maybe it’s not. If you’re not sure, it’s time to ask yourself some hard questions: could that be me? Could I be “choking” myself? Almost literally?

Now … what to do about it? Here are several relevant self-help articles:

About Paul Ingraham

I am a science writer, former massage therapist, and assistant editor of Science-Based Medicine. I have had my share of injuries and pain challenges as a runner and ultimate player. My wife and I live in downtown Vancouver, Canada. See my full bio and qualifications, or my blog, Writerly. You might run into me on Facebook and Google, but mostly Twitter.

Notes

  1. All of these common symptoms are notoriously difficult to diagnose because they have many possible causes … even non-medical ones. Fatigue could be an early warning sign of the Marian Death Flu or of dinner with your in-laws. Abdominal pain is notoriously the hardest kind of pain to diagnose in hospital emergency rooms — so many possibilities! Shortness of breath is not quite in the same league, but it still has a rather a lot of possible causes. BACK TO TEXT
  2. Padula et al. Inspiratory muscle training: integrative review. Research & Theory For Nursing Practice. 2006.

    This review of the evidence indicates that exercising your breathing musculature probably works pretty darned well, and benefits take about “20 to 30 minutes per day for 10 to 12 weeks” to achieve. Better yet, the evidence also shows that it’s reasonable to expect some benefits “regardless of method”! In other words, there’s no great concern about which technique to use. Common protocols for respiratory training “are generally safe, feasible, and effective.”

    BACK TO TEXT
  3. Enright et al. Effect of Inspiratory Muscle Training Intensities on Pulmonary Function and Work Capacity in People Who Are Healthy: A Randomized Controlled Trial. Physical Therapy. 2011. PubMed #21493747.

    Since we know that inspiratory muscle training can improve inspiratory muscle function, lung volume, lung capacity, and work capacity, what level of intensity will “do the trick”? This was a randomized and controlled trial — good science stuff — with three groups, each group training at a different level. The results suggest that high intensity is better than low intensity: “High-intensity IMT set at 80% of maximal effort resulted in increased MIP and SMIP, lung volumes, work capacity, and power output in individuals who were healthy, whereas IMT at 60% of maximal effort increased work capacity and power output only. Inspiratory muscle training intensities lower than 40% of maximal effort do not translate into quantitative functional outcomes.”

    BACK TO TEXT
  4. Hill et al. Effects of High-Intensity Inspiratory Muscle Training Following a Near-Fatal Gunshot Wound. Physical Therapy. 2011. PubMed #21737521.

    After a gunshot wound, a “high-intensity, interval-based threshold inspiratory muscle training (IMT) was undertaken” for the 38-year-old man. The treatment was found to be “safe and well tolerated. It was associated with improvements in maximum forced inspiratory flow and changed the locus of symptom limitation during high-intensity exercise from dyspnea to leg fatigue.”

    BACK TO TEXT
  5. I am really up on my muscle anatomy, so it was easy for me to quickly test and confirm that it was a specific muscle, and not something else. It hurt on contraction and stretch of that muscle, and I could stress my neck in all kinds of other ways with no pain. BACK TO TEXT
  6. This is pretty speculative: it is unknown whether the diaphragm can actually develop trigger points, and a bit unlikely. Muscles that have to work all the time, like the diaphragm and the heart, are physiologically quite different than skeletal muscle, and are probably much less vulnerable to trigger points in general. Significant trigger points typically cause pain on contraction. Diaphragmatic trigger points would therefore cause a deep, hard-to-locate pain with every breath — a fairly rare symptom. However, I have experienced it. Sometimes what I am inclined to call a “stitch” in my side feels like it could be diaphragmatic pain. That is, it feels deep, under the ribs. However, I have never experienced or heard of a consistent, long-lasting breathing pain. BACK TO TEXT
  7. Again, this is hypothetical, but not completely far out: medical researchers have documented minor cases of trigger points interfering with the autonomic nervous system. This is discussed in Simons. BACK TO TEXT
  8. This is the “out of the frying pan and into the fire” phenomenon, in which trigger points form in response to an injury or some other problem, and then eventually become the main problem as the original fades away. See Into the Fire. BACK TO TEXT
  9. Not always right where the pain was, but usually close — within an inch or two. Often the pain was more lateral than the massage spot that relieved it. I didn’t know it at the time, but that’s actually a common feature of a phenomenon called “referred pain.” Pain often radiates outwards and downwards — laterally and distally, to speak precisely — from a point of origin. BACK TO TEXT