Costochondritis: Rib Pain, Causes & Physiotherapy

What Is Costochondritis?

Costochondritis is inflammation of the costal cartilage — the flexible tissue connecting the bony ribs to the sternum (breastbone). It produces anterior chest wall pain that can be alarming, as it mimics cardiac chest pain. Understanding its distinguishing features is essential for correct diagnosis and appropriate management.

Anatomy of the Costo-Sternal Junction

The thorax has 12 pairs of ribs:

• Ribs 1 to 7 attach directly to the sternum via their own costal cartilage (true ribs)
• Ribs 8 to 10 attach via shared cartilage (false ribs)
• Ribs 11 to 12 float (no anterior attachment)

Costochondritis most commonly affects the 2nd to 5th costochondral junctions and is frequently bilateral.

Causes of Costochondritis

| Cause | Mechanism | |---|---| | Repetitive upper limb activity | Repeated stress on costal cartilage during lifting or rowing | | Poor posture (kyphotic) | Sustained anterior chest wall compression | | Respiratory infection | Repeated forceful coughing strains cartilage-rib junctions | | Trauma | Direct blow to the chest, RTA, contact sports | | Post-surgical | Following thoracotomy or sternotomy (cardiac surgery) | | Fibromyalgia | Widespread musculoskeletal tenderness including chest wall |

Costochondritis vs Tietze Syndrome

| Feature | Costochondritis | Tietze Syndrome | |---|---|---| | Swelling | No visible swelling | Localised fusiform swelling | | Joints affected | Multiple (2nd–5th) | Single (usually 2nd or 3rd) | | Demographics | Females, athletes | Young adults | | Pain | Localised tenderness | Tenderness + visible swelling |

Differentiating Costochondritis from Cardiac Chest Pain

| Feature | Costochondritis | Cardiac (Angina/MI) | |---|---|---| | Palpation pain | YES — reproduces pain exactly | NO | | Movement pain | YES — worse with trunk movement | Usually not | | Radiation | Rarely | Arm, jaw, back, neck | | Shortness of breath | Usually no | Often yes | | Diaphoresis (sweating) | No | Often yes | | ECG changes | Normal | Abnormal |

If in doubt, seek emergency medical evaluation immediately.

Physiotherapy Treatment for Costochondritis

Postural Correction

Kyphotic posture (rounded upper back) compresses the anterior chest wall and maintains mechanical stress on costal cartilages. Key corrections:

• Thoracic extension exercises — foam roller thoracic extension, seated thoracic extension over chair back
• Pectoral stretching — doorway chest stretch, corner stretch
• Scapular retraction — shoulder blade squeezes, prone Y-T-W exercises

Breathing Exercises

Costochondritis restricts the depth of breathing due to pain. Physiotherapy breathing exercises:

• Diaphragmatic breathing — reduces mechanical stress on the upper costal junctions
• Lateral costal breathing — expands the lower thorax, reducing upper rib strain
• Pursed-lip breathing — controlled exhalation for pain management

Manual Therapy

• Thoracic joint mobilisation — gentle Grade I-II mobilisation to restore thoracic extension without stressing the sternocostal junctions
• Soft tissue massage — paraspinal and pectoral muscle release to reduce mechanical chest wall compression
• Rib mobilisation — gentle posteroanterior pressure to maintain costovertebral joint mobility

Electrotherapy

• TENS over the painful sternocostal junction for acute pain management
• Laser therapy — may accelerate inflammatory resolution of costal cartilage
• Ultrasound — phonophoresis (ultrasound with topical anti-inflammatory gel) at the junction

Activity Modification

• Avoid activities that require arms raised above shoulders
• Sleep with a pillow supporting the unaffected side to avoid chest wall compression
• Apply ice (acute phase) or heat (sub-acute) to the affected rib area
• Gradual return to exercise — begin with gentle cycling or walking before returning to upper body training

For related thoracic conditions, see thoracic spondylosis symptoms and physiotherapy.

References

• Proulx AM, Zryd TW. Costochondritis: diagnosis and treatment. American Family Physician. 2009.
• Fam AG, Smythe HA. Musculoskeletal chest wall pain. Canadian Medical Association Journal. 1985.
• Disla E et al. Costochondritis: a prospective analysis in an emergency department setting. Archives of Internal Medicine. 1994.