Costochondritis is inflammation of your costal cartilage. The costal cartilage is an elastic bridge that connects your ribs to your breastbone. These joints move when you breathe, and costochondritis symptoms give new and painful meaning to the Police lyrics “every breath you take.” The sides of your breastbone become painful when you move, and even breathing causes sharp chest pain. A vital component of the diagnosis is first to exclude any heart or lung pathology as the cause of your chest pain. The “wait-and-rest” approach is frustrating at best, while our costochondritis treatment program is an option for quicker recovery. Costochondritis is confused with Tietze’s syndrome, which is a more severe form of the same problem.

What is the difference between Costochondritis and Tietze syndrome?

Costochondritis is inflammation of any or all of the ribs’s costal cartilage attachments on your sternum, on one or both sides. This abnormal inflammation causes the symptoms and is warmer during a physical evaluation, but there’s rarely any swelling visible.

Tietze syndrome affects mainly the 3rd, 4th & 5th costal cartilage of only one side and is diagnosed when swelling is visible. Sharp chest wall pain is the main problem with Tietze syndrome. They may also have an elevated ESR rate with blood tests, indicating that a medical condition is causing excessive abnormal inflammation. This is merely a symptom of a more profound underlying, primarily undetected,  systemic condition.

The Anatomy of your Ribcage

Your thoracic cavity includes the thoracic spine and ribcage as the “hard frame” and connects your neck, shoulder girdle, and lower back. Even though most modern lifestyles contribute to rigidity and stiffness of the upper back, because of how we work, travel, and relax, the thorax has 150 articulations or joints that need to move in harmony. This includes the thoracic facet joints, costotransverse, costovertebral, and costochondral joints. Normal breathing requires these joints to move 3 million times per day. Understandably, the slightest defect can quickly escalate.

The costochondral joints are the connection of your ribs onto your breast bone. There is a cartilage extension, almost like a small bridge, of all your ribs where they travel from your thoracic spine at the back to the front. You have 12 pairs of ribs, 24 in total. Your ribs are divided into different teams depending on the type of connection to your breastbone. The true ribs, ribs 1 – 7, are connected directly via their own cartilage to your breastbone, while the false ribs, ribs 8 – 10, have cartilaginous connections that merge together and then connect to your breastbone. Finally, you have two floating ribs, ribs 11 & 12, that don’t connect to your breast bone at all.

What do costochondral joints do?

Normal breathing produce very little movement of your ribcage, it’s so subtle it happens unnoticed. It’s similar to the small amount of swaying that occurs when you balance, you only notice these movements when you close your eyes. Even as you sit and read this article your breathing is moving your ribcage, expanding and collapsing.

Your costochondral joints are responsible for a tiny rotation as you breathe in and out. These tiny movements from each joint add up to allow volume changes like yawning or taking a deep breath in, allows your chest to expand. When there is inflammation in any or all of these joints it causes pain with every movement, that is every breath you take.

Bigger movements of the ribcage happen when you cough or do forced breathing techniques, like the Wim Hof method. Normal, resting breathing is almost exclusively done by your diaphragm. Forced inhales and exhales recruits your intercostal muscles, between your ribs. During a cough, sneeze or forced exhale your diaphragm relaxes, while your internal intercostals contract and bring your ribs closer together. The volume of your chest cavity decreases rapidly which in turn increases the pressure and air is forced outwards.

Your ribcage protects your vital organs, the heart and lungs, and also the trachea and spinal cord as it descends down your back.

Why is my costochondritis so sore?

Inflammation is your body’s ambulance. It gets what is needed for healing at the site of the injury to kick-start your recovery. That is why taking anti-inflammatory medication within the first 48 hours of injury is not recommended. When the inflammation cycle gets out of control it can wreak havoc, as we are familiar with the cytokine storm described during the Covid pandemic.

Overuse or doing something new that you are not used to, like overhead training, climbing, hanging curtains or lifting an ever-growing child causes more movement of the costochondral joints than normal. Chest infections and coughing or being confined to bed because of illness or surgery can have the same effect. Excessive, unaccustomed movement causes inflammation. If not treated, or rested and then resuming the same activity, the cycle can continue. This leads to pain whenever the costochondral joints do their small rotary movement and pain with breathing, coughing or shoulder and upper back movement.

Blood tests will show elevated CPR, ESR or WBC counts. Active infection can elevate these counts too, however blood tests are not needed to confirm the diagnosis of costochondritis.

Causes of Costochondritis

  • Excessive coughing from a chest infection, like pneumonia, bronchitis or croup.
  • Sternotomy during surgical intervention, like open heart surgery.
  • Limited thoracic mobility, because of bad posture, working or driving hunched forward.
  • Rigidity in older people.
  • Limited shoulder movement and stiffness.
  • Heavy breasts and the unsupportive underwear.
  • Front body training that only focuses on biceps, pecs and deltoids.
  • Autoimmune disease, like Ankylosing Spondylitis.
  • New movements, from hobbies or training, or caring for a newborn.

All of these positions limit your costochondral joint range of motion. When you need to use that range you do not have access to it. Pushing the joint into these outer boundaries of rib motion, triggers the inflammatory response.

Symptoms of Costochondritis

Tests that you can do to see if you have costochondritis

  • Sit comfortably on a chair or bed, with your feet supported on the floor and back free to move.
  • Turn your upper body to one side as far as you can go.
  • Take five deep breaths.
  • Repeat this movement to the other side.
  • Pain over the side of your breastbone increases with this test, which may indicate that you have costochondritis.
  • The test is positive if your chest or rib pain symptoms worsen.
  • Cough 5 times.
  • If coughing, sneezing, or laughing increases the pain in your breastbone, you may have costochondritis.
  • These actions increase the pressure in your thoracic cavity and move the rib articulation with your breastbone.
  • The test is positive if your chest or rib pain symptoms worsen.
  • If lying on your affected side increases your symptoms, you may have costochondritis.
  • The test is positive if your chest or rib pain symptoms worsen.
  • Stand in a doorframe with the unaffected arm open at a 90/90 angle (elbow in line with shoulder open to the side).
  • Rest your forearm on the doorframe and take a small step forward to stretch your pectoralis muscle.
  • Take your other hand to touch the costovertebral joints where the ribs articulate with your breastbone.
  • Tenderness with gentle palpation can be an indication of costochondritis.
  • The test is positive if your chest or rib pain symptoms worsen.

How severe is my costochondritis?

Costochondritis varies in intensity, from intermittent symptoms only after use to severe, constant pain with small movements or deep breathing. Initially, your symptoms may not stop you from exercising, training, or lifting, but once stuck in a cycle of inflammation, your symptoms can get more intense and more frequent.

Symptoms starting the middle of your breastbone and can radiate to your shoulder and around the ribcage. Bruising is rarely a symptom, while visible swelling and redness indicate a more severe, chronic type of pathology known as Tietze’s syndrome. Due to the intensity of the pain, you may find restricting your shoulder movements to protect the costochondral joints and avoid chest pain. Still, the longer you follow this strategy, the more likely you will lose shoulder and upper back flexibility in the long run.

Diagnosis of Costochondritis

Physiotherapy diagnosis

Physiotherapists are uniquely qualified to diagnose and treat costochondritis because of our anatomy, biomechanics, and pulmonology training. We understand how breathing translates into ribcage movement and how shoulder range of motion and muscle endurance influence your thoracic spine and ribcage. Everything is connected, and we have the experience to identify your problem and what contributes to it and give you guidance and treatment to relieve your rib pain symptoms.

Our practitioners test not only chest motion but each rib’s movement. Breaking down the components one by one establishes the problem’s true origin. No laboratory evaluation is necessarily required to diagnose costochondritis. Using the laboratory evaluation for other diagnoses in your differential is essential.


X-rays will show the integrity and alignment of your ribcage and rule out certain pulmonary pathologies, like pneumothorax and abscesses. Rib fractures can be ruled out as the cause of your symptoms with an X-ray too.

Your physiotherapist can refer you to get x-rays taken if necessary.


An electrocardiogram should be done routinely for anyone above 35 years of age or with a family history of coronary artery disease to check the rhythm and electrical activity of the heart muscle. Once the heart and lungs are excluded as the cause of your symptoms, costochondritis is diagnosed.


Computerized Tomography is more sensitive to diagnosing underlying pathology that contributes to chest pain from the skeletal frame. If your physiotherapist suspects anything more than inflammation of the costal joints, you will be referred to the right specialist.

Why is the pain not going away?

You become stuck in a rib inflammation and pain cycle, not trusting your body to move. Make sure you are getting the right advice and treatment from the start. Without intervention, you risk losing range of motion, muscle strength, and endurance. No problem goes away by ignoring it.

If you don’t understand what you’re dealing with, you might miss far more dangerous underlying conditions than rib inflammation. Because you’re here, reading this article is one step closer to understanding the next step.

What NOT to do

  • Do not ignore chest pain that gets worse (it could be a sign of a serious problem)

  • Sporadic use of anti-inflammatory medication

  • Manage your pain by only taking medication or muscle relaxants.

  • Stretch through the pain

  • Train through the pain

  • Leave it untreated, if you are uncertain of the diagnosis, rather call us and be safe

What you SHOULD do

  • Rest as needed.

  • Avoid activities that are flaring up your pain, like deep breathing practices, overhead lifting, and end-range backbends.

  • Make a list of movements or activities that bring on your pain and rank them.

  • Make an appointment to confirm the diagnosis and start your recovery.

  • Finish your treatment program for better long-term results.

Making chostochondritis worse

  • Sleeping on your side

  • Overhead activities, like hanging laundry, blow drying your hair, or reaching for something on a high shelf

  • Picking up heavy loads, like groceries bags, full kettles, weights or a child

  • High intensity cardiovascular exercise forcing you to breathe deeply

  • Driving long distances

  • Working at your computer for long periods at a time

  • Coughing, stay away from smokers and fires that can cause a coughing attack

  • End range stretches with overpressure

  • Bench press

Problems we see when patients come to us with costochondritis

We strive to empower you. Most people come and see us because the “wait and see” approach didn’t work. Waiting too long puts you at risk of developing protective strategies that limit you. The longer you don’t use it, the harder it is to get back. Lost upper back and shoulder range of motion is a big problem we must deal with.

Prolonged use of medication, even if it is available over the counter, can cause side effects. Acid reflux and digestive discomfort caused by anti-inflammatories are a big problem. Medication use also has the risk that it allows you to continue doing aggravating activities because you are masking the symptoms.

Physiotherapy facilitates healing but doesn’t half your recovery time. Think of us as guides, not magicians. Your recovery needs commitment and perseverance. The big problem is that patients think their bodies are similar to their cars; getting it “serviced” should take the symptoms away immediately and forever. This is not how it works. Multiple small components need fixing, from joint motion to muscle adaption and larger muscle shortening. During each session, we merely nudge the tissue in the right direction.

Physiotherapy Costochondritis Treatment

Our physiotherapists have years of experience in diagnosing musculoskeletal injuries. Your physio will take a history and clinical assessment to determine if you have costochondritis. They will guide you through your recovery by implementing the correct treatment techniques and home programs to make your recovery as comfortable as possible.

The treatment for costochondritis is simple and easy, but if it’s allied too late, the gains may be much slower, as much of the treatment time is spent on returning the accommodation to normal. However, the primary focus is first to rule out other lung, heart, and chest pathologies.

Phases of rehabilitation for costochondritis treatment

Physiotherapists are uniquely qualified to identify and treat costochondritis, because of our background in pulmonary rehabilitation. We can auscultate your lungs to determine if you have adequate air entry throughout both lungs and all lobes to prevent complications like atelectasis. Your lung function can be assessed and treated by incorporating breathing and chest expansion exercises into your rehabilitation program from the start. We will assess rib, chest and thoracic mobility, muscle strength and endurance of your shoulder girdle and core stabilisers. Your recovery will be guided and progressed to get you back to what you love doing.

1st Phase of Costochondritis Treatment: Symptom relief (weeks 0 – 3)

Our first aim is to get the proper diagnosis and identify and prioritize any contributing factors to your unique problem. Now, we can guide you in avoiding any aggravating activities for the time being and managing your symptoms. This includes a list of things that are safe to do and some that are not.

We will use different techniques during your costochondritis treatment, like electrotherapy, joint mobilisations, strapping and breathing control exercises.

To progress to the next phase of your costochondritis treatment, you should be able to take moderate deep breaths in different positions with minimal pain.

2nd Phase of Costochondritis Treatment: Shoulder and T-spine integration (weeks 4 – 6)

During this phase of your costochondritis treatment, we expect the inflammation to have settled and the pain to be under control. We can now incorporate deeper mobilizations and focused exercises on integrating shoulder and upper back movement. Range of motion, shoulder strength, endurance, and core control exercises will now form part of your costochondritis treatment.

You should be able to take full, deep breaths and cough without any symptoms before moving on to the next phase.

3rd Phase of Costochondritis Treatment: Cardio drills (weeks 6 -7)

Once we have eased your symptoms and improved the rest of the team’s (shoulder and thoracic spine) collaboration, we need to focus on the depth of your breathing. There is no easier way to do this than getting your heart beating faster by cycling, going for fast-paced walks or jogs, or climbing a few flights of stairs. We’ll monitor you for any chest or rib symptoms as we train.

You need to be able to do this with ease so we can progress to the next phase of treatment.

4th Phase of Costochondritis Treatment: Return to your routine (weeks 8 – 11)

During this phase of your costochondritis treatment, we re-introduce your training or hobbies. You should know your condition and new, full-proof movement patterns that make returning to your training a breeze.

Sport-specific drills, like throwing, catching, and lifting, will be included during those phases of your costochondritis treatment, and you should be back to 90% of your previous strength, considering weights, reps, and sets or distance and speed before moving on to the final phase.

5th Phase of Costochondritis Treatment: Final clearance tests (week 12)

By now, you should be able to return to your routine. During the final week of your costochondritis treatment, we want you to be able to train at your full capacity. Your costochondral joints should be able to handle stretch stress, max load, and compressive forces.

So we can sign off on your recovery, knowing you’re safe.

Healing time for costochondritis

Costochondritis takes as little as one week of rest to heal or, on the other hand, progressively gets worse over a few months. How long you need to recover from your unique situation is greatly dependent on why you developed it in the first place. Your physiotherapist needs to see you once weekly for the first months of your rehabilitation. After this, the interval between sessions is extended as we introduce more specific exercises to your routine. Don’t confuse recovery and return to sport with the healing period. Nothing worthwhile can be rushed; decreasing the intensity of symptoms and improving functionality in your daily life are our aims.

Other forms of treatment for costochondritis

  • The information and knowledge of costochondritis are bleak, as most medical professionals are taught it is self-limiting. This means you have to wait for the pain to go away.
  • Your doctor (GP) will probably prescribe anti-inflammatories and analgesic medication to ease your rib symptoms.
  • Steroids can be injected into the affected joints.
  • Getting your back or neck ‘aligned’ could worsen or trigger a muscle spasm. You must look at the bigger picture and stop searching for a quick fix.
  • A biokineticist will be able to help you in the final stages of your rehabilitation and get you back to training for your sport, be it throwing, lifting, or handstands.

Is surgery an option for costochondritis?

No. Costochondritis does not require surgical intervention.

What else could it be?

A rib fracture can cause chest pain with breathing, coughing, or laughing after a fall.

  • Pleuritis

Inflammation of the lining surrounding the lung can cause pain when taking deep breaths or coughing. Shallow breaths reduce the intensity of the pain.

  • Acute coronary syndrome

Severe chest pain caused by decreased blood supply to the heart muscle itself is a medical emergency. Pressure in the chest, rapid heart rate, nausea, unusual fatigue, fainting, and sweating should be evaluated by a doctor ASAP. This may be caused by acute coronary syndrome, angina, myocardial infarction, or aortic dissection.

  • Compression fracture of the thoracic vertebral body

Moderate to severe upper back pain that is worse with movement. This can result from osteoporotic changes to the vertebral body or direct trauma from a fall.

  • Shingles

This viral infection is mainly limited to a single side of the chest wall with an accompanying blister-like rash, pain, and dermatomal spreading pattern.

  • Lung infection

Pain is felt especially when breathing out and accompanied by fever, general malaise, and increased heart rate and secretion when you cough.

Costochondritis is also known as

  • Tietze syndrome
  • Costochondral pain syndrome
  • Chest pain in the front
  • Breastbone pain