Costochondritis: Rapid Evidence Review


Am Fam Physician. 2021 Jul ;104(1):73-78.

  Patient information: See related handout on costochondritis.

Author disclosure: No relevant financial affiliations.

Costochondritis is a common cause of chest pain. It most commonly occurs in adults between 40 and 50 years of age, with a slight predominance in women. Although musculoskeletal and other chest wall conditions are the most common etiology for chest pain presenting to primary care, an initial differential diagnosis should include cardiovascular, psychogenic, pulmonary, gastrointestinal, and miscellaneous or unknown sources (more to less common, respectively). Additionally, physicians should remain vigilant throughout the workup because a notable portion of patients with chest wall tenderness to palpation may also have acute myocardial infarction. After a musculoskeletal or chest wall source is determined, differential diagnosis includes costochondritis, muscle trauma (including postoperative) or overuse, arthritis, fibromyalgia, neoplasm, infection, herpes zoster, Tietze syndrome, painful xyphoid syndrome, and slipping rib syndrome. The diagnosis of costochondritis is largely based on history and a physical examination that demonstrates reproduction of pain through palpation of the parasternal region of the chest wall, performance of a crowing rooster maneuver, and/or a crossed-chest adduction maneuver. Although high-quality evidence is lacking, treatment options include local application of heat, oral or topical nonsteroidal anti-inflammatory drugs, lidocaine patches, capsaicin cream, physical therapy, and acupuncture. Most patients will have complete resolution of symptoms in a few weeks' time with conservative therapy. Recalcitrant cases may respond to corticosteroid injections.

Costochondritis is a commonly encountered condition in primary care that is characterized by chest wall pain from inflammation in the costochondral joints. It most commonly occurs in adults 40 to 50 years of age. This article reviews the best available patient-oriented evidence for costochondritis.


  • The most common age for costochondritis is middle age (between 40 and 50 years

The Authors

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TIMOTHY MOTT, MD, is the program director of the South Baldwin Regional Medical Center Family Medicine Residency Program, Foley, Ala....

GREGORY JONES, MD, is the associate program director of the South Baldwin Regional Medical Center Family Medicine Residency Program.

KIMBERLY ROMAN, MD, is a faculty member of the South Baldwin Regional Medical Center Family Medicine Residency Program.

Address correspondence to Timothy Mott, MD, South Baldwin Regional Medical Center, 1613 N. McKenzie St., Foley, AL 36535 (email: Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.


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1. Bösner S, Becker A, Hani MA, et al. Chest wall syndrome in primary care patients with chest pain: presentation, associated features and diagnosis. Fam Pract. 2010;27(4):363–369....

2. Disla E, Rhim HR, Reddy A, et al. Costochondritis. A prospective analysis in an emergency department setting. Arch Intern Med. 1994;154(21):2466–2469.

3. Proulx AM, Zryd TW. Costochondritis: diagnosis and treatment. Am Fam Physician. 2009;80(6):617–620. Accessed November 11, 2020.

4. Pantell RH, Goodman BW Jr. Adolescent chest pain: a prospective study. Pediatrics. 1983;71(6):881–887.

5. Haasenritter J, Biroga T, Keunecke C, et al. Causes of chest pain in primary care—a systematic review and meta-analysis. Croat Med J. 2015;56(5):422–430.

6. McConaghy JR, Oza RS. Outpatient diagnosis of acute chest pain in adults. Am Fam Physician. 2013;87(3):177–182. Accessed November 17, 2020.

7. Verdon F, Herzig L, Burnand B, et al.; GMIRG. Chest pain in daily practice: occurrence, causes and management. Swiss Med Wkly. 2008;138(23–24):340–347.

8. Verdon F, Burnand B, Herzig L, et al. Chest wall syndrome among primary care patients: a cohort study. BMC Fam Pract. 2007;8:51.

9. Hsiao C-J, Cherry DK, Beatty PC, et al. National ambulatory medical care survey: 2007 summary. Natl Health Stat Report. 2010;27:1–32.

10. Hoorweg BB, Willemsen RT, Cleef LE, et al. Frequency of chest pain in primary care, diagnostic tests performed and final diagnoses. Heart. 2017;103(21):1727–1732.

11. Klinkman MS, Stevens D, Gorenflo DW; Michigan Research Network. Episodes of care for chest pain: a preliminary report from MIRNET. J Fam Pract. 1994;38(4):345–352.

12. Ebell MH. Evaluation of chest pain in primary care patients. Am Fam Physician. 2011;83(5):603–605. Accessed November 17, 2020.

13. Wertli MM, Dangma TD, Müller SE, et al. Non-cardiac chest pain patients in the emergency department: do physicians have a plan how to diagnose and treat them? A retrospective study. PLoS One. 2019;14(2):e0211615.

14. Cilia C, Malatino LS, Puccia G, et al. The prevalence of the cardiac origin of chest pain: the experience of a rural area of southeast Italy. Intern Emerg Med. 2010;5(5):427–432.

15. Bhuiya FA, Pitts SR, McCaig LF. Emergency department visits for chest pain and abdominal pain: United States, 1999–2008. NCHS Data Brief. 2010;43:1–8.

16. Panju AA, Hemmelgarn BR, Guyatt GH, et al. The rational clinical examination. Is this patient having a myocardial infarction? JAMA. 1998;280(14):1256–1263.

17. von Kodolitsch Y, Schwartz AG, Nienaber CA. Clinical prediction of acute aortic dissection. Arch Intern Med. 2000;160(19):2977–2982.

18. Zimmerman J. Validation of a brief inventory for diagnosis and monitoring of symptomatic gastro-oesophageal reflux. Scand J Gastroenterol. 2004;39(3):212–216.

19. Wang WH, Huang JQ, Zheng GF, et al. Is proton pump inhibitor testing an effective approach to diagnose gastroesophageal reflux disease in patients with noncardiac chest pain?: a meta-analysis. Arch Intern Med. 2005;165(11):1222–1228.

20. Wang CS, FitzGerald JM, Schulzer M, et al. Does this dyspneic patient in the emergency department have congestive heart failure? JAMA. 2005;294(15):1944–1956.

21. Löwe B, Gräfe K, Zipfel S, et al. Detecting panic disorder in medical and psychosomatic outpatients: comparative validation of the Hospital Anxiety and Depression Scale, the Patient Health Questionnaire, a screening question, and physicians' diagnosis. J Psychosom Res. 2003;55(6):515–519.

22. Imazio M, Brucato A, Cemin R, et al.; CORP (COlchicine for Recurrent Pericarditis) Investigators. Colchicine for recurrent pericarditis (CORP): a randomized trial. Ann Intern Med. 2011;155(7):409–414.

23. Maisch B, Seferović PM, Ristić AD, et al. Guidelines on the diagnosis and management of pericardial diseases executive summary; The Task Force on the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology. Eur Heart J. 2004;25(7):587–610.

24. Diehr P, Wood RW, Bushyhead J, et al. Prediction of pneumonia in out-patients with acute cough—a statistical approach. J Chronic Dis. 1984;37(3):215–225.

25. Metlay JP, Kapoor WN, Fine MJ. Does this patient have community-acquired pneumonia? Diagnosing pneumonia by history and physical examination. JAMA. 1997;278(17):1440–1445.

26. Wells PS, Anderson DR, Rodger M, et al. Excluding pulmonary embolism at the bedside without diagnostic imaging: management of patients with suspected pulmonary embolism presenting to the emergency department by using a simple clinical model and d-dimer. Ann Intern Med. 2001;135(2):98–107.

27. Tamariz LJ, Eng J, Segal JB, et al. Usefulness of clinical prediction rules for the diagnosis of venous thromboembolism: a systematic review. Am J Med. 2004;117(9):676–684.

28. Dale AP, Marchello C, Ebell MH. Clinical gestalt to diagnose pneumonia, sinusitis, and pharyngitis: a meta-analysis. Br J Gen Pract. 2019;69(684):e444–e453.

29. How J, Volz G, Doe S, et al. The causes of musculoskeletal chest pain in patients admitted to hospital with suspected myocardial infarction. Eur J Intern Med. 2005;16(6):432–436.

30. Spalding L, Reay E, Kelly C. Cause and outcome of atypical chest pain in patients admitted to hospital. J R Soc Med. 2003;96(3):122–125.

31. Fam AG, Smythe HA. Musculoskeletal chest wall pain. CMAJ. 1985;133(5):379–389.

32. Zapatero J, López Longo J, Monteagudo I, et al. Costal chondritis in heroin addicts: a comparative study with postsurgical chondritis. Br J Dis Chest. 1988;82(4):341–346.

33. Chicarilli ZN, Ariyan S, Stahl RS. Costochondritis: pathogenesis, diagnosis, and management considerations. Plast Reconstr Surg. 1986;77(1): 50–59.

34. DynaMed. Fibromyalgia (subscription required). Accessed April 9, 2020.

35. DynaMed. Herpes zoster. Accessed April 9, 2020.

36. Gregory PL, Biswas AC, Batt ME. Musculoskeletal problems of the chest wall in athletes. Sports Med. 2002;32(4):235–250.

37. Saltzman DA, Schmitz ML, Smith SD, et al. The slipping rib syndrome in children. Paediatr Anaesth. 2001;11(6):740–743.

38. Wolf E, Stern S. Costosternal syndrome: its frequency and importance in differential diagnosis of coronary heart disease. Arch Intern Med. 1976;136(2):189–191.

39. Wise CM, Semble EL, Dalton CB. Musculoskeletal chest wall syndromes in patients with noncardiac chest pain: a study of 100 patients. Arch Phys Med Rehabil. 1992;73(2):147–149.

40. Tietze A. Ueber eine eigenartige Häufung von Fällen mit Dystrophie der Rippenknorpel [About a peculiar accumulation of cases with dystrophy of costal cartilage]. Berliner Klinische Wochenschrift. 1921;30:829–831. Accessed January 19, 2021.

41. Epstein SE, Gerber LH, Borer JS. Chest wall syndrome. A common cause of unexplained cardiac pain. JAMA. 1979;241(26):2793–2797.

42. Ronga A, Vaucher P, Haasenritter J, et al. Development and validation of a clinical prediction rule for chest wall syndrome in primary care. BMC Fam Pract. 2012;13:74.

43. Bösner S, Haasenritter J, Becker A, et al. Ruling out coronary artery disease in primary care: development and validation of a simple prediction rule. CMAJ. 2010;182(12):1295–1300.

44. Harskamp RE, Laeven SC, Himmelreich JC, et al. Chest pain in general practice: a systematic review of prediction rules. BMJ Open. 2019;9(2):e027081.

45. Van Den Berg P, Body R. The HEART score for early rule out of acute coronary syndromes in the emergency department: a systematic review and meta-analysis. Eur Heart J Acute Cardiovasc Care. 2018;7(2):111–119.

46. Ayloo A, Cvengros T, Marella S. Evaluation and treatment of musculoskeletal chest pain. Prim Care. 2013;40(4):863–887, viii.

47. Rovetta G, Sessarego P, Monteforte P. Stretching exercises for costochondritis pain. G Ital Med Lav Ergon. 2009;31(2):169–171.

48. Boran M, Boran E. Tietze syndrome and idiopathic costochondritis—treatment modalities, recurrence rates, seasonality. World J Pharm Res. 2017;6(8):76–85.

49. Li B. 106 cases of non-suppurative costal chondritis treated by acupuncture at xuanzhong point. J Tradit Chin Med. 1998;18(3):195–196.

50. Kamel M, Kotob H. Ultrasonographic assessment of local steroid injection in Tietze's syndrome. Br J Rheumatol. 1997;36(5):547–550.



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