Costochondritis

Costochondritis is one of the most common causes of chest pain, and it is not dangerous. But any guide to it has to begin with what chest pain can be. New, unexplained chest pain should always be treated as potentially serious, including possibly coming from the heart, until it has been properly assessed, whatever your age and however fit you are.

Call 999 immediately if you have chest pain that:

• Feels crushing, tight, heavy or pressure-like, or does not go away
• Spreads to an arm, the jaw, the neck, the back or the stomach
• Comes with breathlessness, sweating, feeling sick, light-headedness or feeling faint

Costochondritis is a diagnosis usually made after serious causes have been considered and excluded, not instead of considering them. Nothing in this guide is a way of deciding for yourself that chest pain is harmless. If you have new chest pain without the emergency features above, NHS 111 or your GP can advise how urgently you should be seen.

Costochondritis is inflammation of the cartilage that joins the ribs to the breastbone, at the points known as the costochondral junctions. Why the cartilage becomes inflamed is often unclear, and in many people no single cause is ever found.

There are, however, recognised triggers. Costochondritis often follows a bout of heavy coughing, a strain or minor injury to the chest, repetitive upper-body activity such as lifting, or unaccustomed exercise, particularly exercise involving the arms and chest. It can also occur alongside other conditions: it is recognised in people with fibromyalgia, where the chest wall can be one of several tender areas, and occasionally it accompanies an infection or an inflammatory arthritis.

The pain of costochondritis is usually felt at the front of the chest, beside the breastbone, and may involve more than one rib. It is often sharp or aching, can affect either side, and is typically made worse by deep breathing, coughing, twisting or reaching, or by lying on the affected side.

Its most characteristic feature is that pressing on the affected cartilage reproduces the pain. Pain that can be brought on by gentle pressure on the chest wall points towards the chest wall rather than the heart as the source. That is a useful sign for the clinician examining you, but it is not a self-test: chest wall tenderness and heart disease can exist side by side, so tenderness alone is never a safe reason to ignore new chest pain.

Costochondritis usually settles by itself over a few weeks to several months, and it can come back from time to time. A recurrence is unwelcome but does not mean anything has been damaged.

Tietze syndrome is a rarer, closely related condition in which inflammation of the rib cartilage causes a firm, visible swelling as well as pain, usually of an upper rib. In costochondritis the area is tender to press but not swollen; in Tietze syndrome the swelling is the distinguishing feature, and it can persist for a while after the pain has settled. Both conditions are benign and are managed in much the same way.

Most costochondritis stands alone and settles. Sometimes, though, pain at the front of the chest wall that persists or keeps returning is part of a wider inflammatory condition, and this is where a rheumatology opinion earns its place.

The front of the chest is a recognised site of involvement in SAPHO syndrome, a rare condition in which inflammation of the bones and joints, often where the collarbone meets the breastbone, occurs alongside characteristic skin problems. Chest wall pain and stiffness also occur in axial spondyloarthritis, where the joints between the ribs, the spine and the breastbone can become inflamed and the chest can feel tight or restricted, typically alongside inflammatory back pain. And the chest wall contains many entheses, the points where tendons and ligaments attach to bone, so enthesitis here can be a feature of that same family of conditions.

Clues that chest wall pain may have an inflammatory cause include prominent morning stiffness, back or buttock pain that eases with movement, psoriasis or another inflammatory condition, or symptoms that keep returning over months rather than settling. None of these proves anything on its own, but together they are a good reason for a specialist review.

There is no single test that confirms costochondritis. The diagnosis is clinical: a careful history of how the pain began and behaves, and an examination in which gently pressing on the costochondral junctions reproduces the pain, with no swelling and nothing else to explain the picture.

The first task in assessing any chest pain is to make sure nothing serious is going on. Depending on your symptoms and history, that can mean a heart tracing (ECG), blood tests or a chest X-ray before the chest wall is accepted as the source. These steps are not a formality: chest wall pain and heart disease can affect the same people, and the two are told apart safely only by proper assessment.

Imaging of the chest wall itself is often normal in costochondritis, and its main role is to exclude other causes. Where there is doubt, the chest wall is well suited to ultrasound. Point-of-care ultrasound during the consultation can look directly at the costochondral junctions, the nearby joints and the entheses of the chest wall, helping to distinguish simple costochondritis from the swelling of Tietze syndrome or the inflammation seen in the conditions above and, where appropriate, guiding treatment. Dr Borukhson uses point-of-care ultrasound in the clinic, and you can read more on the ultrasound clinic page.

Costochondritis usually needs little more than an explanation, reassurance and time. Knowing that the pain is coming from the chest wall, that the serious causes have been considered, and that the condition settles by itself removes much of its power to worry, and for many people that is treatment enough.

Simple pain relief helps while the inflammation settles. Paracetamol, or an anti-inflammatory such as ibuprofen, can be used, with the usual care over the stomach, kidneys and blood pressure that anti-inflammatory tablets call for; a pharmacist or your GP can advise if you take other medicines. Warmth over the tender area, such as a heat pack, eases the pain for many people, and it makes sense to scale back the movements that aggravate it, such as heavy lifting or repetitive upper-body exercise, and to build back up gradually as it settles.

Where the pain is persistent, physiotherapy can help, with gentle stretching and attention to posture and to how the chest wall and upper back move. For stubborn, well-localised pain that has not settled with these measures, an ultrasound-guided injection of steroid around the tender area is occasionally considered, with ultrasound guidance helping to place it precisely. The plan is agreed with you.

Costochondritis rewards patience more than intervention, and a few practical habits help while it settles.

• Keep gently active. Normal daily movement helps the chest wall settle, whereas complete rest tends to stiffen it. Let pain guide you rather than stop you.
• Use warmth. A heat pack or a warm shower over the tender area often eases the pain, taking care not to burn the skin.
• Ease off the triggers. Cut back for a while on the lifting, training or repetitive movements that set the pain off, and reintroduce them gradually.
• Deal with a cough. If coughing triggered or aggravates the pain, treating the cough gives the cartilage a chance to settle, and supporting the sore area with your hand when you cough can make it more comfortable.
• Expect it to take time. Weeks to a few months is usual, and flares along the way are common and not a sign of harm.

The red flags at the top of this page matter every time, not just the first time. Call 999 or go to A&E immediately for chest pain that:

• Feels crushing, tight, heavy or pressure-like, or does not go away
• Spreads to an arm, the jaw, the neck, the back or the stomach
• Comes with breathlessness, sweating, feeling sick, light-headedness or fainting

Even if you have had costochondritis before, chest pain that feels different from your usual pattern deserves the same caution as new pain.

Arrange urgent, same-day advice from your GP or NHS 111 if chest pain comes with a fever or feeling generally unwell, if you become breathless, or if you have new chest pain that has not yet been assessed by anyone.

Book a routine review if chest wall pain is not settling after several weeks, keeps coming back, or comes with features such as morning stiffness, back pain that eases with movement or skin problems, which can point to an inflammatory cause. When you are unsure how quickly to act, it is always safer to be checked.

Costochondritis sits in an unusual position: the condition itself is harmless, but the symptom it causes is never trivial until it has been assessed. A proper assessment does two things at once. It makes sure the pain is not coming from the heart, the lungs or elsewhere, which is the part that can never be skipped. And it gives the chest wall pain a clear name and a plan, which turns a frightening symptom into a manageable one. For the smaller group whose chest wall pain is persistent or recurrent, specialist review can also pick up the inflammatory conditions that occasionally lie behind it, where earlier recognition means earlier treatment. Reassurance built on careful assessment is worth far more than reassurance assumed.

How do I know if my chest pain is costochondritis and not my heart?

You cannot safely settle that question yourself, and this is the most important message on this page. Call 999 if chest pain is crushing, tight or pressure-like, spreads to an arm, the jaw, the neck or the back, or comes with breathlessness, sweating, feeling sick or feeling faint. Any new, unexplained chest pain needs medical assessment before it is put down to the chest wall. Costochondritis typically causes sharp pain that is worse with movement, deep breaths or pressing on the area, but tenderness does not rule out a heart problem, so assessment always comes first.

How long does costochondritis last?

It usually settles on its own over a few weeks to several months, and simple measures such as pain relief, warmth and easing off aggravating activity help while it does. It can come back from time to time, and a recurrence does not mean anything has been damaged. Pain that is not settling after several weeks, or that keeps returning, is worth a review, both to confirm the diagnosis and to consider treatments such as physiotherapy or, occasionally, an ultrasound-guided steroid injection.

What is the difference between costochondritis and Tietze syndrome?

Both involve inflammation of the cartilage that joins the ribs to the breastbone, and both are benign. The difference is swelling. In Tietze syndrome, which is rarer, there is a firm, visible swelling over the affected cartilage, usually of an upper rib, and the swelling can persist after the pain has gone. In costochondritis the area is tender to press but not swollen. The two are managed in much the same way.

Can costochondritis be a sign of arthritis?

Usually not: most costochondritis stands alone and settles. But the front of the chest wall is a recognised site of inflammation in some rheumatological conditions, including SAPHO syndrome and axial spondyloarthritis, and inflammation where tendons and ligaments attach to the chest wall can be a form of enthesitis. Chest wall pain that persists, keeps returning, or comes with morning stiffness, inflammatory back pain or skin problems is worth a rheumatology review.

What is the best treatment for costochondritis?

Time and reassurance are the mainstay, because it usually settles by itself. Simple pain relief such as paracetamol, or an anti-inflammatory such as ibuprofen used with the usual cautions, warmth over the tender area, and temporarily easing back on the activities that aggravate it all help. Physiotherapy is useful for persistent cases, and for stubborn, well-localised pain an ultrasound-guided steroid injection is occasionally considered.