Costochondritis

Written by: Dr Don Ponnamperuma; additional contribution by: Dr Jeremy Steinberg – created: 12 February 2025; last modified: 8 April 2025

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Costochondritis
Synonym	Costosternal syndrome, Parasternal chondrodynia, Anterior chest wall syndrome
Epidemiology	Affects up to 30% of chest pain presentations in ED settings; 6–13% of primary care chest pain cases; more common in women and middle-aged adults; also occurs in pediatric populations (13–14%).
Causes	Often idiopathic; associated with microtrauma, upper body exertion, coughing, respiratory infections, chest surgery, or post-trauma; rare links to rheumatologic conditions.
Pathophysiology	Localized inflammation at the costochondral or costosternal junctions, often due to repetitive microtrauma or biomechanical strain; sometimes overlaps with fibromyalgia or enthesopathy.
Classification	Non-cardiac musculoskeletal chest pain syndrome; distinguished from Tietze syndrome by absence of swelling.
Risk Factors	Female sex, middle age, upper body strain, coughing, trauma, prior thoracic surgery, fibromyalgia, respiratory infections.
Clinical Features	Localized anterior chest pain, tenderness at ribs 2–5, worsened by movement, deep breathing, coughing, or pressure; no systemic symptoms. positive “crowing rooster” and horizontal adduction tests; no visible swelling or systemic signs.
Diagnosis	Clinical; based on history and reproducible tenderness; investigations (e.g. ECG, imaging) used to rule out serious conditions.
DDX	Angina, myocardial infarction, Tietze syndrome, rib fracture, pleuritis, GERD, anxiety, fibromyalgia, thoracic disc disease, pulmonary embolism.
Treatment	Activity modification, NSAIDs, paracetamol, manual therapy, stretching, injections in refractory cases.
Prognosis	Most resolve within weeks to months; 30% may have symptoms at 1 year; ~4% may have recurrent episodes over 2 years.

Costochondritis is a benign musculoskeletal condition characterized by inflammation and pain at the costochondral or costosternal joints, where the ribs meet the cartilage and sternum. Publications group together pain at the articulations between ribs and sternum and pain of the costal cartilages as “costochondritis.”

Tietze syndrome is a similar condition but is characterised by non-suppurative swelling over the costal cartilages and will not be discussed in this work.

History

Historically, it has also been referred to as costosternal syndrome, parasternal chondrodynia, or anterior chest wall syndrome

After Tietze’s initial description of a painful, swollen costochondral junction in 1921, clinicians came to recognize a similar chest wall pain condition lacking visible edema – what we now call costochondritis​. Throughout the 20th century, costochondritis (sometimes termed “chest wall syndrome”) was increasingly recognized as a common cause of non-cardiac chest pain. By the 1970s-1990s, studies in emergency departments (EDs) and clinics identified costochondritis as a frequent diagnosis in patients with chest pain once cardiac causes were excluded​​. Today, costochondritis is understood as a self-limited, albeit sometimes distressing, pain syndrome of the anterior chest wall, distinct from serious cardiopulmonary conditions.

Epidemiology

Costochondritis is thought to account for up to 30% of cases presenting to an acute medical service with chest pain.

Prevalence: Costochondritis is a common cause of chest pain, especially in ambulatory care. Approximately 1–3% of all primary care visits are for chest pain, of which 20–50% are musculoskeletal chest wall pain syndromes​. Costochondritis specifically accounts for an estimated 6–13% of chest pain presentations in primary care​.

In emergency department populations, studies have found costochondritis in about 30% of non-traumatic chest pain cases after serious causes are ruled out​​. A prospective ED study by Disla et al. reported a 30% incidence of costochondritis among 122 chest pain patients​. Importantly, costochondritis was significantly more frequent in women (approximately 69% of cases) than in men​, a female predominance echoed in other studies and reviews​.

The condition most often affects adults in midlife (40–50 years of age)​​, though it can occur in a wide age range.

Pediatric Cases: In children and adolescents, musculoskeletal causes account for up to one-third of chest pain complaints. Costochondritis is diagnosed in roughly 13–14% of pediatric/adolescent chest pain cases, making it a leading benign cause of chest pain even in younger patients​. While the clinical features are similar, pediatric costochondritis is usually self-limited and benign; however, it is crucial to distinguish it from congenital or serious cardiac causes of chest pain in that population.

Risk Factors and Associations: The etiology of costochondritis is often idiopathic, but several risk factors and associated conditions have been reported.

• Trauma: Repetitive microtrauma or strain to the chest wall (for example, heavy lifting, vigorous upper-body exercise, or severe coughing) is thought to precipitate inflammation at the costochondral junctions​.
• Respiratory Infection: Some cases have been linked to respiratory infections or excessive coughing bouts, which may strain the chest wall.
• Post-surgical: Costochondritis can also occur post-surgically (e.g. after thoracic surgery) or after direct chest wall trauma. In rarer instances, it may be associated with underlying rheumatologic conditions (such as seronegative spondyloarthropathies) or infection of the costosternal joint (seen in high-risk patients like IV drug users or those with recent chest surgery)​. However, these secondary causes (e.g. septic costochondritis) are uncommon and usually present with additional signs (erythema, fever, etc.).
• Fibromyalgia: Notably, there is an overlap with chronic pain syndromes: patients with fibromyalgia often report costochondral pain. Classic fibromyalgia includes tender points at the second costochondral junction, and indeed some patients with fibromyalgia have recurrent costochondritis. Conversely, only a minority of costochondritis patients fulfill fibromyalgia criteria (8% in one ED series)​., though many have some elements of widespread pain.

Overall, female sex and middle age are the strongest demographic correlates, and vigorous physical activity or chest wall strain are common historical antecedents.

Anatomy

An understanding of chest wall anatomy is crucial to comprehending costochondritis. The pain arises from the joints and connective structures that link the ribs to the sternum. There are 12 pairs of ribs: the first seven pairs are “true ribs” that articulate anteriorly with the sternum via costal cartilage, ribs 8–10 are “false ribs” connecting indirectly to the sternum via the cartilage of the superior ribs, and ribs 11–12 are “floating” with no anterior attachment​.

The junction between each bony rib and its cartilage is the costochondral junction, and the junction between the costal cartilage and the sternum is the costosternal (chondrosternal) joint. The upper costosternal joints (ribs 2 through 7) are synovial joints, allowing slight gliding movements with respiration and arm motion, whereas the first rib’s junction is a synchondrosis (cartilaginous union)​. These joints, along with the costal cartilages, provide elasticity to the thoracic cage during breathing.

The costal cartilage is composed of hyaline cartilage and can undergo calcification with age, but in general it permits flexibility. The rib cage moves with respiration and upper limb movement, and is stabilized by the thoracic spine and numerous chest wall muscles (pectoralis major/minor, intercostals, etc.). The innervation of the anterior chest wall is primarily via the intercostal nerves (ventral rami of thoracic spinal nerves) which run along each rib​ Pain from costochondral joints is carried by these intercostal nerves, which is why it is typically well-localized. There is also anatomic continuity in innervation between the lower cervical spine and the upper chest wall (the shoulder girdle muscles originate from cervical segments) – as a result, cervical spine or shoulder pathology can refer pain to the anterior chest wall​. This overlap is one reason that somatic dysfunction in the neck or upper back may contribute to chest wall pain.

Pathophysiology

The precise pathophysiological mechanism of costochondritis remains incompletely understood. By definition, costochondritis implies an inflammatory process at the costochondral junction or chondrosternal joint, but in many cases the inflammation is low-grade or not directly evident (no swelling or redness). Microtrauma or overuse is thought to be a common inciting factor – repetitive micro-tears or stress at the cartilage–rib interface may lead to localized inflammation and tenderness​.

For example, unaccustomed heavy lifting, certain sports, or severe coughing (such as during bronchitis) can strain these junctions. Over time, this results in pain and tenderness that can persist for days to weeks as the micro-injuries heal. Another theory posits that abnormal biomechanics of the thoracic spine and rib cage contribute to costochondritis. Restriction or dysfunction in the costovertebral joints or thoracic spine may increase stress on the anterior rib joints, leading to pain – this concept of a regional mechanical cause is supported by the success of manual therapy in many patients and has been suggested in the literature (sometimes termed a “costo-thoracic dysfunction”)​​. In other words, costochondral joint inflammation may sometimes be secondary to poor posture, spine misalignment, or repetitive motion that concentrates force on the rib ends.

Systemic inflammation is usually absent in primary costochondritis – patients typically have normal acute phase reactants, and histologic examination (when done) shows no purulent or specific pathology​. This distinguishes it from Tietze’s syndrome, where biopsy may show cartilage degeneration and inflammatory cell infiltration with localized edema. However, in rare instances costochondritis can be part of a generalized inflammatory disorder. For example, seronegative spondyloarthropathies (like ankylosing spondylitis or psoriatic arthritis) can involve the sternocostal joints, leading to chronic chest wall pain and tenderness as part of the disease. Similarly, patients with relapsing polychondritis (a rare cartilage autoimmune disease) have recurrent costochondral inflammation, though that condition has distinct clinical features. These are uncommon scenarios but should be kept in mind for refractory or atypical presentations.

In post-infectious or post-surgical cases, a more intense inflammatory reaction can occur. For instance, after cardiothoracic surgery or chest wall trauma, costochondral junctions can become inflamed or even infected (septic costochondritis, e.g. Staphylococcal infection of the joint). Infection causes true suppurative inflammation of the cartilage, but this is outside the scope of typical benign costochondritis.

Overall, the pathology in ordinary costochondritis appears to be a combination of mechanical strain and localized inflammation of cartilage. The term “chest wall syndrome” is sometimes used when a definitive single cause isn’t identified​. Research has not identified a consistent structural lesion in idiopathic costochondritis – imaging is often normal – which suggests the pain could also involve neurogenic mechanisms (such as irritation of the intercostal nerve) in addition to subtle inflammation​. Some authors have postulated that costochondritis might result from a form of enthesopathy (inflammation at tendon/ligament attachment to bone) at the chondrosternal ligaments, or from articular dysfunction at the costosternal joints leading to secondary nerve irritation. These theories, while unproven, align with the observation that treating adjacent joint dysfunction (e.g. mobilizing the thoracic facets or ribs) often alleviates the chest wall pain​​.

Clinical Features

Diagnosis is made on history and examination

History

Patients may complain of chest wall pain of a sharp or aching character, with varying intensity. The pain is most commonly localised over the 2^nd-5^th sternocostal joint, though any one of the seven ribs that articulate with the sternum may be affected. The pain may be exacerbated by movement, deep inspiration and exertion.

Patients may report a gradual or sudden onset. Movements that stretch or contract the chest wall, such as reaching overhead, twisting the torso, pushing or pulling motions, or taking a deep inhale, tend to exacerbate the pain​. Likewise, coughing or sneezing can aggravate the discomfort due to jarring of the rib joints. The pain may radiate in a dermatomal pattern across the chest; occasionally it can radiate to the shoulder or arm, mimicking cardiac pain, though radiation below the chest or to the jaw is uncommon in costochondritis.

Many patients note that the pain is variable with position and activity – for example, it might be worse when lying down or turning in bed, and better when sitting still. Unlike angina, costochondritis pain is not consistently triggered by exertion (it might even ease with gentle exercise once warmed up, in contrast to cardiac ischemia). There are no systemic symptoms such as fever, cough, or breathing trouble in isolated costochondritis – if those are present, other diagnoses should be suspected

Examination

Examination may demonstrate pain on palpation the over affected joints; the ipsilateral upper arm and shoulder range of motion should also be examined as this will typically elicit movement-related pain.

Typically, more than one site is tender (in >90% of cases multiple levels are involved)​. The overlying skin and tissue usually appear normal with no swelling, erythema, or warmth. In contrast, Tietze’s syndrome would show a visible or palpable swelling of the costal cartilage at one level​. In costochondritis, pressing on the rib-cartilage junctions 2 through 5 (often at the level just lateral to the edge of the sternum) reproduces the pain sharply.

There are also specific maneuvers that can provoke pain by stressing the costosternal joints

• The “crowing rooster” maneuver (hands clasped behind head with elbows drawn back, which expands the chest)
• The crossed-chest adduction maneuver (also called the horizontal arm flexion test, where the patient adducts the arm across the chest) both compress the costosternal junctions and can produce pain in costochondritis​.

Pain produced by these maneuvers or by direct palpation strongly supports the diagnosis. The remainder of the exam in costochondritis is usually unremarkable – heart sounds are normal, lungs are clear, and there are no neurologic deficits. The chest wall may have some restriction of motion due to pain (the patient may take shallow breaths to avoid discomfort). It is important to palpate widely: tenderness limited to the costochondral areas suggests costochondritis, whereas point tenderness over the chest muscles or along the ribs could indicate muscular strain or fracture, and tenderness at the costovertebral joints (near spine) could indicate a thoracic spine issue.

Diagnosis

There is no gold standard investigation to diagnose costochondritis and it remains a clinical diagnosis. Any investigations done are used to rule out more serious conditions (e.g. ECG for MI). As such, there are no studies examining the validity of any physical examination techniques for diagnosing costochondritis, despite the description of special tests such as the crowing-rooster and crossed-arm adduction manoeuvres in aiding the diagnosis. Neither are there any studies examining the reliability of using these techniques for diagnosis.

Referred Pain Considerations: A thorough workup for chest pain always keeps in mind the possibility of visceral referred pain. Pain perceived at the chest wall might originate from elsewhere via viscerosomatic reflexes or nerve paths. For example, cervical spine disease can refer pain to the chest (cervical angina syndrome), and gallbladder disease classically refers pain to the right shoulder (via diaphragmatic irritation) which is a different region but exemplifies referred pain patterns. Clinicians sometimes encounter patients who have chest wall tenderness but whose pain is actually exacerbated by esophageal acid (visceral pain can co-exist with tenderness due to muscle tension).

Viscerosomatic reflexes occur when an internal organ’s pain causes muscle tension or tenderness in the corresponding dermatomes/myotomes. In the case of myocardial ischemia, some patients exhibit increased paraspinal muscle tone or even tenderness in the upper chest wall due to a reflex – though this is not common enough to rely on clinically. Conversely, gastrointestinal causes like acid reflux might cause patients to unconsciously tense their chest muscles, leading to secondary tenderness. Thus, in the diagnostic approach, one should ensure that the chest wall tenderness is primary (i.e. pressing on it reproduces the exact pain and there are no other strong clues of a visceral origin). If any doubt exists, appropriate tests (like endoscopy for suspected reflux, or spine imaging for suspected disc disease) should be conducted.

Differential Diagnosis

Chest Wall Pain Differential Diagnoses

• Costochondritis
• Lower rib pain syndromes (slipping rib syndrome)
• Pain from thoracic spine
  • costovertebral joints
  • interspinous ligaments and paravertebral muscles
  • possibly not costotransverse joints or facet joints
• Sternalis Syndrome
• Stress fractures
• Tietze’s Syndrome
• Xiphoidalgia
• Spontaneous sternoclavicular subluxation
• Rheumatic diseases
  • Fibromyalgia
  • Rheumatoid Arthritis
  • Axial Spondyloarthritis (including ankylosing spondylitis)
  • Psoriatic Arthritis
  • Systemic lupus erythematosus
  • Relapsing polychondritis
• Sternoclavicular hyperostosis
• Septic arthritis of the chest wall
• Non-rheumatic systemic causes
• Osteoporotic fracture
• Neoplasms
• Pathological fracture
• Bone pain
• Sickle cell disease (rare)

Management

There is a paucity of evidence on the management options for all causes of musculoskeletal chest wall pain.

Non-pharmacological

The mainstay of managing costochondritis is analgesia and activity modification, such as avoiding activities that exacerbate the pain. Heat or ice can be used, or alternated.

Stretching: Stretching or postural exercises may be helpful. Simple doorway stretches for the pectoralis muscles, gentle thoracic extension exercises, and posture correction (avoiding slumping) can relieve stress on the costosternal joints.

Thoracic Spine and Rib Mobilization: Mobilizing the thoracic spine (through manual therapy techniques or chiropractic adjustments) can address any joint dysfunction in the spine that might be contributing to anterior chest pain. In a case series, patients with chronic costochondritis who underwent an impairment-based PT regimen focusing on the cervicothoracic spine and rib cage showed significant improvements in pain and function​. All patients in that series returned to full activity after a few sessions of manual therapy and exercise.

Soft Tissue Mobilization: Techniques such as myofascial release or massage to the chest wall muscles and fascia can reduce muscle guarding and pain. In one reported case, a combination of rib manipulation and soft tissue mobilization led to complete resolution of 2-year chronic costochondral pain after three sessions.

Shockwave: In a 2021 randomized controlled trial by Çiftçi et al., high-energy shockwave therapy to the costochondral areas was compared to steroid injections in patients with chronic costochondritis​. Both treatments were effective in reducing pain at 1 month, but the shockwave therapy group had significantly greater improvement in pain scores and pressure pain thresholds than the injection group.

Pharmacological

This includes NSAIDs, paracetamol, topical lidocaine, and muscle relaxants.

Injections

Corticosteroid: One study describes the use of corticosteroid injections to the tender areas of the chest wall, but this study did not describe whether imaging was used to confirm that the injection was into the sternocostal joint. There are no large studies examining the efficacy of corticosteroid injections in treating sternocostal joint-generated pain in the absence of an inflammatory condition

There are no anatomical studies describing the volume of the sternocostal joint, knowledge of which would aid in making decisions about the volume of injectate to utilise. Another anatomical consideration is the safety of introducing needles close to the lungs and pleurae and risking a pneumothorax.

Costochondritis discussed in literature were deemed to be of idiopathic aetiology. There is limited literature describing post-traumatic sternocostal joint-generated pain; one case report describes post-traumatic pain at the first sternocostal joint. MRI demonstrated increased signal intensity on STIR sequence, correlating with the site of pain. This was treated with fluoroscopy-guided corticosteroid and local anaesthetic injection, which provided complete pain relief. However, this publication did not detail the type (of either corticosteroid or local anaesthetic) or volume of injectate used. Treatment yielded four months of analgesia, after which the patient underwent resection arthroplasty of the first sternocostal joint, and the patient remained pain-free at two years.

Intercostal nerve block: Instead of injecting the joint. By injecting anesthetic (and steroid, if desired) near the neurovascular bundle of the rib, the pain signals from that segment can be interrupted. This can be both diagnostic and therapeutic. If relief is obtained, it suggests the pain was indeed arising from that segment’s structures. Nerve blocks may provide weeks of relief. In persistent cases, a series of blocks or even radiofrequency ablation of the intercostal nerve (to create a longer-term denervation) could be considered by pain specialists, although published experience with this specifically for costochondritis is limited.

PRP and prolotherapy: Anecdotally, some clinicians have tried platelet-rich plasma (PRP) injections or prolotherapy (injecting irritant solution to strengthen ligaments) for chronic chest wall pain, though no robust studies exist for costochondritis specifically. These remain investigational

Prognosis

Most cases resolve within a matter of months, but approximately 30% may have pain at one year and up to 4% may experience recurrence over the subsequent two years.

Literature Review

Literature Review

Reviews from the last 7 years: review articles, free review articles, systematic reviews, meta-analyses, NCBI Bookshelf

Articles from all years: PubMed search, Google Scholar search.

TRIP Database: clinical publications about evidence-based medicine.

Other Wikis: Radiopaedia, Wikipedia Search, Wikipedia I Feel Lucky, Orthobullets,