Diaphragm Injury

What to do after an injury to the chest or upper belly

• Call 911 for any significant trauma, especially if breathing is difficult.
• Keep the person still and sitting up if that eases breathing, unless a spinal injury is suspected.
• Do not remove any object stuck in the chest or abdomen.
• Even if symptoms seem mild after a high-speed crash or fall, get assessed: diaphragm tears are easily missed at first.

What the diaphragm does

The diaphragm separates the chest from the abdomen. When it contracts, it flattens and pulls air into the lungs. It is controlled by the two phrenic nerves, which run from the neck (spinal levels C3 to C5) down through the chest. The esophagus, aorta and major veins pass through openings in it.

Types of diaphragm injury

Traumatic diaphragm tears

Diaphragm tears occur in a small percentage of people with serious chest and abdominal trauma. The left side is affected more often, because the liver protects the right. The danger is that abdominal organs, such as the stomach, bowel or spleen, slide through the tear into the chest, compressing the lung or becoming trapped. Small tears can be missed initially and present months or years later as a diaphragmatic hernia. See traumatic diaphragm injury for detail.

Diaphragm paralysis

When a phrenic nerve is damaged, the diaphragm on that side stops working and rises into the chest.

• One-sided paralysis: often causes few symptoms at rest, but breathlessness with exercise, lying flat or bending over.
• Both sides: causes severe breathlessness when lying down and may need breathing support at night.

Common causes include heart surgery (from cooling or stretching of the nerve), neck surgery or injury, shoulder nerve blocks, tumors in the chest, and nerve inflammation after viral infections (neuralgic amyotrophy).

Diaphragm strain and spasm

The diaphragm can be strained like any muscle, causing pain under the ribs, pain when breathing deeply or coughing, and sometimes a hiccup-like spasm. A "side stitch" during exercise may involve diaphragm or nearby tissues. A blow to the upper belly can cause temporary diaphragm spasm ("having the wind knocked out of you"), which passes within a minute or two.

Symptoms

• pain in the lower chest or upper belly, worse with deep breaths or coughing
• shoulder-tip pain (referred through the phrenic nerve)
• shortness of breath, especially lying flat
• rapid, shallow breathing
• with herniation: bowel sounds heard in the chest, nausea, vomiting, pain after eating, constipation
• reduced breath sounds on one side

Diagnosis

• Chest x-ray: may show a raised diaphragm, abnormal contour, or bowel or stomach in the chest.
• CT scan: the main test for trauma; shows tears and herniated organs.
• Ultrasound: can show diaphragm movement and thickness.
• Fluoroscopy "sniff test": watches the diaphragm move during a quick sniff; a paralyzed side moves upward paradoxically.
• Laparoscopy or thoracoscopy: a keyhole camera may be used after penetrating injuries to the lower chest, because small tears can be invisible on scans.
• Lung function tests and nerve studies: for paralysis.

Treatment

• Strain or bruising: rest, pain relief with acetaminophen (paracetamol) or ibuprofen following the label dose, gentle breathing exercises, and gradual return to activity.
• Tears: surgical repair, usually through the abdomen in acute trauma (to also check for other injuries), or through the chest or laparoscopically for delayed hernias. Large defects may need a mesh patch.
• Paralysis: many phrenic nerve injuries recover over 6 to 24 months. Treatment may include breathing support at night, weight loss, and diaphragm plication (surgery to tighten the paralyzed muscle so it does not compress the lung). Nerve reconstruction or pacing are options in selected cases.

Recovery

• Strains: usually heal in 1 to 6 weeks.
• After surgical repair: most people leave hospital within a week or two depending on other injuries, with full recovery over 6 to 12 weeks. Avoid heavy lifting for about 6 weeks.
• Paralysis: recovery, if it occurs, takes months to years.

Frequently asked questions

What are the symptoms of a diaphragm injury?

Symptoms include pain under the ribs or in the upper belly, shoulder-tip pain, pain when breathing deeply or coughing, and shortness of breath, especially when lying flat. A torn diaphragm can let organs move into the chest, causing breathing difficulty, vomiting and pain after eating.

How do you know if your diaphragm is torn?

A tear is usually found on a CT scan after significant trauma such as a car crash, fall or stab wound. Breathlessness, chest pain, and bowel sounds heard in the chest are warning signs. Small tears may only be found during surgery or years later as a hernia.

How long does a diaphragm injury take to heal?

A strained diaphragm usually heals within 1 to 6 weeks. Recovery after surgery for a tear takes about 6 to 12 weeks. Diaphragm paralysis from nerve damage may improve over 6 to 24 months, though some cases are permanent.

Can you pull your diaphragm?

Yes. Heavy lifting, intense exercise or violent coughing can strain the diaphragm, causing pain under the ribs and with deep breaths. It usually heals with rest. Persistent pain or breathlessness should be checked to rule out other causes.

Can you live with a paralyzed diaphragm?

Yes. Many people with one paralyzed side have mild symptoms and live normally, though exercise may be harder. Paralysis of both sides is more serious and may require breathing support during sleep. Surgery can help some people.