Costochondritis

Disease/Disorder

Definition

Costochondritis is a benign musculoskeletal condition causing atypical, noncardiac chest pain due to inflammation at the costosternal or costochondral junctions, worsened by movement or palpation. Also called costosternal syndrome or parasternal chondrodynia, it is a clinical diagnosis that differs from Tietze syndrome in that there is no swelling, skin changes, and without findings on imaging or elevated inflammatory markers.¹ Pain is typically reproducible at the anterior chest wall, most often involving the second to fifth costochondral joints unilaterally, though any junction may be affected.

Etiology

In most cases, there is no specific etiology. However, costochondritis may be the result of a mixture of inflammatory, noninflammatory and infectious conditions that involve chest wall structures listed below.

Epidemiology including risk factors and primary prevention

Costochondritis most commonly occurs in adults 40-50 years of age. A single center retrospective study in 2021 found that 45% of 13,000 ER visits for chest pain had a musculoskeletal etiology.⁹ Another meta-analysis found that 16% of 15,000 ER visits for chest pain were also musculoskeletal in nature,¹⁰ whereas that number jumps to 33-47% in the ambulatory care setting,¹¹ especially among adolescents with 13% being related to costochondritis.¹²

Avoidance of aggravating activities along with careful observation of proper mechanics during strenuous activities, especially those that involve repetitive arm and trunk movements can help prevent occurrences.¹³ For example, in competitive rowers, costochondritis is typically noted in the sweep phase, and patients may experience pain during shoulder adduction.

Improvement of posture can reduce spasms from surrounding musculature that refer pain to the anterior chest.¹

Patho-anatomy/physiology

The pathophysiology remains unclear. Postulated mechanisms include dysfunction of neurogenic and/or musculoskeletal structures. Repetitive microtrauma or poor posture/musculature can increase stress on the costal cartilage. The superior ribs move within a flexion-extension pattern mimicking the upper limbs, respiration, and with axial motion, resulting in increased inflammation.  

Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)

• Acute: Sharp, stabbing, or pressure-like pain over the chest, worsened by upper body movement, deep breaths, or exercise.¹⁴
• Sub-acute: Similar pain but with reduced intensity.¹
• Resolution: Pain diminishes or resolves, typically within 1-2 months, but may persist up to a year.¹

Specific secondary or associated conditions and complications

Costochondritis is not associated with secondary conditions and given that it is typically self-limiting and self-resolving, there are no predictable or expected complications. Over 90% of patients with idiopathic costochondritis experience symptom resolution within 3-4 weeks. A small percentage of patients may experience refractory or recurrent costochondritis for which they should be referred for further evaluation to assess for systemic chest pain or autoimmune conditions.¹ Prolonged symptoms can result in limited chest wall movement and shortness of breath. After 2 years the recurrence rate was approximately 4%.² Both costochondritis and stress fractures are seen in cases of repetitive movement or activity, but there is no evidence to suggest that costochondritis causes stress fractures. It is possible that irritation to the soft tissues proximal to a stress fracture of the ribs may precipitate costochondritis in a susceptible individual.

Essentials of Assessment

History

Patients with costochondritis commonly report sharp or dull pain in the upper anterior chest wall that worsens with movements including coughing, stretching, and deep inspiration/expiration.¹ Some patients, especially adolescents can complain of “trouble catching a complete breath” or “tightness”.¹⁵ Costochondritis can often mimic acute coronary syndrome, pulmonary embolism, pericarditis, aortic dissection, pneumonia, esophageal injury, or pneumothorax.¹ Questions regarding cardiac or upper abdominal causes of pain should be investigated, particularly if patient is over the age of 35 and/or has a personal or family history consistent with cardiac dysfunction, gastrointestinal or rheumatologic disease, or neoplasm in particular asking about location, intensity, nature, and exacerbating symptoms, and associated conditions like shortness of breath, fever, emesis, etc.

A recent history of strenuous activity, blunt trauma, respiratory infections, or surgical procedures involving the anterior chest wall are more likely to indicate a musculoskeletal origin, as well as having hobbies that involve repetitive upper body movements. The pain is variable in intensity and may be in multiple areas. Concordant pain reproducible by palpation suggests costochondritis but does not exclude other etiologies, such as those listed below.¹

A similarly presenting condition is Tietze syndrome, which is characterized by localized swellings in the regions of pain along with inflammation over the second and third ribs (70% of cases). Tietze syndrome is more common in younger patients (< 35).

Conditions that can present similarly include sternoclavicular joint arthritis, sternomanubrial joint pain, xiphoid syndrome, slipping rib syndrome, local neoplasms, traumatic myalgia, or herpes zoster.

Physical examination

Careful palpation of the anterior chest wall using a single digit to reproduce concordant pain. Auscultate lungs for possible respiratory etiology and examine the skin to rule out rashes or other lesions, e.g., vesicular or dermatomal patterned.

Active and passive range of motion of the anterior chest wall musculature should be assessed. This should include, but is not limited to, the pectoralis major, the levator scapulae, the serratus anterior, and platysma. Similarly, anterior and posterior rib motion can also be evaluated with inspiration and expiration.^1,16

Maneuvers, such as the “crowing rooster,” in which the patient is seated with either hands clasped behind the back of their head or shoulders abducted to 90 degrees and the examiner applies a superior-posterior directed force while the patient extends their neck to illicit symptoms. Horizontal arm flexion maneuvers can also be performed to reproduce symptoms and involve the patient flexing an arm anteriorly to the chest while rotating their head towards the ipsilateral shoulder while the examiner applies a steady, prolonged horizontal traction.² A study involving 1212 patients, done in an outpatient primary care setting, showed that the presence of at least two of four specific features (localized muscle tension, stinging pain, pain reproducible by palpation, and absence of cough) was associated with a diagnosis of chest wall syndrome, with 63 percent sensitivity and 79 percent specificity.¹⁷

Functional assessment

Inflammation of the costochondral joints or the anterior chest wall can cause a reduction in spinal mobility, which can limit cervical and thoracic range of motion. While there is no specific questionnaire developed for costochondritis the Patient-Specific Functional Scale (PSFS) can be used as a valid, reproducible, and responsive functional assessment measure for patients with neck pain, back pain, and upper quarter complaints to determine which activities are impacted, such as breathing, lifting or other upper body movements. The Global Rating of Change (GROC) scale can be used at follow-up appointments to determine a patient’s subjective rate of improvement of said activities.¹

Laboratory studies

No specific lab test diagnoses costochondritis. Elevated CRP, ESR, and WBC may indicate infection or inflammation, requiring further investigation to rule out rheumatologic, cardiac, pulmonary, or gastro-esophageal causes.¹

Imaging

Imaging is not required to diagnose costochondritis; however, imaging can be utilized to eliminate differential diagnoses such as cardiac, pulmonary, infectious or malignant etiologies.

Options include

• Plain Radiographs – often used first-line to rule out rib fracture, cardiac, pulmonary etiology, especially in patients with over 35 with risk factors, though insensitive to detect rib cartilage, costochondral junction, costovertebral joint and chest wall soft tissue abnormalities.¹
• Musculoskeletal ultrasound – to differentiate between muscular, tendinous, bony, or inflammatory etiology. Under ultrasound, an area of chest wall with costochondritis would be hypoechoic, whereas in Tietze syndrome, the area being inspected would have a dishomogeneous increase of the echogenicity in pathological cartilage and an increased thickness reflecting edema. Dynamic ultrasound, including palpation or compression during scanning can help localize the site of maximal tenderness and increase clinical suspicion of a musculoskeletal pain generator.  In the emergency setting, point of care ultrasound can be useful in detecting rib fractures as well as used to assess for other etiologies of chest pain like effusion, abscess or other lesions.¹⁹

The following advanced imaging is reserved for cases with suspicion of malignancy, infection or when initial radiographs are inconclusive.

• Triple-phase bone scan – usually not useful as the initial imaging modality, not specific for costochondritis and should not be used to confirm diagnosis as increased uptake at the costochondral junctions can be seen in both symptomatic and asymptomatic individuals.¹⁹ Has been shown to have 95% sensitivity in patients with osteoblastic skeletal tumors either primary or secondary metastasis. Ideal secondary study for patients with metallic implants.¹⁴
• CT scan (with or without contrast) – rule out cardiac, pulmonary, or chest wall soft tissue etiology.¹ Higher sensitivity and specificity than triple-phase bone scan when differentiating between chest wall tumors and inflammatory changes.¹⁹
• MRI – typically not necessary in the evaluation of atraumatic chest wall pain but can be used complementary to CT for better tissue characterization to differentiate neoplasm from non-neoplastic processes and to determine neurovascular involvement.¹⁹

Supplemental assessment tools

There is no specific assessment tools required for the diagnosis of costochondritis. It is primarily a clinical diagnosis.¹

Early predictions of outcomes

Symptoms are usually resolved within one to two months but may last for up to one year. There is insufficient data to show recurrence rates of similar presentations.^1,16

Environmental

Environmental allergies causing frequent sneezing or coughing, as well as activities with repetitive upper limb movements, may increase the risk of costochondritis.¹

Social role and social support system

Although not life-threatening, costochondritis chest pain can be distressing. Reassurance that costochondritis is self-resolving can help reduce anxiety. Changes in pain or symptoms like nausea, dyspnea, or fever require further investigation.^1,16

Professional issues

Ruling out more serious etiologies of anterior chest pain in patients with high risk is important to consider.

• Wells Criteria to assess risk for pulmonary embolism (Level A evidence)²⁰
• Diehr Criteria to assess risk for pneumonia (Level A evidence)²⁰
• Rouan Criteria to assess risk for myocardial infarction (Level C evidence)²⁰

Rehabilitation Management and Treatments

Available or current treatment guidelines

Typical

Costochondritis in the acute phase can be “typical” when symptoms usually last less than one month or symptoms resolve during this period. Typical costochondritis involves mainly conservative management with the expectation that the rib pain will go away without interventional pain management, such as injections, acupuncture, or manipulations. First-line treatment of costochondritis anecdotally suggests the use of oral analgesics such as acetaminophen and NSAIDs as needed. Both have demonstrated pain reduction as early as 2 hours and usually within 1-7 days of initiation of therapy. Hypothetically, ice can be used adjunctively for short-term pain relief though studies are mixed and only speak about generalized musculoskeletal conditions and show little efficacy beyond the first 1-3 days and in general are less effective than oral analgesics. Similarly, localized heat may provide short term pain relief especially in the setting of muscle overuse but should not replace first line treatment. Otherwise, reassurance, relative rest, and minimizing activities that provoke symptoms are sufficient to resolve symptoms.

Persistent

Costochondritis can be considered “persistent” when symptoms continue or recur more than the one-month period and beyond. In this state, costochondritis may be treated with multimodal pain management and medical interventions to ablate or reduce symptoms.

Physical therapy can be considered for cases where first line treatment fails. Approaches include combining manual therapy, stretching, range of motion, postural correction, and therapeutic exercise targeting the thoracic spine, rib cage, and associated muscles (pectoral, intercostal, and thoracic and scapular stabilizers) have demonstrated clinically meaningful improvements in pain and function¹. Modalities such as iontophoresis have been used in general musculoskeletal inflammatory disorders as an adjunct to therapy to deliver anti-inflammatories though its efficacy for costochondritis remains to be studied.

Some case studies have reported the use of osteopathic manipulation as a treatment option for persistent symptoms. OMM aimed at correcting rib dysfunction or myofascial dysfunctions can be used in this patient population with greater efficacy arising from multimodal care rather than just spinal manipulation alone. Techniques include counter-strain, indirect myofascial release, facilitated positional release, muscle energy, high-velocity, low amplitude manipulation, and articulatory and thrusting techniques for inhalation or exhalation dysfunctions of the ribs.¹⁸

Consider using local anesthetic injections with and without steroids to affected joints for persistent symptoms. Anecdotally, the use of steroids may improve pain intensity and duration as in any other musculoskeletal conditions. However, steroids may also worsen skin conditions causing infection or unwanted cosmetic skin indentation, raise blood glucose levels in diabetes, worsen costochondral joint pain, or may not have any pain relief benefits. The decision to use local steroids in rib injections has not been well delineated in the medical literature. When performed blindly, the patient is supine, prone, or sidelying with the needle advanced to the cartilage of the costochondral joint. ^24-27 Ultrasound or fluoroscopic image guidance, however, can increase injection accuracy and significantly reduces the chances of potential pneumothorax.^24-27 The use of oral steroids has yet to be defined.²¹

Some case reports studying the effects of acupuncture for persistent symptoms showed effective pain relief between 1-3 treatments. Preliminary research is promising regarding the role of acupuncture in adolescents suffering from costochondritis and can serve a safe low risk option.^17,23

Recent studies suggest that ESWT may provide superior pain relief compared to steroid injections at one-month post-treatment, though evidence is limited, and long-term outcomes are unclear. More research is needed to standardize protocols and confirm efficacy.²²

Coordination of care

A multidisciplinary approach—including patient education, coordinated care, and various therapies—helps manage musculoskeletal pain by promoting activity modification, proper body mechanics, ergonomics, and postural training.

Patient & family education

Patients should be reassured that costochondritis is benign with a full recovery expected. Further evaluation is warranted if over 35 or with cardiac risk factors.¹ Mild analgesics, ice/heat, activity modification, and complementary therapies aid in acute and persistent cases.

Translation into practice: practice “pearls”/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills

When encountering patients with chest pain, it is important to gather a thorough history and physical exam to differentiate costochondritis from other etiologies. Costochondritis is a clinical diagnosis, so it is imperative to gather a detailed history and perform a thorough physical exam. Patients should be reassured about their diagnosis and educated that it is a self-limiting condition and that initial treatment is similar to other acute musculoskeletal injuries which includes relative rest and analgesics. 

Adjunctively, manual therapies, such as myofascial release, balanced ligamentous tension (BLT), rib mobilization techniques, and muscle energy techniques are non-invasive modalities of addressing pain.¹⁸ Correcting biomechanical dysfunctions may be both preventive and curative.

Acupuncture can also be an effective adjunct to NSAIDs.¹⁷

Corticosteroid injections, though rarely indicated, can be used in refractory cases. Like other forms of musculoskeletal pain, an injection of a 2-mL mixture of 1 mL of 40 mg/mL of methylprednisolone acetate or equivalent and 1 mL of local anesthetic can work quite well helping to resolve pain if symptoms persist for more than a few months.¹⁸

Gaps in the Evidence-Based Knowledge

The mechanism of costochondritis is unclear and is often a diagnosis of exclusion. There are limited high-quality studies. Further research is needed to establish evidence-based guidelines for diagnosis and treatment.¹

References

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2. Schumann, J. A., Sood, T., & Parente, J. J. (2024, April 20). Costochondritis. In StatPearls. StatPearls Publishing. https://pubmed.ncbi.nlm.nih.gov/30422526/
3. Hudes, K. (2008). Low-tech rehabilitation and management of a 64 year old male patient with acute idiopathic onset of costochondritis. Journal of the Canadian Chiropractic Association, 52(4), 224–228.
4. Nowicki, J. L., Dean, N. R., & Watson, D. I. (2016). A case report of Candida albicans costochondritis after a complicated esophagectomy. Plastic and Reconstructive Surgery – Global Open, 4(1), e608. https://doi.org/10.1097/GOX.0000000000000599
5. Mohammad A, Benjamin SR, Mallampati S, Gnanamuthu BR, Prabhu AJ, Ninan MM. Aspergillus flavus costochondritis following coronary artery bypass grafting: a case report and a brief review of literature. Asian Cardiovasc Thorac Ann. 2021 Nov;29(9):960-963. doi: 10.1177/0218492320988458. Epub 2021 Jan 14. PMID: 33444067.
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7. Collins RA, Ray N, Ratheal K, Colon A. Severe post-COVID-19 costochondritis in children. Proc (Bayl Univ Med Cent). 2021 Sep 27;35(1):56-57. doi: 10.1080/08998280.2021.1973274. PMID: 34966216; PMCID: PMC8477585.
8. Qureshi, A., Nazeef, A., Ali, H., Gyawali, J., & Subhan, N. (2024, August 29). Tubercular costochondritis presenting as chest wall swelling: A case report of an atypical tuberculosis presentation. Cureus, 16(8), e68158. https://doi.org/10.7759/cureus.68158 
9. Wertli, M. M., Dangma, T. D., Müller, S. E., Gort, L. M., Klauser, B. S., Melzer, L., Held, U., Steurer, J., Hasler, S., & Burgstaller, J. M. (2019). Non-cardiac chest pain patients in the emergency department: Do physicians have a plan how to diagnose and treat them? A retrospective study. PLOS ONE, 14(2), e0211615. https://doi.org/10.1371/journal.pone.0211615
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14. Gregory, P. L., Biswas, A. C., & Batt, M. E. (2002). Musculoskeletal problems of the chest wall in athletes. Sports Medicine, 32(4), 235–250. https://doi.org/10.2165/00007256-200232040-00003
15. Waggoner, R., & Needleman, J. P. (2024, September 1). Costochondritis. Pediatrics in Review, 45(9), 543–545. https://doi.org/10.1542/pir.2023-006141 
16. Flowers LK, Wippermann BD. Costochondritis. eMedicine. eds. William Chiang, et al. 2007. Medscape. 6 Mar. 2009.
17. Lin, K., & Tung, C. (2017). Integrating Acupuncture for the Management of Costochondritis in Adolescents. Medical Acupuncture, 29(5), 327-330. doi:10.1089/acu.2017.1233
18. Savarese R, Copobianco J, Cox J. OMT Review: A Comprehensive Review of Osteopathic Medicine. 3rd ed. Satas Librairie Editions, Brussels, Belgium, 2003;129-133.
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21. Gandhi, V., & Costello, J. (2012). THE USE OF CORTICOSTEROIDS IN THE MANAGEMENT OF COSTOCHONDRITIS. Emergency Medicine Journal, 29(8), 686-686. doi:10.1136/emermed-2012-201590.4
22. WorkSafeBC. (2024, May). Effectiveness of extra corporeal shockwave therapy (ESWT) in treating costochondritis and soft tissue contusion: 2024 update — A rapid systematic review. https://www.worksafebc.com/resources/health-care-providers/guides/effectiveness-extra-corporeal-shockwave-therapy-eswt-treating-costochondritis-soft-tissue-contusion-2024-update?lang=en
23. Alexander R. P15 Acupuncture treatment of Costochondritis, a case series. Rheumatol Adv Pract. 2022;6(Suppl 1):rkac067.015. Published 2022 Sep 28. doi:10.1093/rap/rkac067.015
24. Thomson ACS, Portela DA, Romano M, Otero PE. Evaluation of the effect of ultrasound guidance on the accuracy of intercostal nerve injection: a canine cadaveric study. Vet Anaesth Analg. 2021;48(2):256-263. doi:10.1016/j.vaa.2020.12.003
25. Aguilar LA, Portela DA, Moura RA, Vettorato E, Otero PE, Romano M. Ultrasound-guided intercostal nerve injection in rabbit cadavers: Technique description and comparison with blind approach. Vet Anaesth Analg. 2025;52(2):228-235. doi:10.1016/j.vaa.2024.12.008
26. Bhatia A, Gofeld M, Ganapathy S, Hanlon J, Johnson M. Comparison of anatomic landmarks and ultrasound guidance for intercostal nerve injections in cadavers. Reg Anesth Pain Med. 2013;38(6):503-507. doi:10.1097/AAP.0000000000000006
27. Shankar H, Eastwood D. Retrospective comparison of ultrasound and fluoroscopic image guidance for intercostal steroid injections. Pain Pract. 2010;10(4):312-317. doi:10.1111/j.1533-2500.2009.00345.x

Original Version of the Topic

Mark A. Young, MD MBA FACP, Ayanna Kersey-McMullen, DO, MSPH. Costochondritis. 9/20/2014.

Previous Revision(s) of the Topic

Michael Bruce Furman, MD, Vivek Narendra Babaria, DO and Shannon Schultz, MD, MPH. Costochondritis. 7/3/2018.

Shannon Schultz, MD, MPH, Vivek Babaria, DO, Michael Bruce Furman, MD. Costochondritis. 5/11/2022

Author Disclosure

Lawrence Chang, DO, MPH
Nothing to Disclose

Gabrielle Avancena, MD
Nothing to Disclose

Bryan Lebron-Solis, DO
Nothing to Disclose