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

Tietze's Sign / Costochondral Palpation

Procedure

Palpate the costochondral junctions systematically, particularly at ribs 2–5. Apply firm direct pressure to reproduce tenderness and assess for swelling or inflammation at the junction between the costal cartilage and bony rib.

Positive Finding

Localized tenderness and/or swelling at one or more costochondral junctions; reproduction of patient's chest pain

Sensitivity / Specificity

Unknown / Unknown

Interpretation

Reproducing tenderness and swelling at the costochondral junction is highly suggestive of costochondritis. Absence of palpable tenderness at the costochondral junction argues against the diagnosis. This is the primary clinical finding and aids differential diagnosis from other chest wall conditions.

Cyriax Chest Wall Palpation Test

Procedure

Systematically palpate the entire anterior chest wall, including intercostal spaces, pectoralis major, and costochondral junctions. Move from superficial to deep structures and assess for areas of maximal tenderness and muscle tension.

Positive Finding

Reproducible tenderness in the costochondral region or intercostal musculature; localized pain that mimics the patient's presenting complaint

Sensitivity / Specificity

Unknown / Unknown

Interpretation

Identifies regional chest wall pain generators and helps exclude cardiac or pulmonary pathology. Positive findings support a musculoskeletal diagnosis of costochondritis or related chest wall syndrome.

Anterior Chest Wall Compression Test

Procedure

Patient supine or seated. Apply gentle-to-moderate anterior–posterior compression across the anterior chest wall at the level of the costochondral junctions and intercostal spaces.

Positive Finding

Reproduction or exacerbation of chest pain; patient guarding or splinting response

Sensitivity / Specificity

Unknown / Unknown

Interpretation

Reproducing pain on chest wall compression supports a musculoskeletal cause and helps exclude cardiac sources. Negative result does not rule out costochondritis but suggests pain is not directly compression-related.

Modified Carnett's Test

Procedure

Patient supine. First, identify and mark the area of maximum tenderness with patient relaxed. Then have patient perform a sit-up or tense abdominal muscles while you re-palpate the same area to assess whether tenderness persists or diminishes.

Positive Finding

Persistence or increase in tenderness when abdominal muscles are tensed; indicates superficial or chest wall origin of pain

Sensitivity / Specificity

Unknown / Unknown

Interpretation

A positive test (persistent tenderness during muscle contraction) confirms that pain originates in the chest wall rather than intra-abdominal structures. This helps exclude visceral or cardiac sources. Negative test (tenderness disappears with muscle contraction) suggests deeper, visceral pathology.

Pectoral Muscle Stretch Test

Procedure

Patient supine or seated. Passively stretch the pectoralis major muscle by abducting and externally rotating the shoulder, or use a doorway pectoral stretch. Assess for pain reproduction.

Positive Finding

Reproduction of anterior chest wall pain during pectoral stretch; guarding or limitation of range of motion

Sensitivity / Specificity

Unknown / Unknown

Interpretation

Positive finding suggests pectoralis major involvement or referred pain from costal/intercostal structures. Helps identify musculoskeletal contributors to chest wall pain and informs treatment directed at pectoral musculature and rib mechanics.

⚠ 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 Tissue

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

Thoracic spine (T1-T5)

Technique

HVLA

Rationale

Restores normal segmental mobility in upper thoracic spine to correct altered biomechanics; reduces aberrant rib motion patterns that perpetuate costochondral stress; improves thoracic outlet mechanics and reduces referred pain

Region

Costal articulations and rib cage

Technique

Articulation

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

MET

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

Functional

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

Lymphatic

Rationale

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

Add-On Approaches

Chinese Medicine

TCM identifies costochondritis as Qi and blood stagnation in the Liver and Pericardium meridians; acupuncture points such as PC3 (Quze), LV3 (Taichong), and ST36 (Zusanli) combined with local ashi points address inflammation and pain. Herbal formulas like Xiao Yao San support Qi movement and emotional stress component common in anxiety-related presentations.

Chiropractic

Chiropractic approach focuses on rib vertebral adjustment and costovertebral joint manipulation to correct biomechanical dysfunction; soft tissue techniques to intercostal and pectoral muscles; emphasis on postural correction and ergonomic counseling to prevent recurrence

Physiotherapy

Physiotherapy emphasizes graduated breathing exercises to normalize diaphragmatic function; postural retraining and ergonomic modification; graded exercise progression from passive to active-assisted to resistance exercises; thoracic mobility work; upper limb coordination and scapular stabilization exercises

Remedial Massage

Deep tissue massage to pectoralis major/minor and intercostal muscles releases muscle tension; myofascial release to chest wall fascia improves mobility; gentle lymphatic drainage reduces swelling; trigger point release addresses referred pain patterns from associated myofascial dysfunction

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
  • •Patient unable to differentiate symptoms from cardiac pain despite reassurance requiring cardiology clearance for peace of mind