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1 · SNAPSHOT

Costochondritis / Tietze's Syndrome body chart — Illustrative, not diagnostic. Canva body chart for Costochondritis / Tietze's Syndrome.

Who: Any age, including children and adolescents. Often post-viral or after a bout of postural or repetitive loading.
What: Pain at the costosternal or costochondral junctions.
How it behaves: Sharp, anterior, and localised. Aggs: deep breathing, coughing, trunk rotation. Eases: rest, heat, gentle mobility. Reproducible on palpation.

Costochondritis or Tietze's?

	Costochondritis	Tietze's syndrome
Tenderness	Yes	Yes
Local swelling	No	Yes — that's the difference
Sites	Often multiple, 2nd–5th	Usually one, often 2nd or 3rd
Why it matters		Tietze's has its own small treatment literature

The one thing to take from this page:

"If you can poke it and it hurts, it's not your heart" is a heuristic, not a test. Reproducible tenderness lowers the probability of something serious. It does not empty the box — the published mimics include tumour, tuberculosis and infection. Do the screen first, then reassure properly.

2 · SE — THE SUBJECTIVE PATTERN (the 70%)

Five stages, in your course's order.

MAIN PROBLEM

"There's a sharp pain right here at the front."
"It catches when I take a deep breath."
"It started after I had that chest infection."

BODY CHART

Anterior chest, at the junctions. Get them to point with one finger. Localisable pain is the pattern.
Mark any swelling. That's the Tietze's question and nobody asks it.
Mark radiation. Radiation to the jaw, neck or left arm changes the conversation entirely.

BEHAVIOUR

Aggs: deep breathing, coughing, sneezing, trunk rotation, pushing, lying on that side.
Eases: rest, heat, gentle movement.
24-hr pattern: linked to breath and position rather than the clock — ask which. Exertion-linked is a different page.
Night: lying on that side is in the Aggs. Pain at rest or at night unrelated to position is a §4 flag.
Severity: VAS 0–10 at best / at worst / right now.
Coding: M / In / P / Is as usual.
Irritability: resting symptoms + vigour of the provoking activity + time to settle.
The key behavioural question: is it linked to exertion, or to position and breath? Exertion-linked is a different page.

HISTORY

Recent viral illness? Post-viral onset is described — including post-COVID cases in adults and in children [1][2].
Recent trauma, however minor? Read further: chest wall pain after minor trauma [3].
New or unaccustomed loading — rowing, throwing, pressing, a house move, prolonged coughing.
Cardiac and respiratory history, risk factors, and family history.
Any inflammatory or autoimmune history? Costochondritis is described as a presentation of relapsing polychondritis [4].

SPECIAL / SCREENING QUESTIONS — the ones that decide the page

Any breathlessness, sweating, nausea, dizziness?
Any fever, night sweats, weight loss?
Any lump or swelling you can feel?
Any history of cancer, tuberculosis exposure, immunosuppression, or recent surgery or procedure to the chest?
Is the pain there at rest, or at night?

Assessing this region? Download the Thoracic Spine assessment template →

3 · HYPOTHESIS RANKING

Competing pattern	The one discriminating feature
Costovertebral / costotransverse dysfunction	Posterior, reproduced by rib springing at the back rather than junction palpation at the front.
Rib contusion or stress injury	A trauma or overuse history, and tenderness over the rib rather than the junction.
Thoracic facet (PIV) joint	Posterior, provoked by unilateral PA, may wrap around — and wrapping pain is what gets confused with this.
Thoracic outlet syndrome	Arm symptoms, positional, with paraesthesia. Not junction tenderness.
Axial spondyloarthritis	Costosternal pain with the inflammatory time pattern — morning stiffness, relief with movement, under forty.
Sternal fracture	Trauma. Read further: ultrasound for sternal fracture [5].

The ones that outrank the table — and these are the page

These are not theoretical differentials. Each one is a published presentation.

Mimic	What it looked like
Chest wall tumour	Liposarcoma mimicking an inflammatory chest wall condition [6].
Tuberculosis	Paravertebral TB mimicking costochondritis [7].
Infection	Infectious costochondritis with sternal osteomyelitis [8].
Systemic inflammatory disease	Costochondritis in relapsing polychondritis [4].
Cardiac and pulmonary causes	The reason anterior chest pain gets screened at all.

Every one of those could be tender when you press it.

4 · RED FLAGS — DON'T MISS THIS

This section is free, on every pattern, forever. Safety is never gated.

On this pattern section 4 is deliberately longer than section 5. That is the correct weighting.

Finding	What it suggests	What you do
Central or crushing chest pain, breathlessness, sweating, nausea, radiation to jaw or arm	Cardiac	000 / EMERGENCY
Exertional onset, settling with rest	Cardiac until proven otherwise	Same-day medical review
Pleuritic pain with breathlessness, calf symptoms, recent immobility or surgery	Pulmonary embolus	EMERGENCY
Fever, night sweats, unexplained weight loss	Infection, tuberculosis, malignancy	Urgent medical review
A palpable mass, or swelling that is growing	Tumour	Urgent medical review
Immunosuppression, IV drug use, recent chest surgery or procedure	Infective costochondritis, osteomyelitis	Urgent medical review
Pain at rest or at night, unrelated to position	Not mechanical	Medical review
Known cancer history with new chest wall pain	Metastasis	Urgent medical review
Ear, nose or airway cartilage involvement alongside it	Relapsing polychondritis	Medical review
Significant trauma	Fracture	Medical review and imaging

The pearl, corrected

A common teaching: "If you can poke it and it hurts, it's not your heart."

Keep it as a heuristic. Do not use it as a rule-out. Reproducible chest wall tenderness lowers the probability of a serious cause — no verified accuracy data for that claim exists in our library, and it certainly does not reach zero. Chest wall tumour, tuberculosis, infection and systemic inflammatory disease have all been published presenting exactly this way, and all of them can be tender to palpation.

Screen first. Reproduce second. Reassure third — and reassure properly, because you've earned it.

Cross-links: Cardiac / pulmonary referred pain · Rib contusion / stress injury · Costovertebral / costotransverse dysfunction · Ankylosing spondylitis / axSpA

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Twelve slides on this pattern: what you'll hear, what to examine, what to do. Free with an account.

Guideline anchor

No Australian guideline for this presentation.

Anchored to the ACR Appropriateness Criteria for nontraumatic chest wall pain (Stowell et al. 2021, PMID 34794596) for imaging, and to the rapid evidence review in Am Fam Physician (Mott et al. 2021, PMID 34264599) with its predecessor (Proulx et al. 2009, PMID 19817327) for clinical management. Physiotherapy-specific evidence is anchored to the OPTIMa systematic review of noninvasive interventions for musculoskeletal thoracic spine pain (Southerst et al. 2015, PMID 26141077) — everything below that is case-level.

PubMed Source

There is no clinical practice guideline for costochondritis. The anchors above are an imaging appropriateness document and a primary-care evidence review. The physiotherapy evidence for this pattern is case reports and case series — this page says so rather than dressing it up.

Members

The evidence summary is for members

Verified diagnostic accuracy, where the evidence stands and what it doesn't settle. Free with an account.

Sources · 20

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Every source on this page resolves and title-verifies against PubMed. Newest first.

2023Kuridze et al. (2023). Tietze Syndrome as a Cause of Chest Pain in the Post-COVID-19 Period. Cureus, 15(4), e37360. https://doi.org/10.7759/cureus.37360
2022Collins et al. (2022). Severe post-COVID-19 costochondritis in children. Proceedings (Baylor University. Medical Center), 35(1), 56-57. https://doi.org/10.1080/08998280.2021.1973274
2020Chandwani et al. (2020). Chest Wall Pain after Minor Trauma. Clinical practice and cases in emergency medicine, 4(3), 468-469. https://doi.org/10.5811/cpcem.2020.6.46961
2025van Gaalen et al. (2025). Costochondritis in relapsing polychondritis. EULAR rheumatology open, 1(1), 4-5. https://doi.org/10.1016/j.ero.2025.01.001
2024Park et al. (2024). Diagnostic Value of Ultrasound for Sternal Fractures in Patients with Trauma Experiencing Anterior Chest Wall Pain. Journal of clinical medicine, 13(17). https://doi.org/10.3390/jcm13175123
2024Tully et al. (2024). Double diagnostic deviance: Case report of chest wall liposarcoma mimicking inflammatory myofibroblastic tumor mimicking costochondritis. SAGE open medical case reports, 12, 2050313X241289031. https://doi.org/10.1177/2050313X241289031
2025Amarnani et al. (2025). Atypical chest wall pain: paravertebral tuberculosis mimicking costochondritis. BMJ case reports, 18(10). https://doi.org/10.1136/bcr-2025-266521
2025Fujiu et al. (2025). Infectious Costochondritis With Sternal Osteomyelitis. Cureus, 17(3), e80132. https://doi.org/10.7759/cureus.80132
2021Stowell et al. (2021). ACR Appropriateness Criteria® Nontraumatic Chest Wall Pain. Journal of the American College of Radiology : JACR, 18(11S), S394-S405. https://doi.org/10.1016/j.jacr.2021.08.004
2007Aspegren et al. (2007). Conservative treatment of a female collegiate volleyball player with costochondritis. Journal of manipulative and physiological therapeutics, 30(4), 321-5. https://doi.org/10.1016/j.jmpt.2007.03.003
2010Grindstaff et al. (2010). Treatment of a female collegiate rower with costochondritis: a case report. The Journal of manual & manipulative therapy, 18(2), 64-8. https://doi.org/10.1179/106698110X12640740712653
2012Westrick et al. (2012). Evaluation and treatment of musculoskeletal chest wall pain in a military athlete. International journal of sports physical therapy, 7(3), 323-32. PubMed 22666647
2017Zaruba & Wilson (2017). IMPAIRMENT BASED EXAMINATION AND TREATMENT OF COSTOCHONDRITIS: A CASE SERIES. International journal of sports physical therapy, 12(3), 458-467. PubMed 28593100
2015Southerst et al. (2015). The effectiveness of noninvasive interventions for musculoskeletal thoracic spine and chest wall pain: a systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) collaboration. Journal of manipulative and physiological therapeutics, 38(7), 521-31. https://doi.org/10.1016/j.jmpt.2015.06.001
2022Elsayed et al. (2022). The efficacy of oral corticosteroids for treatment of Tietze syndrome: A pragmatic randomized controlled trial. Journal of clinical pharmacy and therapeutics, 47(12), 2279-2286. https://doi.org/10.1111/jcpt.13810
2021Yıldız et al. (2021). Local treatment of pain in Tietze syndrome: A single-center experience. Turk gogus kalp damar cerrahisi dergisi, 29(2), 239-247. https://doi.org/10.5606/tgkdc.dergisi.2021.21120
2024Waggoner & Needleman (2024). Costochondritis. Pediatrics in review, 45(9), 543-545. https://doi.org/10.1542/pir.2023-006141
2009Proulx & Zryd (2009). Costochondritis: diagnosis and treatment. American family physician, 80(6), 617-20. PubMed 19817327
2020Mettola & Perricone (2020). Tietze Syndrome. Mediterranean journal of rheumatology, 31(2), 224. https://doi.org/10.31138/mjr.31.2.224
2021Mott et al. (2021). Costochondritis: Rapid Evidence Review. American family physician, 104(1), 73-78. PubMed 34264599

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