When To Worry About Shortness of Breath … and When Not To
Three minor causes of a scary symptom that might be treatable
Ever feel like you
need one of these?
Difficulty breathing (dyspnea) is a common complaint, affecting about 1 in 10 adults1 .… and a tough diagnostic challenge. Like abdominal pain, dizziness, or fatigue,2 minor breathing difficulties can have many possible causes.3
Obviously you should discuss stubborn breathing troubles with a doctor — especially if you have other worrisome symptoms, like pain or trouble staying upright. In older patients who mostly feel short of breath during exercise, it’s much more likely to be a symptom of disease of the heart and/or lungs.
For everyone else, there are (at least) three causes of shortness of breath that are common, minor, and often partially treatable:
- myofascial pain syndrome (trigger points or “muscle knots” in the respiratory muscles)
- bad respiratory “habits” and weak breathing muscles
- anxiety, which is a surprisingly potent cause of shortness of breath (and it’s not necessarily “minor,” but it is a reassuring diagnosis compared to the serious medical problems we worry about when we feel short of breath)
Honourable mentions, because they are also both minor and fairly common: hiatal hernia, anemia, and obesity.
There’s definitely hope for some breathing troubles
If you’re short of breath for any (or all) of those 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 try.
Changing bad habits is always tricky, but it’s a more likely path to relief, and increasing your respiratory strength is possible with a little oomph456 — and it’s a worthwhile fitness goal in any case.
Anxiety is the toughest problem to beat, but anyone can benefit from trying.
These three issues may all get tangled up, each one complicating the others, but progress with one is also likely to help the others. Some simple and interesting ideas for self-treatment are suggested in this short article, plus links to much more information 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 dyspnea 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.
- Have you developed other unusual and/or persistent symptoms?
- Do you have a chronic wheeze or cough?
- Are you tired all the time? Do you look pale? These two together are a red flag.
- Do you have a dry, painful cough and your shortness of breath gets worse when you exercise?
- Are your feet and ankles swollen, and is it harder to breathe when you lie down flat?
- Have you worked in or around asbestos, wood dust, industrial fumes or in a coal mine? If so, you probably already understand why you’re having trouble!
Any of these factors could be associated with a slow, sneaky onset of a serious condition.
The quality of the sensation and what it might mean
Many things contribute to a sensation of shortness of breath,7 and the symptom breaks down into three messily overlapping qualities, which are interesting but don’t tell us much about what’s going on, just a couple rough clues:
- Effort: a sensation of excessive work or effort to breathe, like breathing is just a slog. It is loosely associated with impairment of the muscular function and chronic obstructive pulmonary disease (COPD).
- Tightness: feeling tight may involve actual contstriction of airways (bronchocontriction) as would occur in the early stages of an asthma attack (which then gives way to effort and air hunger). However, tightness can also be caused by actual spasticity of respiratory muscles, which could be ordinary muscle pain or more serious, like the infamous squeezing “hug” of multiple sclerosis.
- Air hunger: the most complex sensation, unsatisfied inspiration is described by patients in many ways, like “starved for air” or “my breaths feel too small.” Of the treatable causes, it is most clearly associated with anxiety. Although it sure doesn’t feel like it, it can occur without any actual loss of respiratory capacity.
Part I: Trigger points
The effects of 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 “micro cramp,” or possibly neurological hypersensitivity. Trigger points are a big, tricky 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.8
Trigger points in the muscles of the throat, neck, chest, and back may also interfere with the nervous system’s control of respiration.9
Trigger points may afflict the respiratory musculature for reasons unrelated to breathing, such as postural stress. 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.10 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 mysterious: exactly what they are and how to treat them is controversial. Sometimes they seem to melt as easily as ice cream in the sun, and so the first thing to try is just a little simple self-massage, or a warm bath, or both. 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 it go like that many times, and even experienced it myself …
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. 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! 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.11 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, and that benefit has now persisted for many years.
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. There’s a large free introduction.
Where exactly to massage (muscles of respiration)
The main muscles of respiration are:
- The diaphragm, which you can’t really massage. A professional might be able to rub the lower reaches of the diaphragm by prying under the ribs, but it’s difficult to do, and it’s not clear that it’s a good idea. Personally, I would have to feel really quite desperate before I paid for that experiment. But I might.
- The muscles between the ribs (intercostals). These are easy to self-treat: the ribs are pretty obvious structures. Aim your thumbs and fingers anywhere between ribs … but the best target area is in the lower half of the rib cage, on your sides, where the most rib movement takes place, and where the intercostals work the hardest.
- Some muscles on the front and sides of the neck (sternocleidomastoid and scalenes), and some chest muscles (the pectoralis minor, a small muscle under the larger, more famous pectoralis major), pull up on the rib cage from above. Most of these muscles should mainly kick in only for a strong inhalation, but are often over-used, exhausted, and cranky (more about this below).
- The scalenes are particularly interesting to work with, and I have an entire article about scalenes massage.
- The pectoralis minor is pretty difficult to rub yourself, but firm massage in the upper, lateral chest will reach it through the thick pectoralis major.
- The serratus anterior muscle is just under the skin on the ribs below the armpit, but this muscle is visible only on body-builders. It either pulls shoulder blades forward, or lifts ribs. It can be quite sensitive: gentle fingertip rubbing on the rib surfaces is usually adequate, and easy.
And here’s one more minor respiratory muscle in the low back that could be clinically significant:
- The quadratus lumborum is a sheet of muscle spanning from the pelvis to the lower rib. A crampy quadratus lumborum can pull down on the lower rib like an action hero clinging to the landing skid of a helicopter. It may painfully resist elevation of the rib cage during inhalation and/or hurt when contracting to pull it down during exhalation. Read more about quadratus lumborum massage.
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. 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!
A quick success story about sore breathing muscles
I once developed a sharp pain in the side of my neck when I coughed or sneezed. It was clearly a muscular pain,12 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?
Part II: Respiratory dysfunction
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, especially anxiety, which is the next major topic.
Water pressure resists expansion of the rib cage & abdomen uniformly on all sides — & therefore it resists diaphragm contraction. Simply deep breathing while submerged to your chin is a simple way to challenge & exercise your respiratory musculature & much greater resistance is possible with snorkels & breathing tubes. This & other breathing exercises are described in The Respiration Connection.
Part III: Anxiety
Head games and shortness of breath
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? Don’t underestimate this possibility.
Anxiety — excessive worry, either too much, or too long, or both13 — is a surprisingly potent and amazingly common cause of many odd symptoms. Shortness of breath and chest pain are among the most frequently reported.
Although it’s common, anxiety is badly neglected as an explanation for many problems. Even though it’s almost the same thing as “stress,” many people don’t recognize that they are anxious, or they deny it or minimize it. And many people just don’t know that shortness of breath can be caused by anxiety! It really can.
There’s no clear explanation for how anxiety causes shortness of breath, chest pain, or any other strange symptom: it’s just one of those things. And while anxiety can cause shortness of breath as a direct and immediate symptom, it can also probably cause trouble indirectly by chronically eating away at us in other ways, like creating the dysfunctional breathing pattern discussed above.
Indirect consequences of stress and anxiety
The way we breathe is a powerful aspect of self-expression. Anxiety, “emotional constipation,” and other habits of mind and dysfunctional and self-limiting behavioural patterns might be associated with strong breathing patterns, especially shallow breathing.
Shallow breath is what we do when we literally hide (from a predator, say). It is also what we do when we feel like we want to hide! Deep breathing is one of the main practical suggestions for fighting anxiety. It’s a feedback loop.
Habitually breathing shallowly can be so subtle for so long 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 classic “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. 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 attitudes and behaviours.
All of this is a rather complicated mess to try to sort out, but I’m not going to leave you hanging. Here are several relevant, practical self-help articles. They all focus on what you can do about these issues:
- Anxiety & Chronic Pain — A self-help guide for people who worry and hurt
- The Art of Bioenergetic Breathing — A potent tool for personal growth and transformation by breathing quickly and deeply. This article is about a kind of breathing that is the opposite of stunted, weak breathing, but it doesn’t require strength to do. It is the “good example.” This is how you practice good breathing.
- Pain Relief from Personal Growth — Treating tough pain problems with the pursuit of emotional intelligence, life balance, and peacefulness. Also highly relevant to shortness of breath.
- The Respiration Connection — How dysfunctional breathing might be a root cause of a variety of common upper body pain problems and injuries. Detailed suggestions for respiratory exercise are provided in this article, and much more detail about how shallow breathing works in a biomechanical sense.
- The Insomnia Guide for Chronic Pain Patients — Serious insomnia-fighting advice from a veteran of the sleep wars. The same psychological factors that drive shallow breath tend to power insomnia as well … and in turn insomnia is remarkably “toxic” to almost everything else we do. Many people who are short of breath are also sleeping poorly. Both problems need to be solved! And, as with shortness of breath, insomnia is often mainly about head games.
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About Paul Ingraham
I am a science writer in Vancouver, Canada. I was a Registered Massage Therapist for a decade and the assistant editor of ScienceBasedMedicine.org for several years. I’ve had many injuries as a runner and ultimate player, and I’ve been a chronic pain patient myself since 2015. Full bio. See you on Facebook or Twitter., or subscribe:
What’s new in this article?
2020 — Added brief note about COVID-19.
2017 — Thorough editing of the introduction, upgraded sources, various minor corrections, and a new section about the qualities of dyspnea.
2016 — Major revision. Rewrote and revised to put a much stronger spotlight on anxiety and “head games” as a factor in shortness of breath. Reorganized the article in three clearer parts. Added a new summary.
2007 — Publication.
Mild to moderate dyspnea occurs in about 10% of adults under the age of 40, climbing to nearly double that in middle age and beyond, in adults who are still up and about. Source (for this and many other factoids in this article):
Parshall MB, Schwartzstein RM, Adams L, et al. An official American Thoracic Society statement: update on the mechanisms, assessment, and management of dyspnea. Am J Respir Crit Care Med. 2012 Feb;185(4):435–52. PubMed 22336677 ❐ PainSci Bibliography 53725 ❐
- Many common symptoms are notoriously difficult to diagnose because they have so many possible causes … including non-medical ones. Fatigue could be an early warning sign of the Martian Death Flu or of dinner with your in-laws. Abdominal pain is notoriously the hardest kind of pain to diagnose in hospital emergency rooms — endless possibilities! Shortness of breath is not quite in the same league, but it still has rather a lot of possible causes. It is a classic “non-specific” symptom: a sensation that doesn’t indicate a specific problem. Surely it’s “specific” to the respiratory system at least? But no: shortness of breath often occurs without any problems with the lungs or other breathing anatomy and physiology. Shortness of breath is a complicated sensation only, like a form of pain, which can indicate practically anything, but nothing in particular.
Here are a few possible causes that often get missed, especially in the early stages:
- Asthma — Do you have episodes of shortness of breath along with wheezing and/or coughing? This may be the beginning of asthma.
- Anemia — Are you tired all the time, and do you look pale? You may not be getting enough iron in your diet. This is more common among women.
- Sarcoidosis or pulmonary hypertension — Are you tired all the time and do you have a dry cough, possibly with chest pain, and does your shortness of breath get worse when you exercise or do other physical activity?
- Congestive heart failure — Are your feet and ankles swollen, and is it harder to breathe when you lie down flat? These are symptoms of congestive heart failure.
- Mesothelioma — Have you worked in or around asbestos, wood dust, industrial fumes or in a coal mine? You could have occupational lung disease, such as mesothelioma.
- Hiatal hernia — Bulging of the stomach through the hole in your diaphragm is, unsurprisingly, a cause of shortness of breath.
- Padula CA, Yeaw E. Inspiratory muscle training: integrative review. Research & Theory For Nursing Practice. 2006 Winter;20(4):291–304.
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.”
- Enright SJ, Unnithan VB. Effect of Inspiratory Muscle Training Intensities on Pulmonary Function and Work Capacity in People Who Are Healthy: A Randomized Controlled Trial. Phys Ther. 2011 Jun;91(6):894–905. 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.”
- Hill K, Gain KR, McKay SW, Nathan C, Gabbay E. Effects of High-Intensity Inspiratory Muscle Training Following a Near-Fatal Gunshot Wound. Phys Ther. 2011 Jul. 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.”
- Parshall et al (full citation above) lists more than a dozen factors, arcane biology like “medullary respiratory corollary discharge” and “metaboreceptors in respiratory pump muscles.” The point is just that dyspnea is extremely complex neurologically.
- This is highly speculative: it is unknown whether the diaphragm can actually develop trigger points, and somewhat unlikely. Muscles that have to work all the time, like the diaphragm and the heart, are physiologically quite different than skeletal muscle, and 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.
- 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 Mense.
- This is the “out of the frying pan and into the fire” phenomenon, in which trigger points complicate an injury or some other problem, eventually becoming the main problem as the original trouble heals and fades away.
- 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.
- 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.
Association, American Psychiatric (2013). Diagnostic and statistical manual of mental disorders: DSM-5. (5th ed.). Washington, D.C.: American Psychiatric Association. p. 222.
Anxiety is a feeling of worry, nervousness, or unease, usually specific. Generalized anxiety disorder (GAD) is when that feeling gets chronic, excessive, uncontrollable, irrational, and associated with surprisingly diverse symptoms. At least 3 symptoms must persist for at least 6 months for a formal GAD diagnosis.