Costochondritis

Other

Overview

Costochondritis is inflammation of the costochondral junctions where the ribs articulate with the sternum, causing anterior chest wall pain. It is a common, self-limiting condition that typically presents with localized tenderness and pain on movement or palpation. While benign, it can significantly impact quality of life and requires careful differentiation from serious cardiac or pulmonary pathology.

Pathophysiology

Costochondritis results from inflammation of the cartilaginous articulations between ribs and sternum, typically involving the 2nd-5th costochondral junctions. The underlying mechanism involves mechanical stress, repetitive upper limb movements, direct trauma, or viral respiratory infections causing cartilage irritation and inflammatory response. Associated muscle tension in the pectoralis major/minor and intercostal muscles perpetuates symptoms through altered biomechanics and referred pain patterns. Inflammatory mediators and local soft tissue edema contribute to pain amplification and movement restriction.

Typical Presentation

Site

Anterior chest wall, typically unilateral, most commonly affecting 2nd-5th costochondral junctions near the sternum; may have multiple site involvement

Quality

Sharp, burning, or aching pain; often described as stabbing or pressure-like; may mimic cardiac pain

Intensity

Mild to moderate (3-7/10), variable throughout day, often worse with exertion and worse in morning

Aggravating

Deep breathing, coughing, sneezing, repetitive upper limb activities, horizontal adduction movements, direct palpation, sleeping on affected side, lifting or pushing movements

Relieving

Rest, anti-inflammatory medication, heat application, gentle movement, avoiding aggravating activities

Associated

Chest wall tenderness on palpation, swelling or visible prominence at costochondral junction, limited upper limb movement, muscle tension in pectoralis and intercostal muscles, associated neck or thoracic spine dysfunction, anxiety regarding cardiac involvement

Orthopaedic Tests

Test descriptions are written with AI assistance from standard clinical texts. Where a test lists Sources, its description has been checked against them; those sources are independent and do not endorse OsteoKit. Accuracy figures and grades (A–D) appear only when checked against the published study; tests without one are marked “No accuracy study”.

Further reading: full test procedures are described in standard clinical examination texts, e.g. Magee & Manske, Orthopedic Physical Assessment (7th ed.), and Cook & Hegedus, Orthopedic Physical Examination Tests: An Evidence-Based Approach (2nd ed.).

No accuracy study

Costochondral Junction Palpation

Procedure

Patient supine or seated. Palpate each costochondral and costosternal junction from the 2nd to the 6th rib on both sides, with firm finger pressure.

Positive Finding

Tenderness at one or more junctions that reproduces the patient's chest pain, without visible swelling.

Interpretation

Reproducible tenderness supports costochondritis. Visible swelling at a single junction points to Tietze syndrome, a separate condition. Reproducing chest-wall tenderness does not exclude heart or lung disease; any chest pain with exertional features, breathlessness or cardiac risk factors needs medical assessment first.

Sources

No accuracy study

Chest Wall Palpation

Procedure

Palpate the whole front of the chest wall: the costochondral junctions, the sternum, the intercostal spaces and the pectoral muscles, and ask the patient to point to the worst area.

Positive Finding

Tenderness that reproduces the familiar pain in one area.

Interpretation

Locates the painful structures on the chest wall. It is a general palpation examination rather than a named test. Finding chest-wall tenderness does not by itself exclude a cardiac or respiratory cause.

Sources

No accuracy study

Anterior Chest Wall Compression Test

Procedure

Patient supine. Apply gentle front-to-back pressure through the sternum and then across the chest from side to side.

Positive Finding

Reproduction of the familiar chest pain with compression.

Interpretation

Suggests a chest-wall source, including rib or costochondral injury. It does not exclude a cardiac cause. After significant trauma, sharp pain on compression should raise concern for a rib fracture.

Further reading

No accuracy study

Modified Carnett's Test

Procedure

Patient supine. Find the most tender point, then ask the patient to lift the head and shoulders to tense the abdominal and chest-wall muscles, and press on the same point again.

Positive Finding

Tenderness stays the same or increases when the muscles are tensed.

Interpretation

Carnett's test was developed for the abdominal wall, where tensed muscles shield deeper organs. Its use for chest pain is not established, and it cannot rule out a cardiac cause. At most it adds weight to a chest-wall source.

Further reading

No accuracy study

Pectoral Muscle Stretch Test

Procedure

Patient supine. Take the arm into horizontal abduction and external rotation to stretch the pectoral muscles, and note any pain.

Positive Finding

Reproduction of the familiar front chest pain with the stretch.

Interpretation

Suggests the pectoral muscles or chest-wall structures contribute to the pain, which helps plan treatment. It does not distinguish costochondritis from a muscle strain.

Further reading

⚠ Red Flags

  • •Severe chest pain with dyspnea, diaphoresis, or radiation to arm/jaw (cardiac emergency)
  • •Fever, chills, and swelling suggesting septic arthritis or Tietze syndrome
  • •Recent cardiac intervention or history of cardiac disease
  • •Unexplained weight loss or systemic symptoms suggesting malignancy
  • •Chest pain with hemoptysis or persistent cough suggesting pulmonary pathology
  • •Pain following significant trauma suggesting rib fracture or pneumothorax
  • •Progressive neurological symptoms or sensory changes

⚡ Yellow Flags

  • •Health anxiety or catastrophic thinking about chest pain being cardiac in origin
  • •Persistent focus on symptoms despite reassurance and negative investigations
  • •Significant psychosocial distress impacting daily function
  • •Poor coping mechanisms or avoidance behaviors limiting activity
  • •High stress levels or recent life stressors correlating with symptom onset
  • •Sleep disturbance related to pain and anxiety
  • •Secondary gain from symptom focus or sick role adoption
  • •Beliefs that condition is serious or will worsen without intervention

Osteopathic Techniques

Costochondritis is benign and settles on its own; care is mainly supportive (heat, and topical or oral pain relief). In a small study, stretching helped pain that had not settled, and in a case series of 8, manual therapy plus exercise to the upper back and ribs helped all of them.

Safety: Costochondritis can mimic heart and lung problems such as acute coronary syndrome, pulmonary embolism and pneumonia, so these are ruled out first. Lung cancer has also presented as "costochondritis": re-check if the pain changes or new symptoms appear.

Region

Rib angles (posterior ribs, upper chest)

Technique

Articulation, ribs (rib raising)
Grade D
Low evidence: expert consensus or could not be verified against literature
No trials. A small case series treating the ribs and upper back with manual therapy and exercise reported improvement.

Rationale

Moves the ribs from behind, so the sore cartilage at the front is not pressed. Evidence is limited to a small case series.

How it's done, cautions & evidence

How it's done

Passive, with the patient supine or seated. The practitioner contacts the rib angles beside the spine and applies a repeated, rhythmic lift into the restriction to improve posterior rib motion and stretch the surrounding muscle and fascia. Gentle enough for unwell or bed-bound patients.

Cautions

Do not use with an acute rib fracture or after recent spinal surgery, or over skin that is infected, red or swollen.

Evidence in Costochondritis

Searched 23 Oct 2026: no trials of rib articulation in costochondritis. In a case series of 8, manual therapy and exercise to the cervicothoracic spine and rib cage gave clinically meaningful gains in all patients.

Region

Upper thoracic spine (T1–T6)

Technique

Muscle energy, thoracic
Grade D
Low evidence: expert consensus or could not be verified against literature
No trials. A small case series treating the upper back and ribs with manual therapy and exercise reported improvement.

Rationale

Restores upper-back motion alongside rib work. Evidence is limited to a small case series.

How it's done, cautions & evidence

How it's done

Seated or supine. The restricted segment is localised (using the head and neck as a lever for T1–T4, the trunk for T5–T12) and taken to its barrier while the transverse process is monitored. The patient gently pushes back toward neutral for a few seconds against equal resistance, relaxes, and the new barrier is taken up. Repeat, then re-check.

Cautions

Do not use with an acute fracture or dislocation. Recent ligament, tendon or muscle injury may make it unsuitable, and spasm driven by the central nervous system responds poorly. The patient must be able to follow instructions.

Evidence in Costochondritis

Searched 23 Oct 2026: no trials of thoracic MET in costochondritis. In a case series of 8, manual therapy and exercise to the cervicothoracic spine and rib cage gave clinically meaningful gains in all patients.

Region

Pectoral muscles (anterior chest wall)

Technique

Soft tissue, pectoralis minor
Grade D
Low evidence: expert consensus or could not be verified against literature
No trials. A small case series of manual therapy with exercise, and a small stretching study, reported improvement.

Rationale

Eases tight chest muscles around the sore area without pressing on the inflamed cartilage. Stretching is the better-supported option.

How it's done, cautions & evidence

How it's done

Stretch and sustained pressure to pectoralis minor (ribs 3–5 to the coracoid). A manual stretch can be given supine or sitting; in one study the supine stretch lengthened the muscle more than the sitting one, and a self-stretch most of all. Ischaemic compression of tender trigger points can come first, and a doorway self-stretch (15–20 second holds) suits home care.

Cautions

Conservative care is for pectoralis minor syndrome without arterial or venous thrombosis: rule those out first.

Evidence in Costochondritis

Searched 23 Oct 2026: no trials of soft tissue technique in costochondritis. A case series of 8 improved with manual therapy and exercise to the cervicothoracic spine and ribs, and a retrospective study of 51 found stretching eased pain.

Region

Anterior thoracic tender points (along the sternum)

Technique

Counterstrain, thoracic tender pointsNo trials found

Rationale

Very gentle and indirect, using position rather than force. Untested in costochondritis.

How it's done, cautions & evidence

How it's done

Find an anterior, posterior or lateral thoracic tender point (the upper anterior points run down the sternum from the sternal notch toward the xiphoid). Passively position the patient away from the restriction (for the upper anterior points, by flexing the head toward the sternum) until the tenderness eases. Hold, return slowly to neutral and re-check the point.

Cautions

Do not use over an acute fracture, or in a patient who cannot give feedback. Avoid the positions for thoracic extension dysfunctions after a shoulder dislocation.

Evidence in Costochondritis

Searched 23 Oct 2026: no trials of counterstrain in costochondritis.

Rehabilitation Exercises

Thoracic Spine Rotation in Quadruped

Range of MotionBeginner

Rib Cage Mobilization Breathing

Range of MotionBeginner

Pectoralis Major Doorway Stretch

StretchingBeginner

Pectoralis Minor Release with Ball

StretchingIntermediate

Scapular Stabilization - Prone Y-T-W

StrengtheningIntermediate

Intercostal Muscle Activation - Side-lying Thoracic Extension

StrengtheningIntermediate

Postural Reset - Scapular Retraction with Wall

PosturalBeginner

Diaphragmatic Breathing - Supine with Hand Cues

PosturalBeginner

Cat-Camel Thoracic Mobilization

Range of MotionBeginner

Prone Shoulder Blade Squeeze - Prone Hold

StrengtheningBeginner

Cross-body Chest and Shoulder Stretch

StretchingBeginner

Quadruped Stability with Thoracic Rotation

BalanceIntermediate

Referral Criteria

  • •Presenting symptoms consistent with acute coronary syndrome or cardiac pathology requiring immediate medical evaluation
  • •Fever and systemic inflammatory signs suggesting septic arthritis or serious infection
  • •Signs of Tietze syndrome (painless swelling of costochondral junction) requiring medical investigation
  • •Unilateral symptoms with associated respiratory signs suggesting pleurisy or pulmonary embolism
  • •Persistent symptoms unresponsive to conservative management after 8-12 weeks despite appropriate osteopathic and physiotherapy intervention
  • •Significant psychosocial distress or health anxiety severely impacting function requiring psychological support
  • •Symptoms following significant trauma requiring imaging to exclude fracture or pneumothorax
  • •Progressive neurological symptoms or unexplained systemic symptoms requiring medical investigation
  • •Recurrent episodes suggesting underlying structural dysfunction requiring specialist assessment
  • •Ongoing diagnostic uncertainty between chest wall pain and cardiac pain — costochondritis is a diagnosis of exclusion, so cardiac and pulmonary causes must be formally excluded before chest pain is attributed to the costochondral junctions. Refer for medical or cardiology assessment on diagnostic grounds; reproducible tenderness on palpation does not by itself exclude concurrent cardiac disease.