Costochondritis: Causes, Diagnosis, and When It Is Something Else

Costochondritis is inflammation of the cartilage joining the ribs to the breastbone. It is a diagnosis of exclusion, assigned only after a clinician has ruled out cardiac and other serious causes of chest pain. Once that is done, it presents as sharp or aching pain at the front of the chest, reproduced by pressing on the spot, and in most people it settles on its own over weeks to months.

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, 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
• Lightheadedness, fainting, or a racing or irregular heartbeat
• Pain that comes on with exertion and eases with rest — this pattern needs urgent assessment even when the pain itself is mild

National guidelines treat acute chest pain as a cardiac emergency until testing proves otherwise.¹²

A heart attack does not always cause chest pain. In women, in people with diabetes, and in older adults it can present instead as unusual fatigue, indigestion-like discomfort, breathlessness on its own, or pain felt only in the back, jaw or upper abdomen. 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.¹ 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 evaluated and found not to be cardiac. It is general information, not medical advice, and it is not a substitute for being examined.

What costochondritis actually is

Each upper rib connects to the sternum through a strip of cartilage. Bone meets cartilage at the costochondral junction; cartilage meets the sternum at the chondrosternal joint. Costochondritis is inflammation at those junctions on the anterior chest wall.¹ The pain comes from the joint and cartilage themselves, not the heart, lungs or esophagus behind them — which is why it hurts when the chest wall is loaded rather than tracking with exertion the way angina does.

No single cause has been established, and the condition is often attributed by default to mechanical strain — heavy lifting, a new exercise pattern, repetitive overhead work, severe coughing. Traditional management reflects that assumption, advising avoidance of activities that overload the chest muscles.¹ It is a reasonable model for some patients and a poor one for others, and treating it as the only explanation is how an inflammatory cause goes unfound. The causes worth working through are set out below.

How it presents

The presentation is consistent:

• Pain at the front of the chest, usually to one side of the breastbone. The second through fifth costochondral joints are most often affected, especially the third and fourth, and more than one level is involved in about 90% of patients.¹
• Reproducible tenderness when the affected cartilages are pressed. This is the finding that supports the diagnosis once cardiac causes have been excluded.¹ On its own it excludes nothing.
• Worse with deep breathing, coughing, twisting, lying on that side, or moving that arm.
• No swelling, no redness, no fever, no drainage.

Because the pain is sharp and worsens with breathing, it frequently sends people to an emergency department. That is the correct response the first time; reassurance comes after the evaluation, not before.

What causes it

Costochondritis is frequently labeled idiopathic, and that label is often where the workup stops. It should not be. There are multiple causes, and in our practice the most productive place to look is systemic inflammatory and autoimmune disease.

The published evidence points the same way. In the DESIR cohort of 708 patients with recent inflammatory back pain suggestive of spondyloarthritis, 44.6% reported anterior chest wall pain, and that pain was associated with enthesitis, thoracic spine involvement, radiographic sacroiliitis and a diagnosis of ankylosing spondylitis.¹¹ The spondyloarthritis family — ankylosing spondylitis, psoriatic arthritis, reactive arthritis and the inflammatory-bowel-associated arthritides — has a particular affinity for the entheses and for the cartilaginous joints of the anterior chest wall, which is exactly the tissue involved here. Rheumatoid arthritis and other connective tissue diseases can involve the same joints.

The mechanical and infectious causes are real but narrower: repetitive strain or unaccustomed upper-body exertion, direct trauma to the chest, severe or prolonged coughing, and — uncommonly, and usually in the setting of surgery, injection drug use or immunocompromise — infection of the joint itself.

The practical consequence is what to do when the pain does not behave like a self-limiting strain. Costochondritis that recurs, persists beyond the expected window, involves several joints, or occurs alongside back stiffness, joint pain elsewhere, skin or bowel disease, eye inflammation or a family history of these conditions deserves a systemic evaluation rather than another course of anti-inflammatories. The chest wall pain is sometimes the presenting complaint of a disease that has not yet been named.

How the diagnosis is made

There is no blood test and no imaging finding for ordinary costochondritis. The diagnosis rests on history and examination documenting pain reproduced by palpation over the costal cartilages; in children, adolescents and young adults with no cardiac risk factors, that examination is usually all that is required.¹

The threshold changes with age and risk. Patients older than 35, anyone with a history of or risk factors for coronary artery disease, and any patient with cardiopulmonary symptoms should have an electrocardiogram and possibly a chest radiograph, with further cardiac testing if clinically indicated.¹ Anyone with suspicion of acute coronary syndrome, or with changes on the electrocardiogram, belongs in an emergency department immediately.²

The other half of the diagnosis is knowing how common chest wall pain is once cardiac causes are excluded. In a Swiss primary care study, 672 of 24,620 patients (2.7%) presented with chest pain; chest wall syndrome was the most frequent diagnosis at 43%, ahead of coronary artery disease at 12% and anxiety at 7%, while unstable angina, myocardial infarction and pulmonary embolism together accounted for about 1.8%.³ Costochondritis is one of a family of chest wall pain conditions, and sorting between them happens only after the cardiac question is closed.

Tietze syndrome is a different entity

Tietze syndrome is often used interchangeably with costochondritis. It should not be. It is a benign, self-limiting, non-purulent arthropathy of the sternocostal, sternoclavicular or costochondral joints, and its defining feature is edema — visible or palpable swelling — with pain and tenderness, usually at one joint on one side. Diagnosis uses examination, inflammatory markers and imaging such as ultrasound or MRI, and the differential requires excluding coronary syndrome and inflammatory lung or pleural disease.⁴

The practical difference: costochondritis is tenderness without a lump. A firm, tender swelling over a costal cartilage is a different finding, deserves imaging, and should not be waved off as costochondritis.

The natural history is usually favorable

Costochondritis is usually self-limited and benign.¹ Most people improve over weeks; some take a few months. No reliable figure exists for what proportion resolve by what week; any site giving you one is inventing it. The expected trajectory is gradual improvement; failure to improve is itself clinical information.

Conservative management, and how thin the evidence is

Clinical trials of treatment for costochondritis are essentially absent. Traditional practice is to treat with acetaminophen or anti-inflammatory medication where safe and appropriate, advise avoiding activities that overuse the chest muscles, and provide reassurance.¹ That is convention and physiologic reasoning, not trial data. Reasonable measures include:

• Acetaminophen or a nonsteroidal anti-inflammatory drug, if safe for you — NSAIDs carry real gastrointestinal, kidney and cardiovascular risk and do not suit everyone.¹
• Relative rest from the specific loading that provokes it: pressing, pulling, overhead work, heavy lifting.¹
• Heat or ice, whichever you tolerate — no trial evidence, but unlikely to hurt — plus gentle thoracic and shoulder movement rather than immobility, since prolonged guarding tends to worsen chest wall pain.

For Tietze syndrome specifically, local injection has been reported in very small numbers: nine patients given corticosteroid and local anesthetic, with clinical benefit and reduced cartilage size on ultrasound,⁵ and an older breast-pain series in which the 7 of 10 patients with Tietze syndrome who had failed drug therapy responded to injection around the affected junction.⁶ Nine and ten patients are not a basis for promising anything — only for saying the option exists and has helped some people.

When it does not resolve

Costochondritis that fails to settle is sometimes called atypical costochondritis, and it carries substantial expense and psychological burden as patients cycle through repeat evaluations.⁷ Two things should happen. First, the diagnosis should be revisited rather than repeated, because persistent anterior chest wall pain can reflect something other than simple costochondral inflammation:

• Infectious costochondritis. Uncommon, usually arising when infection spreads from a surgical wound or adjacent focus. It presents with chest pain plus swelling and can progress to skin drainage and sternal osteomyelitis; it needs cross-sectional imaging, antibiotics and often debridement.⁸
• Systemic inflammatory disease. Seronegative arthropathy is listed among the conditions associated with costochondritis,⁴ and a case report describes costochondral inflammation as a presentation of relapsing polychondritis.⁹
• Rib joint mechanics or myofascial pain. One case report described two years of rib pain that resolved after rib manipulation and soft tissue mobilization — a reminder that the generator may be joint movement rather than cartilage.⁷
• Post-viral inflammation. One case report describes severe costochondritis in a child after COVID-19, unresponsive to NSAIDs or steroids and managed with colchicine.¹⁰ One case is a hypothesis, not a protocol.

Second, the cardiac question should be re-asked if anything about the pain has changed. New exertional pattern, new shortness of breath, new radiation — those reopen the workup regardless of a prior costochondritis label. Aortic dissection, pericarditis, pneumonia, heart failure and pulmonary embolism sit in the chest pain differential and are not excluded by an old diagnosis.²

What interventional pain management can and cannot offer

For most people, no procedure is needed. A pain specialist earns a role only when pain persists past the expected window and the cardiac and pulmonary evaluation came back without an answer — and there the work is diagnostic before it is therapeutic: is the generator the costochondral junction, an adjacent rib joint, a myofascial source in the chest wall musculature, or a thoracic nerve? Image guidance matters, because chest wall structures sit close to the pleura and to neurovascular bundles; at Padda Institute, procedures are performed under ultrasound or fluoroscopic guidance for that reason. Which intervention fits, if any, follows from that assessment — review the treatments offered rather than assuming an injection is the answer. Persistent chest wall pain also carries a real anxiety load, and counseling for chronic pain belongs in the plan, not as an afterthought.

What no honest clinic offers is a guaranteed result or a fixed number of injections. If your pain is improving on its own, the correct intervention is usually none.

If you are in the St. Louis area

Padda Institute evaluates persistent chest wall pain in patients whose cardiac workup is complete. Dr. Gurpreet Singh Padda, MD, MBA, MHP practices at 4477 Woodson Rd, Suite 100, St. Louis, MO 63134 and 12174 Natural Bridge Road, Bridgeton, MO 63044 — both on the locations page. Read more about the practice’s approach to pain management in St. Louis, call (314) 481-5000, or request an appointment.

Frequently asked questions

How long does costochondritis last?

Usually weeks to a few months, since the condition is generally self-limited and benign.¹ No reliable figure exists for the percentage resolved by a given week. If yours is not steadily improving, be re-examined rather than wait — contact the office to arrange that.

Can costochondritis be mistaken for a heart attack?

Yes, and the reverse is more dangerous. Chest wall tenderness does not exclude coronary disease: 3% to 6% of adults with chest pain and reproducible tenderness had coronary artery disease, and anyone over 35 or with cardiac risk factors needs an electrocardiogram first.¹ Imaging such as digital X-ray may follow once cardiac causes are addressed.

What is the difference between costochondritis and Tietze syndrome?

Swelling. Tietze syndrome is defined by edema of the affected joint with pain and tenderness, usually at one joint on one side, assessed with ultrasound or MRI; costochondritis gives tenderness without a lump.⁴ Telling them apart is an examination and imaging question, and it is worth settling before treatment — request an evaluation if you have a lump nobody has looked at.

Do steroid injections work for costochondritis?

The evidence is very thin and mostly concerns Tietze syndrome: nine patients in one corticosteroid series⁵ and seven of ten responders in another.⁶ Enough to say the option exists, not that it will help you. See the treatments page for what is actually offered.

Can costochondritis come back?

It can, particularly when the provoking load returns. Traditional advice is to avoid activities that overuse the chest muscles rather than stop moving.¹ Load management and conditioning matter, which is why lifestyle medicine sits alongside procedural care.

Should I worry if my chest pain comes with anxiety?

Anxiety and chest pain overlap constantly — anxiety was the third most common diagnosis in a large primary care chest pain cohort, at 7%.³ That does not mean anxiety explains your pain, and it never substitutes for cardiac evaluation. It does mean both are worth treating; see anxiety, PTSD and chronic pain.

Sources

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2. McConaghy JR, Sharma M, Patel H. Acute chest pain in adults: outpatient evaluation. American Family Physician. 2020;102(12):721-727. PMID 33320506
3. Verdon F, Herzig L, Burnand B, et al. Chest pain in daily practice: occurrence, causes and management. Swiss Medical Weekly. 2008;138(23-24):340-347. PMID 18561039
4. Rokicki W, Rokicki M, Rydel M. What do we know about Tietze’s syndrome? Kardiochirurgia i Torakochirurgia Polska. 2018;15(3):180-182. PMID 30310397
5. Kamel M, Kotob H. Ultrasonographic assessment of local steroid injection in Tietze’s syndrome. British Journal of Rheumatology. 1997;36(5):547-550. PMID 9189056
6. Pye JK, Mansel RE, Hughes LE. Clinical experience of drug treatments for mastalgia. Lancet. 1985;2(8451):373-377. PMID 2862523
7. Barranco-Trabi J, Mank V, Roberts J, Newman DP. Atypical costochondritis: complete resolution of symptoms after rib manipulation and soft tissue mobilization. Cureus. 2021;13(4):e14369. PMID 33976991
8. Fujiu K, Uesugi K, Maruya Y, Kayama S, Suzuki H. Infectious costochondritis with sternal osteomyelitis. Cureus. 2025;17(3):e80132. PMID 40190880
9. van Gaalen FA, Raghoo R, van de Ven GCM. Costochondritis in relapsing polychondritis. EULAR Rheumatology Open. 2025;1(1):4-5. PMID 42367604
10. Collins RA, Ray N, Ratheal K, Colon A. Severe post-COVID-19 costochondritis in children. Proceedings (Baylor University Medical Center). 2021;35(1):56-57. PMID 34966216
11. Wendling D, Prati C, Demattei C, Loeuille D, Richette P, Dougados M. Anterior chest wall pain in recent inflammatory back pain suggestive of spondyloarthritis: data from the DESIR cohort. The Journal of Rheumatology. 2013. PMID 23678156
12. 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