Costochondritis

Costochondritis is one of the commonest reasons for pain in the chest, and it does no harm. Even so, the place to begin is the other things chest pain can mean. Chest pain that is new and has no explanation is treated as possibly serious, the heart among the possibilities, until someone has assessed it, at any age and at any level of fitness.

Chest pain that is crushing, tight or like a pressure, that spreads to an arm, the jaw, the neck, the stomach or the back, that comes with breathlessness, sweating, feeling sick or feeling light-headed, or that came on suddenly and does not go away, is a 999 or A&E emergency, as the first list under When to seek help says, and that list holds the other signs that need 999 too.

The diagnosis of costochondritis comes after the serious causes have been thought about and ruled out, never in place of that thinking, and nothing here lets you decide on your own that chest pain is harmless. Chest pain that is new to you, without the signs above or any other in that first list, needs NHS 111 or your GP the same day, and they will say how soon you should be seen and where.

It is the cartilage between the ribs and the breastbone that is inflamed, at the meeting points named the costochondral junctions. Often nobody can say why it has flared, and in many people a cause is never found.

Some triggers are known. In some cases it has been linked to a spell of hard coughing, a strain or a small injury to the chest, lifting or other repeated work with the arms and upper body, or exercise the chest and arms are not used to. Other conditions can bring it too. In fibromyalgia the chest wall may be one of many tender places, and occasionally costochondritis appears with an infection or as part of an inflammatory arthritis.

Most people feel it at the front or side of the chest, next to the breastbone, often over more than one rib. Often the pain is sharp, though it can ache, it can be on either side, and it tends to get worse:

• When you move your upper body, twist or reach
• When you breathe in deeply or cough
• When you lie down
• When you press on the breastbone or the ribs

The most telling feature is that pressing the sore cartilage brings the pain on. Pain that gentle pressure on the chest wall reproduces points to the chest wall rather than to the heart, which helps whoever examines you, but it is not a test to do on yourself: a sore chest wall and a heart problem can occur in the same person, so tenderness is never a safe reason to ignore chest pain that is new.

It usually clears on its own within weeks to months, and may flare again now and then. A flare is unwelcome but not a sign of damage.

Tietze syndrome is a rarer relative in which the inflamed cartilage swells as well as hurting, usually at one of the upper ribs. With costochondritis the sore spot is tender but flat; with Tietze syndrome a swelling is the giveaway, and it can linger once the pain has eased. Neither does harm, and the care for both is largely the same.

Most costochondritis comes on its own and goes. Sometimes, though, front-of-chest pain that will not go or keeps flaring belongs to a broader inflammatory illness, and that is when a rheumatologist should take a look.

SAPHO syndrome, a rare condition, brings arthritis at the front of the chest wall together with inflamed bone and particular skin problems, and it is one to think of when costochondritis will not settle. In axial spondyloarthritis, the joints where the ribs meet the spine can become inflamed, with morning stiffness in the back. Psoriatic arthritis can involve the chest as well, and the wider spondyloarthritis family, which also takes in enthesitis, is one of the recognised causes of costochondritis.

The clues that chest wall pain may be inflammatory are long morning stiffness in the back, psoriasis or another inflammatory condition, and pain that keeps returning over months instead of fading. No one clue proves anything, but taken together they are reason enough to see a GP, without leaving it for months, and to ask for a specialist's view.

No single test proves costochondritis. The diagnosis is made by listening and examining: how the pain started and how it behaves, and an examination in which gentle pressure on the costochondral junctions brings the pain on, with no swelling and nothing else to account for it.

With any chest pain, the first task is ruling out something serious. Depending on your account and your health, an ECG, which records the heart's electrical activity, blood tests or a chest X-ray may come before anyone settles on the chest wall. These tests matter: the two problems can exist side by side, and only a proper assessment separates them safely.

In costochondritis a scan of the chest wall often looks normal; its real value is in excluding something else. Where some doubt remains, ultrasound suits the chest wall well. Point-of-care ultrasound is part of the consultation with Dr Borukhson: the scan can look straight at the costochondral junctions, the joints beside them and the places where tendons attach; it may help to tell costochondritis from Tietze syndrome's swelling or from the inflammation of the conditions above, and it can guide treatment where that is needed. The ultrasound clinic page describes what happens during the scan.

For most people the treatment is an explanation, some reassurance and patience. Once you know the pain comes from the chest wall, that nothing serious has been found and that it fades on its own, most of the worry goes, and many people need nothing more.

A painkiller helps while the inflammation settles. The NHS says an anti-inflammatory tablet such as ibuprofen, a painkiller that helps with inflammation, may be recommended for the pain, where it is safe for you; it can upset the stomach, affect the kidneys and clash with medicines for blood pressure, so a pharmacist or your GP can say whether it suits you, and the signs of a bleed from the stomach are in the lists below. Paracetamol is the alternative. Many find that warmth or cold on the sore spot helps, and it makes sense to cut back on the movements that bring it on, heavy lifting or repeated upper-body exercise among them, building them up again slowly as it improves.

Pain that hangs on can be helped by a physiotherapist, through gentle stretching, posture and exercises for the movement of the chest wall and upper back. Where very bad pain has resisted all of that, an injection of steroid around the sore area is occasionally considered, guided by ultrasound so that it goes exactly where it is needed. You and Dr Borukhson settle the plan together.

Time is the main healer here, and some simple habits make the wait easier.

• Keep moving gently. Ordinary daily movement helps the chest wall recover, while too much rest can slow recovery. Use the pain as a guide, not a barrier.
• Use heat or cold. A heat pack or an ice pack on the sore area can ease it. Wrap the pack in a towel, never put it straight on the skin, keep it on for no more than twenty minutes, leave a few hours between goes, and stop if the skin turns redder, changes colour or blisters; if you have problems with your circulation or with feeling in your skin, do not use heat or ice at all.
• Take a painkiller that suits you. An anti-inflammatory such as ibuprofen, or paracetamol, as a pharmacist advises for you.
• Ease off what sets it off. Do less of the lifting, training or repeated arm movements that bring the pain on for a while, then build them back up step by step.
• Treat a cough. If coughing started it or keeps it going, dealing with the cough lets the cartilage calm down, and holding a hand against the sore area as you cough can make it easier.
• Give it time. A few weeks to several months is the usual course, and a flare now and then is not a sign of harm; pain that keeps coming back is one to take to a GP, as the paragraph under When to seek help says.

Costochondritis itself does no harm, but chest pain is never assumed to be harmless until its cause is known. Each sign in the two lists below has its route, the most serious first, and the paragraph that follows says when a GP is the right step.

Treat any of these as a 999 or A&E emergency: call 999 and do not drive yourself to A&E.

• Severe illness with suspected sepsis: a high fever with shaking, confusion, rapid breathing, or feeling dramatically worse over hours
• With a fever or feeling unwell, a rash that does not fade when you press it, a stiff neck with eyes that cannot bear bright light, or skin, lips or tongue turning blue, grey, pale or blotchy, since these can be signs of meningitis or sepsis; on black or brown skin the rash and the change of colour may be easier to see on the palms of the hands or the soles of the feet
• Chest pain that is crushing, tight or like a pressure, that spreads to an arm, the jaw, the neck, the stomach or the back, that comes with breathlessness, sweating, feeling sick or feeling light-headed, or that came on suddenly and does not go away
• Breathlessness that is severe, with gasping, choking or no breath to get words out; coughing up blood; or chest pain with a heart that is racing, since a clot on the lung can make chest pain sharper as you breathe in, much as costochondritis does
• Palpitations happening now that do not stop, or that come with chest pain, breathlessness, feeling faint or fainting, since a heart whose muscle or rhythm is affected has to be checked at once
• Sudden pain in the chest or the back that feels like something tearing inside, all the more with breathlessness or with trouble walking, seeing or speaking, since the body's main artery can tear
• Chest pain that comes with back pain you have not had before, or unlike your usual back pain, or chest pain that began after a serious accident, such as a car crash or a fall from a height
• Vomiting blood, or bleeding from the back passage that is heavy or will not stop, most of all with faintness, confusion or pain in the abdomen, or vomit that is black or dark brown, since anti-inflammatory painkillers, which the NHS suggests for costochondritis, can make the stomach bleed
• Lips, mouth, throat or tongue that suddenly swell, a throat that feels tight, very fast breathing or a struggle to breathe or to swallow, skin, tongue or lips turning blue, grey or pale (on black or brown skin this may be easier to see on the palms of the hands or the soles of the feet), becoming suddenly very confused, drowsy or dizzy, or fainting and not being able to be woken, since this can be a severe allergic reaction, anaphylaxis, which can follow a dose of any medicine
• A faint after which you cannot be woken within a minute, do not fully recover, or have trouble speaking or moving, or a faint with chest pain, a pounding, fluttering or irregular heartbeat, a seizure or a serious injury, or one that happened during exercise or while lying down, since these can mean a problem with the heart or the brain
• Sudden weakness or numbness on one side, a drooping face or difficulty speaking, a sudden severe headache, sudden confusion or a seizure, or sudden loss of vision, any of which can be a stroke, even if it stops after a short time
• An eye that suddenly and completely loses its sight

Any of these needs an assessment that is urgent, on the same day, from your GP or NHS 111:

• Chest pain that is new to you or unlike your usual chest-wall ache, breathlessness that is new or getting worse, new palpitations, pain that stops you breathing in deeply, or tingling or burning in the chest, the neck or the arms, with none of the signs in the first list, since a cause in the heart or the lungs has to be ruled out that day; palpitations happening now that do not stop, or that come with chest pain, breathlessness, feeling faint or fainting, belong to the first list, and so does numbness or weakness that comes on suddenly; in pregnancy, breathlessness that comes on suddenly, or when you lie down, or with dizziness, is for your midwife or maternity unit straight away
• Chest pain that comes on with exercise, stress, strong feelings or the cold, rather than with a particular movement or a press on the ribs, and settles within a few minutes of rest, since a pattern like this can be angina, the chest pain of a heart short of blood; NHS 111 will tell you where to be seen
• Chest pain with a fever, or with feeling hot, cold or shivery or generally unwell, since an infection in the chest or the chest wall has to be found that day
• A rib cage that has changed shape, with a new lump or a dip, or chest pain after a fall or a blow to the chest in the past week, since a broken rib, another injury or another cause of a lump has to be ruled out; chest pain after a serious accident belongs to the first list
• Black or dark red stools, on anti-inflammatory tablets, since a bleed in the stomach or gut has to be found that day

See a GP if eight weeks of self-care at home have not helped, if the pain is getting worse or keeps coming back, or if a cough hangs on or brings up yellow or green phlegm. Take chest wall pain that comes with long morning stiffness in the back, or with psoriasis, to a GP, without leaving it for months, since an inflammatory condition may be the cause. No referral is needed to be seen here; next-working-day appointments can almost always be arranged, and same-day appointments are sometimes possible. If you cannot tell how urgent something is, asking is never a mistake.

Costochondritis is an odd mixture: the condition itself is harmless, yet the pain it causes cannot be taken lightly until it has been checked. A careful assessment does two jobs. It checks that neither the heart, the lungs nor anything else of importance is behind the pain, the step that must never be missed, and it puts a name to the chest wall pain and a plan around it, so that an alarming symptom becomes a manageable one. For the smaller number whose chest wall pain lingers or returns, a specialist review can also find the inflammatory conditions that are occasionally the cause. Reassurance is worth most when it rests on a proper look.

Is my chest pain costochondritis, or could it be my heart?

That is not a question to settle on your own, and it is the single most important point on this page. Chest pain that is crushing, tight or like a pressure, that spreads to an arm, the jaw, the neck, the stomach or the back, that comes with breathlessness, sweating, feeling sick or feeling light-headed, or that came on suddenly and does not go away, is a 999 or A&E emergency; so is chest pain with a racing heart or with coughing up blood, which can be a clot on the lung, and sudden pain in the chest or back that feels like something tearing inside. Call 999 and do not drive yourself to A&E. Chest pain that is new to you, without those signs or any other sign in the first list under When to seek help, needs NHS 111 or your GP the same day. Costochondritis typically hurts sharply and gets worse with movement, deep breaths or pressure on the sore spot, but a tender chest wall does not rule out a problem with the heart, so the checks come first.

Will my costochondritis last for months?

Most often it eases by itself within a few weeks to several months; painkillers, warmth or cold on the sore area and going easy on the movements that set it off help in the meantime. It can return now and then, and a return does not mean that anything has been harmed. If eight weeks of self-care at home have not helped, if it is getting worse, or if it keeps coming back, see a GP, who can confirm the diagnosis and talk through physiotherapy or, occasionally, a steroid injection guided by ultrasound.

How is costochondritis different from Tietze syndrome?

Both are inflammation of the cartilage where the ribs meet the breastbone, and neither is dangerous. What tells them apart is swelling. Tietze syndrome, the rarer of the two, raises a firm swelling you can see over the sore cartilage, most often of one of the upper ribs, and the swelling can outlast the pain. Costochondritis makes the area tender when it is pressed but does not swell it. Treatment for the two is largely the same. A lump or a change in the shape of your rib cage that you have not had checked before is for your GP or NHS 111 the same day.

Could costochondritis point to an arthritis?

As a rule, no: most costochondritis comes on its own and settles. Some inflammatory conditions do reach the chest wall, though, such as SAPHO syndrome, axial spondyloarthritis or psoriatic arthritis, and the spondyloarthritis family they belong to, which also takes in enthesitis, is one of the recognised causes. Pain in the chest wall that lingers or keeps returning, or comes with long morning stiffness in the back or with psoriasis, should go to a GP, without leaving it for months.

What eases costochondritis best?

Time does most of the work, since it usually settles on its own. Meanwhile, painkillers that help with inflammation, such as ibuprofen, may be recommended for the pain, where they are safe for you, and paracetamol is the alternative. A heat pack or ice pack in a towel, held on the sore area for twenty minutes at most each time, and a break from the lifting or upper-body exercise that brings it on, ease it further. Physiotherapy helps pain that hangs on, and for very bad pain that is not easing over time a steroid injection guided by ultrasound is occasionally considered.