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. A doctor gives it only after ruling out heart and other serious causes of chest pain. Once that is done, it shows up as sharp or aching pain at the front of the chest. Pressing on the spot brings it on. 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, or feels like pressure, crushing, squeezing or tightness. Also go if it 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 effort and eases with rest. This pattern needs urgent checking even when the pain itself is mild

National guidelines treat sudden chest pain as a heart emergency until testing proves otherwise.¹²

A heart attack does not always cause chest pain. In women, people with diabetes, and older adults, it can show up as unusual tiredness or discomfort like indigestion. It can show up as 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 often comes on when the chest is pressed. But tenderness does not rule out heart disease. Among adults with chest pain who were also tender on exam, 3% to 6% still had coronary artery disease.¹ Which side the pain is on does not tell the two apart either.

If you were cleared before, that clearance covered the pain you had then. A normal heart workup months ago does not cover a new pain. Nor does it cover a pain that has changed in feel, timing or severity. Get a changed pain checked again.

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. It does not replace being examined.

What costochondritis actually is

Each upper rib connects to the breastbone through a strip of cartilage. Bone meets cartilage at the costochondral junction. Cartilage meets the breastbone at the chondrosternal joint. Costochondritis is inflammation at those junctions on the front of the chest wall.¹ The pain comes from the joint and cartilage themselves. It does not come from the heart, lungs or food pipe behind them. That is why it hurts when the chest wall is loaded, not with effort the way angina does.

No single cause has been proven. The condition is often blamed by default on strain, like heavy lifting, a new workout, repeated overhead work, or bad coughing. Standard care reflects that belief and advises avoiding things that overload the chest muscles.¹ It is a fair model for some patients and a poor one for others. Treating it as the only explanation is how an inflammatory cause goes unfound. The causes worth working through are laid out below.

How it presents

The pattern is consistent:

• Pain at the front of the chest, usually to one side of the breastbone. The second through fifth rib joints are most often affected, especially the third and fourth. More than one level is involved in about 90% of patients.¹
• Tenderness you can bring on by pressing the affected cartilage. This finding supports the diagnosis once heart causes have been ruled out.¹ On its own it rules out nothing.
• Worse with deep breaths, coughing, twisting, lying on that side, or moving that arm.
• No swelling, no redness, no fever, no drainage.

The pain is sharp and gets worse with breathing, so it often sends people to an emergency department. That is the right response the first time. Reassurance comes after the evaluation, not before.

What causes it

Costochondritis is often labeled idiopathic, meaning no known cause. That label is often where the workup stops. It should not be. There are several causes. In our practice, the most useful place to look is body-wide inflammatory and autoimmune disease.

The published evidence points the same way. The DESIR study followed 708 patients with recent inflammatory back pain that suggested spondyloarthritis. Of them, 44.6% reported anterior chest wall pain. That pain was linked to inflamed tendon attachments, mid-back involvement, sacroiliitis on X-ray and a diagnosis of ankylosing spondylitis.¹¹ The spondyloarthritis family includes ankylosing spondylitis, psoriatic arthritis, reactive arthritis and the arthritis tied to inflammatory bowel disease. These diseases favor the spots where tendons attach to bone, and the cartilage joints of the front chest wall. That 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. They include repeated strain or unusual upper-body effort, a direct blow to the chest, and bad or long-lasting coughing. Rarely, the joint itself gets infected. That usually happens after surgery, with injection drug use, or with a weak immune system.

The practical point is what to do when the pain does not act like a strain that clears up. Some costochondritis keeps coming back, lasts past the expected window, or involves several joints. Or it comes with back stiffness, joint pain elsewhere, skin or bowel disease, eye inflammation, or a family history of these. That deserves a body-wide evaluation, not another round of anti-inflammatories. Sometimes the chest wall pain is the first sign 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 exam showing pain brought on by pressing over the rib cartilage. In children, teens and young adults with no heart risk factors, that exam is usually all that is needed.¹

The bar changes with age and risk. Some patients should have an electrocardiogram and maybe a chest X-ray, with more heart testing if needed. These include patients older than 35, anyone with heart disease or its risk factors, and anyone with heart or lung symptoms.¹ Anyone who might be having acute coronary syndrome (a heart attack or a near-heart attack), or whose electrocardiogram shows changes, belongs in an emergency department right away.²

The other half of the diagnosis is knowing how common chest wall pain is once heart causes are ruled out. In a Swiss primary care study, 672 of 24,620 patients (2.7%) came in with chest pain. Chest wall pain was the most common diagnosis at 43%. Coronary artery disease came in at 12% and anxiety at 7%. Unstable angina, heart attack and blood clot in the lung together made up about 1.8%.³ Costochondritis is one of a family of chest wall pain conditions. Sorting them out happens only after the heart question is closed.

Tietze syndrome is a different entity

Tietze syndrome is often used as if it meant the same as costochondritis. It does not. It is a harmless joint problem that clears up on its own and does not form pus. It affects the joints where the ribs or collarbone meet the breastbone, or where rib meets cartilage. Its key feature is edema — swelling you can see or feel — with pain and tenderness, usually at one joint on one side. Diagnosis uses the exam, blood markers of inflammation, and imaging such as ultrasound or MRI. Coronary syndrome (a heart attack or a near-heart attack) and inflammatory lung or lining disease must be ruled out.⁴

The practical difference: costochondritis is tenderness without a lump. A firm, tender swelling over a rib cartilage is a different finding. It needs imaging and should not be brushed off as costochondritis.

The natural history is usually favorable

Costochondritis usually clears up on its own and is harmless.¹ Most people improve over weeks. Some take a few months. No reliable figure exists for what share clear up by what week. Any site that gives you one is making it up. The expected course is slow improvement. Failure to improve is itself useful information.

Conservative management, and how thin the evidence is

Trials of treatment for costochondritis are basically absent. Standard practice is acetaminophen or anti-inflammatory medicine when safe and fitting, advice to avoid overusing the chest muscles, and reassurance.¹ That is habit and body logic, not trial data. Reasonable steps include:

• Acetaminophen or a nonsteroidal anti-inflammatory drug, if safe for you. NSAIDs carry real stomach, kidney and heart risks and do not suit everyone.¹
• Rest from the specific loads that bring it on: pressing, pulling, overhead work, heavy lifting.¹
• Heat or ice, whichever you tolerate. There is no trial evidence, but it is unlikely to hurt. Add gentle mid-back and shoulder movement instead of holding still, since long guarding tends to make chest wall pain worse.

For Tietze syndrome, local injection has been reported in very small numbers. Nine patients got a steroid and numbing drug, with benefit and smaller cartilage on ultrasound.⁵ An older breast-pain series looked at patients with Tietze syndrome who had failed drug therapy. Of them, 7 of 10 responded to injection around the affected joint.⁶ Nine and ten patients are no basis for promising anything. They only show the option exists and has helped some people.

When it does not resolve

Costochondritis that does not settle is sometimes called atypical costochondritis. It brings real cost and mental strain as patients cycle through repeat workups.⁷ Two things should happen. First, the diagnosis should be rethought, not repeated. Lasting front chest wall pain can come from something other than simple rib cartilage inflammation:

• Infectious costochondritis. Uncommon. It usually starts when infection spreads from a surgical wound or a nearby source. It brings chest pain plus swelling. It can progress to drainage through the skin and bone infection of the breastbone. It needs cross-section imaging, antibiotics and often debridement (surgery to clean out the infected tissue).⁸
• Systemic inflammatory disease. Seronegative arthritis is listed among the conditions linked to costochondritis.⁴ A case report describes rib cartilage inflammation as the first sign of relapsing polychondritis.⁹
• Rib joint mechanics or myofascial pain. One case report described two years of rib pain that went away after rib manipulation and soft tissue work. It is a reminder that the source may be joint movement, not cartilage.⁷
• Post-viral inflammation. One case report describes severe costochondritis in a child after COVID-19. It did not respond to NSAIDs or steroids and was managed with colchicine.¹⁰ One case is a theory, not a protocol.

Second, the heart question should be asked again if anything about the pain has changed. A new link to effort, new shortness of breath, or pain spreading somewhere new reopens the workup, no matter what the old label says. Aortic dissection, pericarditis, pneumonia, heart failure and blood clot in the lung all belong on the list of chest pain causes. An old diagnosis does not rule them out.²

What interventional pain management can and cannot offer

For most people, no procedure is needed. A pain specialist has a role only when pain lasts past the expected window and the heart and lung workup found no answer. Even then, the work is diagnosis before treatment. Is the source the rib cartilage joint, a nearby rib joint, a muscle source in the chest wall, or a thoracic nerve (a nerve that runs from the mid-back around the chest)? Image guidance matters, because chest wall structures sit close to the lung lining and to nerves and vessels. At Padda Institute, procedures are done under ultrasound or fluoroscopic guidance for that reason. Which treatment fits, if any, follows from that assessment. Review the treatments offered instead of assuming an injection is the answer. Lasting chest wall pain also carries a real anxiety load. Counseling for chronic pain belongs in the plan, not as an afterthought.

No honest clinic offers a guaranteed result or a fixed number of injections. If your pain is getting better on its own, the right treatment is usually none.

If you are in the St. Louis area

Padda Institute evaluates lasting chest wall pain in patients whose heart 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 Rd, St. Louis, MO 63044. Both are 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 usually clears up on its own and is harmless.¹ No reliable figure exists for the share that clears up by a given week. If yours is not steadily getting better, get re-examined instead of waiting. 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 rule out heart disease. Of adults with chest pain and tenderness on pressing, 3% to 6% had coronary artery disease. Anyone over 35 or with heart risk factors needs an electrocardiogram first.¹ Imaging such as a digital X-ray may follow once heart causes are addressed.

What is the difference between costochondritis and Tietze syndrome?

Swelling. Tietze syndrome is defined by swelling of the affected joint with pain and tenderness, usually at one joint on one side. It is checked with ultrasound or MRI. Costochondritis gives tenderness without a lump.⁴ Telling them apart is a question for the exam and imaging. 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 about Tietze syndrome. One steroid series had nine patients.⁵ Another had seven of ten respond.⁶ That is 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, mostly when the load that set it off returns. Standard advice is to avoid overusing the chest muscles, not to stop moving.¹ Load management and conditioning matter. That is why lifestyle medicine sits alongside procedure care.

Should I worry if my chest pain comes with anxiety?

Anxiety and chest pain overlap all the time. In a large primary care chest pain study, anxiety was the third most common diagnosis, at 7%.³ That does not mean anxiety explains your pain. And it never replaces a heart evaluation. But 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