Chest Wall Pain: When Pressing on It Recreates the Pain

TL;DR: Costochondritis is inflammation of the cartilage joining your ribs to your breastbone, and it is the most common cause of chest wall pain. The signature finding is that pressing on the sore spot reproduces the pain you came in with, which is something a heart problem rarely does. It usually involves several of the second through fifth rib junctions on one side, it often follows a period of coughing, lifting, or unaccustomed exercise, and it settles over weeks with anti-inflammatory treatment, heat, and modified activity. Here is the part that matters more than any of that: reproducible tenderness lowers the probability of a cardiac cause without eliminating it, and some people having a heart attack do have a tender chest wall. New chest pain deserves evaluation rather than self-diagnosis, particularly over 35 or with any cardiac risk factor. Pain that comes with exertion, breathlessness, sweating, nausea, or radiation to the arm or jaw is an emergency until proven otherwise.

Chest pain occupies a category of its own. A sore knee is annoying, and a sore chest is frightening, because everyone knows what chest pain can mean. So you press on it, and it hurts, and you think that must mean it is muscular. Then an hour later you are not so sure, and you spend the evening taking your own pulse.

I want to give you a clear account of what costochondritis is and how clinicians tell it apart from the things that are dangerous, and I want to be plain about the limits of that reasoning, because chest pain is the wrong place for false confidence in either direction.

Read this part first

Call 911 or go to an emergency department if chest pain comes with any of the following:

• Pressure, tightness, or heaviness in the chest, particularly if it comes on or worsens with exertion and eases with rest.
• Radiation to the arm, shoulder, neck, jaw, or back.
• Shortness of breath, sweating, nausea, or vomiting with the pain.
• Lightheadedness or fainting.
• A racing or irregular heartbeat with the pain.
• Sudden sharp pain with breathlessness, which can indicate a clot in the lung, particularly after surgery, a long flight, or a period of immobility.
• Coughing blood, a high fever, or a leg that is swollen and painful alongside chest pain.

Women, people with diabetes, and older adults have heart attacks that present atypically, often as fatigue, nausea, jaw or back discomfort, or breathlessness rather than crushing chest pain. Nothing in this article is a substitute for being evaluated.

What is costochondritis?

Your ribs do not attach directly to your breastbone. They connect through cartilage, and the junctions where rib meets cartilage meets sternum are called the costochondral joints. Costochondritis is inflammation and pain at those junctions.

The pain is typically sharp, aching, or pressure-like along the edge of the breastbone, and it usually affects more than one junction on the same side, most often somewhere between the second and fifth ribs. It gets worse with deep breathing, coughing, twisting, reaching, or lying on that side, since all of those move the joint. It can be severe enough to frighten people badly, and it can persist for weeks.

It is common. Chest wall pain accounts for something like 20 to 50 percent of visits for chest pain in primary care, and costochondritis specifically makes up roughly 6 to 13 percent of those presentations. It occurs most often in adults between 40 and 50, slightly more in women.

The single most useful examination finding is reproducibility. When a clinician presses on the affected junction and you say "that is it, that is my pain," that is the diagnosis declaring itself. Pain from the heart is generated inside the chest and does not usually change when someone presses on the chest wall from outside.

How do you tell it apart from a heart problem?

Several features point in each direction, and knowing them helps you describe your symptoms accurately, which is the most useful thing you can do for whoever evaluates you.

Costochondritis tends to be positional and mechanical: worse with certain movements, twisting, deep breaths, or pressing on it, and better when you hold still in a comfortable position. The tender spot is findable with a fingertip. The pain often lasts for weeks in a waxing and waning pattern.

Cardiac pain tends to be exertional and systemic: brought on by walking uphill or climbing stairs, relieved by rest within minutes, described as pressure or heaviness rather than a point of soreness, often accompanied by breathlessness, sweating, or nausea, and unchanged by pressing on the chest. It is usually diffuse rather than localized to a fingertip.

Now the caveat that matters more than the comparison. Reproducible chest wall tenderness makes a heart attack less likely rather than impossible, and a meaningful minority of people with confirmed heart attacks do have tenderness when their chest wall is pressed. Anyone over 35, anyone with a history or risk factors for coronary disease, and anyone with cardiopulmonary symptoms should have an electrocardiogram and often a chest x-ray before chest pain is attributed to the chest wall. The reasoning runs in one direction: a tender chest wall supports the diagnosis after dangerous causes have been considered, and it is never the step that lets you skip considering them.

This is why I dislike self-diagnosis here. The examination finding is useful and it belongs inside an evaluation rather than instead of one.

What causes costochondritis?

Often there is a plain mechanical explanation, and finding it helps both with treatment and with confidence in the diagnosis.

A recent illness with a lot of coughing is one of the most common precedents, since repeated forceful coughing works those joints hard for days. New or intensified upper body exercise does the same, particularly pushing movements, rowing, or a return to lifting after time away. Repetitive carrying, overhead work, or moving furniture can start it. So can a direct blow to the chest or a seatbelt impact in a minor collision.

Joint hypermobility raises the odds, because more mobile joints are worked differently and irritate more easily, which is one reason costochondritis shows up frequently in people with hypermobile connective tissue. Prolonged desk posture with rounded shoulders contributes for some people. And sometimes nothing identifiable started it.

What is Tietze syndrome?

Tietze syndrome is a close relative that is worth separating, because the distinction is visible.

In Tietze syndrome there is swelling at the affected junction, usually a single one, most often the second or third, and the area may be warm or reddened. It tends to be acute and affects younger people. Costochondritis, by contrast, involves several junctions, produces tenderness without swelling, and is far more common.

The practical importance is that visible swelling of a rib junction is a finding that deserves examination rather than assumption, since a swollen, warm area on the chest wall has other possible explanations, including infection and, rarely, a tumor.

What else causes chest wall pain?

Before settling on costochondritis, a few other conditions belong in the thinking, and several of them are treatable in very different ways.

• Muscle strain of the intercostal or pectoral muscles produces similar mechanical pain without the joint-line tenderness.
• Rib fracture or stress fracture, particularly after trauma, forceful coughing, or in someone with osteoporosis.
• Shingles can produce burning chest pain in a band on one side for several days before the rash appears, which is a diagnosis frequently missed in that window.
• Pericarditis, inflammation of the sac around the heart, causes sharp pain that worsens lying flat and improves sitting forward, often after a viral illness, and it needs its own evaluation.
• Pleurisy, pneumonia, or a clot in the lung produce pain tied to breathing, usually with breathlessness, cough, or fever.
• Reflux causes burning chest discomfort that can mimic both cardiac and musculoskeletal pain, which we cover in our guide to GERD and gastritis.
• Anxiety and panic produce chest tightness and are frequently blamed prematurely; that diagnosis should follow an evaluation rather than replace one.

How is costochondritis treated?

The good news is that this settles, and the less good news is that it takes longer than people expect, often several weeks and sometimes a few months.

The mainstays are anti-inflammatory treatment and time. Nonsteroidal anti-inflammatory medication such as ibuprofen or naproxen, taken with food and cleared against your other conditions and medications, helps most people. Heat applied to the area relaxes the surrounding muscle and eases the ache. Topical anti-inflammatory gel is a reasonable option for those who should avoid oral versions.

Activity modification means backing away from the movements that reproduce the pain, including heavy pushing or pulling, overhead lifting, and whatever started it, while staying otherwise active. Complete rest is unhelpful and prolongs stiffness. As the pain settles, gentle stretching across the chest and upper back plus attention to posture reduces the pull on those joints, and physical therapy is worthwhile when things linger.

For pain that persists despite conservative management, a local injection into the affected area can help, and it is an option to discuss rather than a first step.

What matters alongside all of this is the reassurance, which is a treatment in its own right here. People with chest wall pain frequently spend weeks bracing for a cardiac event, and the anxiety amplifies the pain and the attention paid to it. Knowing what it is, and knowing what would change the picture, lets people go back to their lives.

In my practice, chest wall pain is a diagnosis I am glad to make and never in a hurry to make. The order matters: rule out what can hurt you, then examine the chest wall, then explain what the tenderness means. Done that way, people leave with an answer they can trust. Done in reverse, you get a patient who was told it was muscular and spends the next month afraid it was not, which is its own kind of harm.

How Fishtown Medicine approaches chest pain

At Fishtown Medicine, chest pain gets evaluated before it gets labeled. That means a history focused on the features that separate cardiac from mechanical causes, a cardiovascular risk assessment, an electrocardiogram where age or risk factors call for it, and consideration of the pulmonary and gastrointestinal causes that can mimic both.

When the picture fits chest wall pain, the examination is where the diagnosis is confirmed: palpating the costochondral junctions to find the tender spots and to reproduce your pain, checking for swelling that would suggest Tietze syndrome or something else, and looking for the mechanical trigger, whether that was a coughing illness, a new lifting routine, or an injury. Because this is direct primary care, there is time to do that carefully rather than to hand over a diagnosis of exclusion at the door.

From there we treat it: anti-inflammatory options matched to your other conditions, heat, sensible activity modification, and physical therapy or injection when it lingers. We also tell you clearly what would warrant coming back or going to an emergency department, because that is what allows someone with chest pain to stop monitoring themselves every hour. If you are in Philadelphia and have chest pain that has not been explained, the fastest way to start is to tell Dr. Ash what it feels like and what makes it worse.

Related at Fishtown Medicine

• GERD and Gastritis - the reflux that mimics both cardiac and chest wall pain
• Anxiety vs Physiology - when chest symptoms get attributed to anxiety too early
• Hypermobility and hEDS Care - why chest wall pain recurs in hypermobile people
• Muscle Twitching - another alarming symptom with a reassuring pattern and clear red flags
• Back Pain and Sciatica - the musculoskeletal workup for pain elsewhere in the trunk
• Same-Day Sick Visits - when something new needs looking at today

Scientific References

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3. Disla E, Rhim HR, Reddy A, Karten I, Taranta A. Costochondritis: a prospective analysis in an emergency department setting. Archives of Internal Medicine. 1994;154(21):2466-2469.
4. Ayloo A, Cvengros T, Marella S. Evaluation and treatment of musculoskeletal chest pain. Primary Care: Clinics in Office Practice. 2013;40(4):863-887.
5. Bösner S, Becker A, Hani MA, et al. Chest wall syndrome in primary care patients with chest pain: presentation, associated features and diagnosis. Family Practice. 2010;27(4):363-369.
6. 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.
7. Fam AG, Smythe HA. Musculoskeletal chest wall pain. Canadian Medical Association Journal. 1985;133(5):379-389.