Costochondritis, an inflammation of costochondral junctions of ribs or chondrosternal joints of the anterior chest wall, is a common condition seen in patients presenting to the physician’s office and emergency department. Palpation of the affected chondrosternal joints of the chest wall elicits tenderness. Although costochondritis is usually self-limited and benign, it should be distinguished from other, more serious causes of chest pain. Coronary artery disease is present in 3 to 6 percent of adult patients with chest pain and chest wall tenderness to palpation. History and physical examination of the chest that document reproducible pain by palpation over the costal cartilage is usually all that is needed to make the diagnosis in children, adolescents, and young adults. Patients older than 35 years, those with a history or risk of coronary artery disease, and any patient with cardiopulmonary symptoms should have an electrocardiograph and possibly a chest radiograph. Consider further testing to rule out cardiac causes if clinically indicated by age or cardiac risk status.

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Costochondritis Summary

Costochondritis is a common cause of chest pain. It most commonly occurs in adults between 40 and 50 years of age, with a slight predominance in women. Although musculoskeletal and other chest wall conditions are the most common aetiology for chest pain presenting to primary care, an initial differential diagnosis should include cardiovascular, psychogenic, pulmonary, gastrointestinal, and miscellaneous or unknown sources (more to less common, respectively). Additionally, physicians should remain vigilant throughout the work-up because a notable portion of patients with chest wall tenderness to palpation may also have acute myocardial infarction. After a musculoskeletal or chest wall source is determined, the differential diagnosis includes costochondritis, muscle trauma (including postoperative) or overuse, arthritis, fibromyalgia, neoplasm, infection, herpes zoster, Tietze syndrome, painful xiphoid syndrome, and slipping rib syndrome. The diagnosis of costochondritis is largely based on history and a physical examination that demonstrates reproduction of pain through palpation of the parasternal region of the chest wall, performance of a crowing rooster manoeuvre, and/or a crossed-chest adduction manoeuvre. Although high-quality evidence is lacking, treatment options include local application of heat, oral or topical nonsteroidal anti-inflammatory drugs, lidocaine patches, capsaicin cream, physical therapy, and acupuncture. Most patients will have a complete resolution of symptoms in a few weeks’ time with conservative therapy. Recalcitrant cases may respond to corticosteroid injections.

Definition Of Costochondritis

Costochondritis is a self-limited condition defined as inflammation of costochondral junctions of ribs or chondrosternal joints, usually at multiple levels and lacking swelling or induration. Pain is reproduced by palpation of the affected cartilage segments and may radiate on the chest wall.

It should be differentiated from Teitz syndrome which is an inflammatory process causing visible enlargement of the costochondral junction. It occurs in a single rib 70% of the time, usually within the costal cartilage of the second (predominantly) or third rib. This may be caused by infectious, rheumatological or neoplastic processes. Infection is particularly associated with chest wall trauma, such as in patients with stab wounds, surgical patients and those with a history of intravenous drug use.


Costochondritis can affect children as well as adults. The most common age for costochondritis is middle age (between 40 and 50 years of age) with a slight predominance in women (69%) vs. men (56%). Chest pain in adolescents presenting to an outpatient clinic is most often diagnosed with a musculoskeletal aetiology (31%), with costochondritis being diagnosed 13% of the time.
Costochondritis is a common diagnosis in adults with acute chest pain. It is present in 13 to 36% of these patients, depending on the study and the patient setting. In a prospective study of adult patients presenting to an emergency department with chest pain, 30% had costochondritis.

Signs & Symptoms Of Constochondritis

  • The typical presentation of costochondritis is bilateral parasternal chest wall pain exacerbated by deep breaths, coughing, and stretching.
  • Pain that is reproduced by palpation of the typically affected areas suggests costochondritis but depends on the exclusion of underlying causes. Although pain reproduced by chest wall palpation is considered atypical for a cardiac cause, it does not exclude it.
  • The upper (predominantly second through fifth) costochondral and/or costosternal junctions are most commonly involved
  • The areas of tenderness are not generally accompanied by heat, erythema, or localized swelling.

Tietze syndrome presents similarly to costochondritis but includes visible oedema at the involved joint(s), typically unilateral involving the second rib, and is often incited by infection or trauma.

Pain reproduced by the following manoeuvres has classically proven helpful: direct palpation to the involved costosternal or costochondral junction; the crowing rooster manoeuvre (patient neck extension simultaneously accompanied by the physician placing posterior and superior traction on the patient’s arms from behind and crossed chest adduction of the ipsilateral arm combined with neck rotation toward the ipsilateral shoulder.

Chest wall examination should include palpation with gentle pressure of the anterior, posterior, and lateral thoracic area, noting areas of tenderness. Discrete areas of tenderness can be better localized by palpation with a single digit. Palpation of the cervical spine, clavicle, shoulders, and thoracic and lumbar spine must be included. Movement of the ribcage can be assessed with deep breathing exercises. The effect of upper extremity movement on pain should also be noted because moving the arm on the affected side will usually cause pain. The examination should also include auscultation of the heart and lungs and examination of the skin for herpes zoster rash.


Because the clinical examination lacks specificity, most patients with chest pain still need a thorough evaluation, including electrocardiography at a minimum, to rule out other more serious causes.

In one study, 12% of patients presenting to an emergency department with a chief symptom of chest pain and noted to have chest wall tenderness also had an acute myocardial infarction.

Validated clinical prediction rules have proven useful in assisting with cardiac risk stratification of patients presenting to primary care and the emergency department with chest pain, but they should not completely replace clinical judgment.

There are no laboratory tests, imaging tests, or electrocardiography findings specifically for the diagnosis of costochondritis. If a patient relates a history of dyspnoea or chest wall trauma, a chest radiograph or rib series may be indicated; in adolescent patients with low risk for coronary disease, electrocardiography may be unwarranted. Any diagnostics performed should be directed toward ruling out other possible aetiologies based on each patient’s unique differential diagnosis.

Differential Diagnosis

  • Arthritis of sternoclavicular, sternomanubrial or shoulder joints
  • Destruction of costal cartilage by infections or neoplasm
  • Fibromyalgia
  • Herpes zoster of thorax
  • Painful xiphoid syndrome
  • Slipping rib syndrome
  • Tietze syndrome
  • Traumatic muscle pain and overuse myalgia


No high-quality studies have examined the effectiveness of any treatment options for costochondritis. Most treatment recommendations are conservative in nature and have been traditionally accepted, perhaps because of the self-limited nature of the condition.

Physical Modalities

  • A targeted stretching program under the direction of a physical therapist demonstrated a small reduction in pain among a group of patients who had symptoms for more than one year.
  • Local application of heat is often recommended but lacks evidence from clinical trials. A period of rest from activities that exacerbate pain is often recommended.

Drug Therapy

  • Nonsteroidal anti-inflammatory drugs are the most commonly prescribed medications, although no clinical trials have evaluated their effectiveness. Additionally, higher dosages and frequency of oral nonsteroidal anti-inflammatory drugs may exacerbate gastritis or reflux, further complicating the clinical diagnosis.
  • Capsaicin, diclofenac gel, and lidocaine patches have been recommended primarily based on experience with other inflammatory musculoskeletal conditions.


Acupuncture has been used for treatment, but no randomized, controlled studies for effectiveness are available. Acupuncture is administered at local tender/trigger points on the chest wall and distal traditional acupuncture point locations. A case series published in Sage Journal highlights the fact that acupuncture seems to be a safe and effective treatment for costochondritis, with further research and more access needed for this therapeutic modality.

Injection Treatment For Costochondritis

Local anaesthetic and Steroid injection

Local anaesthetic injection with and without steroids to affected costochondral or sternocostal joints can be effective if patients have not responded to non-invasive treatments. It is not necessary to advance the needle fully into the costochondral joint (to the cartilage only), as infiltration of the tissues over the joint is usually adequate for pain relief. Accuracy of needle placement is enhanced with the use of ultrasound or fluoroscopic guidance, which also significantly reduces the chances of an inadvertent and unpleasant complication of pneumothorax.

PRP treatment for Costochondritis

The use of precise image-guided injections of PRP (Platelet rich plasma) is a novel treatment for Costochondritis. PRP consist of growth factors isolated from your own blood. PRP is a preparation of autologous plasma enriched with a platelet concentration above that normally contained in whole blood. The rationale for the use and therapeutic potential of a high concentration of platelets is based on their capacity to supply supraphysiologic amounts of essential growth factors to provide a regenerative stimulus that promotes repair in tissues with low healing potential. With Costochondritis specifically, aims to reduce inflammation and stabilize the rib connection to the sternum.


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Dr Murli Krishna

Consultant Pain Medicine