What is costochondritis?

Costochondritis occurs when there is pain, and some of the time inflammation, in the front of the chest where the rib cartilage attaches to the sternum (costosternal joints) and/or where the rib attaches to the costal cartilage (costochondral joints). Usually in the second to fifth ribs. It is increasingly thought that the pain is mostly mechanical and not purely inflammatory as there is rarely swelling in the painful joints.

The costochondral  joints do not move as they are cartilage attaching to bone, but strain does pass through these joints, which can make them painful. The costosternal joints have small amounts of glide to allow for movement when breathing. As these joints move, they can have pain that is mechanical in origin.

In addition to the costochondral joints where the ribs connect with the sternum at the front of the chest, there are intervertebral joints, costovertebral joints, and costotransverse joints at the back of the body where the ribs connect to the spine. Dysfunction at these joints may lead to altered rib movments at the costochondral joints causing pain and inflammation. This altered movement occurs with both breathing, coughing and movements of the torso. Tension from fascia in other parts of the body and in the thorax itself can restrict movement in the ribs and thorax/chest causing pain. There are many muscles attaching to the thorax which can directly put tension through the ribs and cause pain if they are creating movement that is dysfunctional. These muscles include intercostal muscles, pectoralis major, pectoralis minor, subclavius, scalenes, latissimus dorsi, serratus anterior and posterior, abdominal muscles such as transversus abdominis, rectus abdominis, internal and external obliques, quadratus lumborum, the erector spinae muscles (iliocostalis, longissimus, and spinalis), and the diaphragm. This wide range of muscles attaching to the thorax may explain why it is often hard to explain why costochondritis has started. Tension from areas far from the chest and thorax and the many muscles attaching to the throax and chest may be creating dysfunctional tension, movement, and pain in the costochondral and costosternal joints.

There are many other conditions which can cause chest pain. Some do not require urgent medial attention, such as fibromyalgia, slipping rib syndrome, inflammatory arthritis such as spondyloarthritis (ankylosing spondilitis) and heart burn (reflux/GORD/GERD). Others such as heart attack (myocardial infarction), angina, infections such as herpes zooster or tuberculosis, fractures, traumatic chest injuries, and malignancies, need urgent medical attention. So it is important to seeek medial attention to privide a diagnosis and appropriate treatment.

Why does costochondritis occur?

As explained above, there is often no obvious reason why costochondritis has started. However, it often startes after increased physical activity levels, especially if you are not used to the particular task or strengthening exercise. Long periods of coughing and sneezing associated with chest infections may also lead to costochondritis.

Inflammatory conditions such as spondylarthritis (ankylosing spondylitis) or rheumatoid arthritis may cause costochondritis.

People with fibromyalgia may also have tender points over the chest and costochondral/costosternal joints.

Stress may lead to individuals holding tension in their chest and neck. Often the chest is held in a forwards and upwards posture associated with stress and fight or flight response. This may lead to increased tension and pain in the costochondral and costosternal joints.

What treatments are successful? 

The most commonly prescribed treatment is anti-inflammatoy medication including corticosteroids. There is no research evidcne to show if this is successful or not.

Relaxation and stress reduction for costochondritis. There are no studies indicating if relaxation helps with costochondritis.

There is limited evidence for the use of manual therapy for treating costochondritis. The evidence that is there is from case studies or non-randomised, no control studies. Manual therapy for the cervical and thoracic spine, including the ribs, and soft tissue and myofascial techniques are though to be helpful.

Stretching. Stretching of anterior chest wall muscles has been shown to be statistically significantly better than no treatment.

Laser therapy. There are no studies into the effectiveness of low level laser therapy for costochondritis, although it is commonly used in the physiotherapy treatment of costchondritis. This does not mean that it does not help, but there is no research to answer if these treatments are effective or not. There is evidence supporting laser therapy in musculoskeletal pain and inflammatory conditions in general however, so it is plausable that it may help with costochondritis.

Therapeutic ultrasound cannot be used on the anterior chest wall as it can interfere with heart function and the air filled lungs can reflect the energy back, causing damage to the adjacent tissues. Additionally, at the costochondral joints, there is very little soft tissue to absorb the ultrasound energy, so the bone absorbs the energy and may heat up, causing pain and damage to the covering of the bone (periosteum).

Acupuncture. There is some case study and clinical trials evidence that traditional acupuncture can reduce the pain of costochondritis. The acupuncture poinst used in case studies are:

CV 17, GB 34, SI6, GB39 or Sp 6 and St36, and Ashi points.

TE 8, LI 4, ST 36, BL 18, BL 19, LR 3, SP 6, Yin-Tang, GV 20, and CV 18

TE 8, GB 34, LI 4, ST 36, TE 5, LR 3, CV 14 and Ashi points.

LI 4, ST 36, TE 5, BL 22, LR 3, BL 57, TE 8, LI 11, GB 34, BL 23,  and Ashi points.

An average of five sessions were needed for patients to stop needing analgesia but some had relief after one session. There has also been a study of 106 patients without a control group, of whom 97% had complete relief of pain. As cases of costochondritis generally improve over time, it is difficult to know if this was due to natural improvement over time or the acupuncture treatment.

If you have persistent or recurrent costochondritis, it is worth being assessed by an experienced physiotherapist as there are many options for treatment. Unfortunately there is not strong research evidence to support or refute the effectiveness of these treatments at the moment.

 

References:

Alexander R. Acupuncture appears to be a rapidly effective treatment for costochondritis. Acupunct Med. 2022 Feb;40(1):99-100. doi: 10.1177/09645284211027582. Epub 2021 Jul 7. PMID: 34231403.

Amarnani R, Branley H, Chatterjee R. Atypical chest wall pain: paravertebral tuberculosis mimicking costochondritis. BMJ Case Rep. 2025 Oct 10;18(10):e266521. doi: 10.1136/bcr-2025-266521. PMID: 41073096.

Ayloo A, Cvengros T, Marella S. Evaluation and treatment of musculoskeletal chest pain. Prim Care. 2013 Dec;40(4):863-87, viii. doi: 10.1016/j.pop.2013.08.007. PMID: 24209723.

Barranco-Trabi J, Mank V, Roberts J, Newman DP. Atypical Costochondritis: Complete Resolution of Symptoms After Rib Manipulation and Soft Tissue Mobilization. Cureus. 2021 Apr 8;13(4):e14369. doi: 10.7759/cureus.14369. PMID: 33976991; PMCID: PMC8106472.

Gandhi V, Costello J. Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. BET 3: The use of corticosteroids in the management of costochondritis. Emerg Med J. 2012 Aug;29(8):686. doi: 10.1136/emermed-2012-201590.4. PMID: 22787240.

Li B. 106 cases of non-suppurative costal chondritis treated by acupuncture at xuanzhong point. J Tradit Chin Med. 1998 Sep;18(3):195-6. PMID: 10453612.

Lin K, Tung C. Integrating Acupuncture for the Management of Costochondritis in Adolescents. Med Acupunct. 2017 Oct 1;29(5):327-330. doi: 10.1089/acu.2017.1233. PMID: 29067144; PMCID: PMC5653338.

McConaghy JR, Sharma M, Patel H. Acute Chest Pain in Adults: Outpatient Evaluation. Am Fam Physician. 2020 Dec 15;102(12):721-727. PMID: 33320506.

Mott T, Jones G, Roman K. Costochondritis: Rapid Evidence Review. Am Fam Physician. 2021 Jul 1;104(1):73-78. PMID: 34264599.

Ian Rabey M. Costochondritis: Are the symptoms and signs due to neurogenic inflammation. Two cases that responded to manual therapy directed towards posterior spinal structures. Man Ther. 2008 Feb;13(1):82-6. doi: 10.1016/j.math.2006.12.007. Epub 2007 Mar 13. PMID: 17360222.

Rovetta G, Sessarego P, Monteforte P. Stretching exercises for costochondritis pain. G Ital Med Lav Ergon. 2009 Apr-Jun;31(2):169-71. PMID: 19827277.

Schumann JA, Sood T, Parente JJ. Costochondritis. 2024 Apr 20. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan–. PMID: 30422526.

Waggoner R, Needleman JP. Costochondritis. Pediatr Rev. 2024 Sep 1;45(9):543-545. doi: 10.1542/pir.2023-006141. PMID: 39217117.

Wu WT, Galluccio F, Lin TS, Chang KV, Özçakar L. Scanning before injection for costochondritis: A case report of ultrasound imaging of Hodgkin’s lymphoma with chest wall invasion. Int J Rheum Dis. 2023 Jan;26(1):164-167. doi: 10.1111/1756-185X.14464. Epub 2022 Oct 14. PMID: 36239043.

Zaruba RA, Wilson E. IMPAIRMENT BASED EXAMINATION AND TREATMENT OF COSTOCHONDRITIS: A CASE SERIES. Int J Sports Phys Ther. 2017 Jun;12(3):458-467. PMID: 28593100; PMCID: PMC5455195.