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

AI

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.

AI

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.

AI

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.

AI

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.

AI

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.

⚠ 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

Region

Anterior chest wall and costochondral junctions

Technique

Soft TissueAI

Rationale

Direct soft tissue techniques to pectoralis major/minor and intercostal muscles reduce muscular tension contributing to costochondral junction loading; improves local circulation and reduces inflammatory mediator concentration around affected articulations

Region

Costal articulations and rib cage

Technique

ArticulationAI

Rationale

Gentle articulation of rib heads and costochondral junctions restores normal gliding mechanics; reduces fixation patterns that concentrate stress on inflamed cartilage; promotes proprioceptive feedback and neuromuscular re-education

Region

Cervical and upper thoracic spine

Technique

METAI

Rationale

Muscle energy techniques to upper trapezius, levator scapulae, and pectoralis muscles address postural dysfunction and reduce shoulder girdle elevation patterns; normalizes breathing mechanics and reduces excessive rib cage motion

Region

Anterior chest wall and intercostal spaces

Technique

FunctionalAI

Rationale

Functional techniques support natural breathing mechanics and rib cage compliance; reduces pain-guarding patterns and excessive intercostal muscle contraction; facilitates return to normal movement patterns

Region

Thoracic inlet and upper mediastinum

Technique

LymphaticAI

Rationale

Lymphatic drainage techniques reduce local inflammatory fluid accumulation; improves tissue fluid dynamics around costochondral junctions; supports systemic inflammatory resolution and pain reduction

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.