Chest wall pain is pain that comes from the parts of the chest itself, not from the heart. That means the rib cartilage, ribs, joints of the mid-back spine, the nerves between the ribs, and the muscles and tissue between them. It is the most common cause of chest pain seen in clinics. A prospective study followed 672 primary care patients in a row with chest pain. Muscle and bone causes made up 49% of cases, and chest wall syndrome alone 43%. Heart and blood vessel causes made up 16%.1
Before you read further: chest pain can be an emergency
Call 911 or go to an emergency department now if your chest pain is sudden and severe, or feels like pressure, crushing, squeezing or tightness, or comes with any of the following:
- Pain spreading to the arm, jaw, neck, shoulder or back
- Shortness of breath
- Sweating or clammy skin
- Nausea or vomiting
- Feeling lightheaded, fainting, or a racing or uneven heartbeat
- Pain that comes on with effort and eases with rest. This pattern needs urgent care even when the pain itself is mild
National guidelines treat sudden chest pain as a heart emergency until tests prove otherwise.12
A heart attack does not always cause chest pain. In women, in people with diabetes and in older adults, it can show up instead as odd fatigue, discomfort like indigestion, shortness of breath alone, or pain felt only in the back, jaw or upper belly. Do not rule out your heart because the pain is not where you expected it.
How the pain feels cannot settle what is causing it. Chest wall pain is often reproduced by pressing on the chest — but tenderness does not exclude heart disease. Among adults presenting with chest pain who also had chest wall tenderness on examination, 3% to 6% still had coronary artery disease.2 Which side the pain is on does not distinguish the two either.
If you were cleared before, that clearance covered the pain you had then. A normal cardiac workup months ago does not cover a new pain, or a pain that has changed in character, timing or severity. Get a changed pain reassessed.
This article is about chest wall pain in people whose pain has already been checked and found not to be from the heart. It is general information, not medical advice, and it does not replace being examined.
What “chest wall pain” actually means
“Chest wall syndrome” is an umbrella term, not one diagnosis. The American College of Radiology uses it to group the many problems that cause muscle and bone pain in any part of the chest wall.3 That vagueness hurts patients, because “it’s just your chest wall” is often where the workup stops, and the part causing the pain never gets named. Naming it is what makes treatment possible.
Chest pain makes up about 1% of primary care visits. Of those patients, 2% to 4% have unstable angina or a heart attack (myocardial infarction). Reflux, pericarditis, pneumonia, a blood clot in the lung (pulmonary embolism) and a tear in the aorta (aortic dissection) must also be ruled out before the search narrows to the chest wall.10 What follows is what is left after those are ruled out. Most of it is settled by history and exam, not imaging.11
How the diagnosis is narrowed on history and examination
Three questions do most of the sorting. A clinician works through them during an exam, after heart and lung causes have been ruled out. They are not a checklist for deciding on your own that pain is harmless.
Where is the pain, and how big is it?
Pain a patient can cover with one fingertip points to one small part: where a rib meets its cartilage, a rib joint at the spine, or a rib. Pain described as a band running from the spine around toward the breastbone follows a nerve between the ribs. That suggests a nerve source. A broad ache across the mid-back that spreads to the front suggests a mid-back facet joint or spine segment.
What reproduces it?
If pressing on one rib cartilage brings back the exact pain, that suggests costochondritis. Pain brought on by twisting and leaning back, and worse with long sitting, suggests a mid-back facet joint. Pain brought on by deep breaths or coughing suggests the ribs, the lung lining or the nerves between the ribs. Pain brought on by a hooking test suggests slipping rib syndrome. In that test, the examiner hooks fingers under the lower rib edge and pulls forward.4
What has it done over time?
Pain that began after a fall, a coughing illness, a new exercise routine or chest surgery has a mechanical or surgical cause until proven otherwise. Pain that began with a rash has a viral cause. In an older adult, pain that began suddenly after a small strain or no injury at all, worse standing and better lying flat, raises the question of a spine compression fracture.
The musculoskeletal causes
Costochondritis and costosternal syndrome
This is inflammation or irritation where the ribs meet their cartilage or the breastbone. The key finding is tenderness when those joints are pressed, bringing back the pain. It is usually at more than one level and most often on one side.2 It usually goes away on its own. It matters mostly for diagnosis. It is so common that it gets used as a default label, so truly different problems get filed under it.
Full article: costochondritis explained, including the inflammation and immune causes that are often missed.
Slipping rib syndrome
The 8th, 9th and 10th ribs attach to each other by tough tissue, not directly to the breastbone. When that attachment gets loose, the rib tip can slip and pinch the nerve beneath it. That causes sharp pain in the lower chest or upper belly, sometimes with a click you can feel.4 This is diagnosed by exam. In a surgical series of 19 adults, the hooking test was positive in every case. Ultrasound pointed to the diagnosis in one.5 It is often missed for years, and patients collect normal scans first.4
Full article: slipping rib syndrome, including why it is so often missed for years.
Thoracic facet-mediated pain
The paired facet joints of the mid-back spine can send pain out to the side and front of the chest. That is why patients call it chest pain, not back pain. An exam and imaging can’t make this diagnosis on their own. Controlled diagnostic blocks, done twice and compared, are the gold standard. In the studies reviewed in the 2020 ASIPP guidelines, mid-back facet joint pain was found in 34% to 48% of patients. A single block gave false positives 42% to 58% of the time.6 That is why one positive block is weak proof, and a second, confirming block matters. See facet joint injection and facet joint radiofrequency ablation.
Rib fracture and thoracic vertebral compression fracture
Rib stress fractures follow repeated strain, like rowing, throwing or long bouts of coughing. They cause sharp tenderness in one spot that pressing brings back every time.11 In older adults with thin bones, mid-back spine compression fractures are also a known non-heart cause of chest pain. They can be felt across the front of the body, not as back pain.7 When a painful fracture does not settle with time and bracing, vertebroplasty and kyphoplasty are the bone cement options.
The neuropathic causes
Thoracic radiculopathy
A pinched or irritated nerve root in the mid-back causes pain in a band running from the spine around the body. It is far less common than nerve root pain in the neck or low back. It is often mistaken for heart, lung lining or belly pain, because the band ends in front. Numbness, odd feeling, or pain from light touch along the same band sets it apart from pure muscle and bone pain. Epidural steroid injection is one treatment used for inflamed nerve root pain.
Full article: thoracic radiculopathy and intercostal neuralgia.
Intercostal neuralgia
This is pain made in the nerve between the ribs itself, not at the root. It can come from a rib fracture, a slipping rib, surgical injury, a scar or tissue trapping the nerve. It feels burning, electric or stabbing. It follows one or two rib spaces and often has a tender spot along the nerve’s path.
Post-herpetic neuralgia in a thoracic dermatome
Shingles most often hits the mid-back bands of skin. In one series of 164 patients, those bands were involved in 45% of cases, more than any other area.8 Sometimes burning, itching or touchy pain lasts in that band after the rash heals. Then the diagnosis is post-herpetic neuralgia, not chest wall pain. A history of a rash in the same band is the whole diagnosis. See post-herpetic neuralgia after the shingles rash heals.
Post-thoracotomy and post-surgical chest wall pain
Lasting pain after chest surgery is common, not rare. Chronic pain affects about 25% to 60% of patients, and injury to the nerves between the ribs seems to be the main cause.9 The same logic applies to a breastbone surgery cut, a chest tube site or a mastectomy scar. These are nerve injuries with a known cause and a known path. That makes them among the easier problems to treat here.
What honest treatment looks like
Treatment follows the structure, not the label. Costochondritis that will go away on its own needs an accurate diagnosis, a change in activity and time. Facet joint pain needs the diagnosis confirmed by a block before anything is ablated. Nerve pain responds to nerve pain drugs, not anti-inflammatories. Muscle knots may respond to trigger point injections. When one nerve is suspected as the source, a test block of that nerve is the usual way to check. If numbing the nerve does not change the pain, the nerve was not the source.
Two honest limits. No procedure here is a cure, and none has a guaranteed result. A test block that does not ease pain is useful information, not a failure. And opioids are a poor answer to chronic chest wall pain. The work is to find and treat the source, and to lower the opioid load in patients who arrive already taking them. The full list of pain treatments sets out what each procedure does and does not do.
When the diagnosis stays unclear
Some chest wall pain never turns into a named structure. The right response is to say so. Keep the heart and lung question open and check it again from time to time, instead of closing it for good. And treat function instead of chasing a label. Chest pain that changes, gets worse or picks up any emergency feature listed above needs urgent rechecking, no matter how many past workups were normal.
Getting evaluated in St. Louis
Padda Institute, Center for Interventional Pain Management, evaluates cardiac-cleared chest wall and thoracic pain at 4477 Woodson Rd, Suite 100, St. Louis, MO 63134 and 12174 Natural Bridge Rd, St. Louis, MO 63044, where Dr. Gurpreet Singh Padda, MD, MBA, MHP practices. See locations, request an appointment, or contact us at (314) 481-5000.
Frequently asked questions
If pressing on my chest reproduces the pain, does that mean it is not my heart?
No. It makes a chest wall source more likely. But heart artery disease is still present in about 3% to 6% of adults who have both chest pain and chest wall tenderness.2 Heart testing comes first. Once you have been cleared, the pain treatments page outlines the options.
How long does costochondritis last?
It usually goes away on its own, though it can last for weeks to months and can come back. If it lasts longer than that, or the pain is sharp in one spot at the lower ribs instead of the rib cartilage, rethink the label. Don’t just repeat the same treatment. A named structure is what the pain treatments aim at.
Do I need an MRI or CT for chest wall pain?
Often not. Most of these diagnoses are made by history and exam.11 Slipping rib syndrome in particular often can’t be seen on standard imaging.5 The suspected structure decides the imaging, for example, confirming a spine fracture before considering kyphoplasty.
Why does my mid-back pain show up as chest pain?
Mid-back facet joints and mid-back nerve roots both send pain forward around the body. So a spine source is felt in front. Proving a facet source takes controlled diagnostic blocks, done twice and compared, not imaging. That is because single blocks in the mid-back give false positives often.6 See facet joint injection.
My shingles rash healed months ago but the burning band is still there. What is that?
That is post-herpetic neuralgia. It is nerve damage the virus left behind, not an ongoing infection or chest wall inflammation. It is treated as nerve pain. See post-herpetic neuralgia after the shingles rash heals.
I had chest surgery a year ago and it still hurts along the incision. Is that normal?
It is common. Lasting pain affects about 25% to 60% of patients after chest surgery, usually from injury to the nerves between the ribs.9 Common does not mean untreatable. The injured nerve has a known location and a known path. That makes this one of the easier causes on this list to treat. It is worth having it checked instead of living with it. The pain treatments page describes the general approaches to nerve pain.
Sources
- Verdon F, Herzig L, Burnand B, et al. Chest pain in daily practice: occurrence, causes and management. Swiss Med Wkly. 2008. PMID 18561039
- Proulx AM, Zryd TW. Costochondritis: diagnosis and treatment. Am Fam Physician. 2009. PMID 19817327
- Stowell JT, Walker CM, Chung JH, et al. ACR Appropriateness Criteria: Nontraumatic Chest Wall Pain. J Am Coll Radiol. 2021. PMID 34794596
- Turcios NL. Slipping Rib Syndrome: An elusive diagnosis. Paediatr Respir Rev. 2016. PMID 27245407
- Mazzella A, Fournel L, Bobbio A, et al. Costal cartilage resection for the treatment of slipping rib syndrome (Cyriax syndrome) in adults. J Thorac Dis. 2020. PMID 32055418
- Manchikanti L, Kaye AD, Soin A, et al. Comprehensive Evidence-Based Guidelines for Facet Joint Interventions in the Management of Chronic Spinal Pain: ASIPP Guidelines. Pain Physician. 2020. PMID 32503359
- Bader AS, Rubinowitz AN, Gange CP, Bader EM, Cortopassi IO. Imaging in the Evaluation of Chest Pain in the Primary Care Setting, Part 2: Sources of Noncardiac Chest Pain. Am J Med. 2020. PMID 32442508
- Goh CL, Khoo L. A retrospective study of the clinical presentation and outcome of herpes zoster in a tertiary dermatology outpatient referral clinic. Int J Dermatol. 1997. PMID 9352407
- Wildgaard K, Ravn J, Kehlet H. Chronic post-thoracotomy pain: a critical review of pathogenic mechanisms and strategies for prevention. Eur J Cardiothorac Surg. 2009. PMID 19307137
- McConaghy JR, Sharma M, Patel H. Acute Chest Pain in Adults: Outpatient Evaluation. Am Fam Physician. 2020. PMID 33320506
- Ayloo A, Cvengros T, Marella S. Evaluation and treatment of musculoskeletal chest pain. Prim Care. 2013. PMID 24209723
- Gulati M, Levy PD, Mukherjee D, et al. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of chest pain. Circulation. 2021;144(22):e368-e454. PMID 34709879
Dr. Gurpreet Singh Padda, MD, MBA, MHP
