Costochondritis Clinical Presentation

Updated: Sep 24, 2021
  • Author: Lynn K Flowers, MD, MHA, ABAARM, FACEP; Chief Editor: Barry E Brenner, MD, PhD, FACEP  more...
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The onset of costochondritis is often insidious. Chest wall pain with a history of repeated minor trauma or unaccustomed activity (eg, painting, moving furniture) is common. Pain may be described as follows:

  • Exacerbated by trunk movement, deep inspiration, and/or exertion
  • Lessens with decreased movement, quiet breathing, or change of position
  • Sharp, nagging, aching, or pressurelike
  • Usually quite localized but may extend or radiate extensively
  • May be severe
  • May wax and wane


Pain with palpation of affected costochondral joints is a constant finding in costochondritis. The second through the fifth costochondral junctions typically are involved. More than one junction is involved in more than 90% of patients. Surprisingly, patients may not be aware of the chest wall tenderness until examination. The diagnosis should be reconsidered in the absence of local tenderness to palpation.

Physical examination can help differentiate costochondritis from Tietze syndrome and from slipping rib syndrome. Although Tietze syndrome also produces costochondral tenderness, it is acute rather than chronic and it is additionally characterized by nonsuppurative edema (usually of the second and third costochondral junctions), heat, and erythema, all of which are absent in costochondritis. [4, 5]

Slipping rib syndrome involves the anterior portions of ribs 8-10—the vertebrochondral false ribs, which unlike the first 7 ribs (the true ribs) are connected not to the sternum directly but to each other by fibrocartilaginous bands (it does not involve ribs 11 and 12, the floating false ribs, whose ventral ends are free). Slipping rib syndrome is caused by laxity of the intercostal attachments of the vertebrochondral false ribs, which allows the costal cartilage tips to subluxate and impinge on the intercostal nerves. [6, 7]

Patients with slipping rib syndrome may or may not report a history of trauma. They may describe insidious onset of dull, chronic pain or sudden onset of sharp, stabbing pain, which may be preceded by a slipping, clicking, or popping sensation. The pain may be precipitated by breathing or by certain movements. It may be thoracic or abdominal.   

The classic diagnostic test for slipping rib syndrome is the hooking maneuver: with the patient supine, the examiner hooks the fingers under the inferior margin of the ribs (ribs 8-10) and pulls straight up. The maneuver is positive if it reproduces the pain or rib movement. Relief of the pain with an intercostal nerve block strongly supports the diagnosis. Treatments include osteopathic manipulation, surgical resection, and diclofenac gel. [6, 7]

A comprehensive physical examination should include assessment of the lateral ribs and the cervical and thoracic spine, as hypomobility in those areas may be a factor in the development of costochondritis. In such cases, upper thoracic mobilization and manipulation for the treatment of rib dysfunction may be incorporated into the treatment plan. [5]



The etiology of costochondritis is not well defined. Repetitive minor trauma has been proposed as the most likely cause. Bacterial or fungal infections of these joints occur uncommonly, usually in patients who are intravenous drug users or who have had thoracic surgery. [8, 9] Costochondritis, among others, is a common cause of atypical chest pain (chest pain not caused by myocardial ischemia) in athletes. [10, 5, 11] Case reports have described costochondritis in vitamin D–deficient patients that resolved with vitamin D supplementation. [12]